‘If It Dries It Dies’: A Surgeon's Guide to Wound Care
⌚️ read time: 4 minutes
Here’s another common topic I get asked about all the time. Whether a scratch on the arm gardening, a skinned knee, or a surgical incision from me, there is a lot of confusion around how to care for skin wounds while they heal.
If you think about it, all wounds progress down the same path. From open wound (red, raw) to closed wound (scab) to scar (new skin).
So the different wounds discussed below are really just different stages of wounds depending on the type of injury or whether you’re dealing with a surgical wound.
Let’s get into it.
Disclaimer: If you’ve recently had surgery or an injury and are being treated by another physician, please follow their instructions, not these. There are some differences in thinking about how to care for wounds, especially in different places around the body.
Surgical (or closed) wounds: When you have stitches
In this category, I would place ‘any wound with stitches.’ So if you have had surgery with me, or if you sustained a cut that was stitched closed at an urgent care, this is the protocol I would follow.
While the debate rages even amongst surgeons as to the exact duration, you will want to keep the wound completely covered for an initial period of time.
For me, this is 5 days.
After stitching up your wound, I place your hand or arm in a sterile dressing. This completely sterile environment gives your wound a nice clean headstart to its healing process.
Even though you have stitches, think of all the little gaps between the stitches where bacteria could theoretically get in to infect your wound. Let those seal up over 5 days before exposing the incision to the outside world.
This means the bandage has to stay completely intact and dry during this time. Yes, that means wrapping a plastic bag around the wound or buying one of these newer ‘cast bags’ (example link here) available on the market (I have no affiliations).
After these first five days, now begin your daily dressing changes. This also is when you can begin to shower or gently wash the incision. Meaning: soap up the limb all around the incision and then let water rinse over the wound. No soaking or scrubbing the wound.
I’m going to emphasize this again. No soaking. No pools, baths, hot tubs, lakes, or dishwater. Showers only.
After the shower, pat the wound dry with a clean towel and apply a new dressing. You can pick your choice of dressing, but I like a non-stick layer (eg, Xeroform, Adaptic, Telfa) followed by a gauze or two. Then wrapped however best to keep the dressing on your limb (eg, gauze wrap). If it’s a small enough wound, a bandaid accomplishes all these goals (an internal non-stick layer and an outer layer that clings to your limb).
A word about ointments.
For a surgical or closed wound, these are completely unnecessary. An in some cases can be harmful. It’s sort of intuitive to want to slather a wound with your choice of antibacterial ointment. I get it.
But what we actually see is that these ointments keep the skin too wet. Patients come back with what we call maceration…sort of a soggy wound.
Also, any antibiotic that’s available over the counter (ie, in these ointments), is sort of a weak, general antibiotic. And what will that do? It’ll just kill off all the weak bacteria, leaving behind any nasty ones to replicate without competition. I just don’t believe in these antibiotic ointments, and there’s never been good evidence to support their use.
Open wounds: The raw areas
For this category, I want you to think of the classic skinned knee. Or road rash. I’d also put irregular wounds into this category, like a dog bite with rough edges that can only be partially closed with sutures.
The point is, these wounds will have some portion that is not closed with sutures. Again, imagine that raw, shiny, red wound bed you see when you skin your knee. That’s deep tissue open to the outside world.
I want to provide more detail below, but here’s the most helpful mantra I’ve ever heard (courtesy of Dr. Don Lalonde, a master in the hand surgery world):
"If it dries, it dies.”
Meaning? While that wound is open and red, it must stay wet or the tissue will die. Dead tissue is a breeding ground for infection.
So for these wounds, they can also get wet in a shower or under a sink. Gently soap around the wound (not directly on it), and then let the soap wash over the wound.
After patting it dry with a clean towel, apply a thick layer of clean/new Aquaphor or Vaseline. This is what I mean by keeping the wound wet. The greasy layer of ointment will keep the wound bed nice and moist as it heals up.
On top of this ointment, you can now put your favorite non-stick layer and wrap (same as above in the closed wound section). Change this dressing at least once a day.
If you notice that the surrounding healthy skin is becoming white and soggy, that’s a sign of maceration. That means you’re either spreading the ointment too broadly onto healthy tissues, or the wound just needs a little less enclosure.
If this is the case, spend some time each day in a calm clean environment with the wound unwrapped (eg, not around your dogs, kids, etc). Still keep the greasy ointment directly over the raw areas so they don’t dry and die…but let the surrounding skin air out.
Continue this until the wound has a true scab. Again, think back to your skinned knee. There’s a period of time when it’s red and raw. Followed by a period of time where there’s a darker red/brown scab.
Once the wound has a scab, you can transition to the “Closed” wound care protocol written out above. Continue that until you have a scar, or new fresh skin healed over without scab.
See?
It’s just a progression from open wound -> closed wound -> scar.
Scar Care: The final stage
I’m sure my dermatology and plastic surgery friends would disagree with me, but by the time you get to the scar phase of most healing wounds, it matters much less what you decide to do with it. I guess I’m a true orthopedic surgeon at heart.
Time
Most scars take around 9-12 months to reach their final state. If you think about it, the skin’s job when healing a wound is to close up a gap that’s open to the outside world. So the first layer it forms is actually just a big hunk of disorganized tissue to close the gap at all costs.
It then goes through a remodeling phase where it’s formalizing the structure within. Slowly, over those 9-12 months, the skin will become less bulky, more pliable, and appear visually more like the skin you’re used to.
We all know that scars don’t go back to looking perfectly normal, but they will be much closer by one year.
Sun
If there’s one thing that’s clear, it’s this. That fresh scar that forms is going to be WAY more sensitive to the sun — so be sure to over-protect the scar with minimum SPF 30 sunscreen for the first year.
Massage
There’s reasonable evidence that massaging thick new scars can help them mature faster. Part of this is the physical manipulation of the tissue and some is the use of topicals. The best products to use for this would be something like Vaseline or Aquaphor. The literature goes back and forth on whether using Vitamin E oil helps with this portion of recovery. It’s never shown an obvious benefit, so in general, I would say ‘don’t waste your money.’
Warning Signs
As with any healing wound, you will want to be on the lookout for signs of infection. While our body can take care of most minor issues, you certainly will want to let your doctor know right away if you’re developing any concerning symptoms.
If you take nothing else away from this, remember that it’s all about the trend. All wounds go through phases of redness, swelling, and pain. Unfortunately, these are also 3 hallmark signs of infection!
So what I’m most interested in when evaluating a patient for infection is ‘what did the wound look like yesterday? Or last week?’
A wound that is improving, but then all of a sudden becomes more painful and swollen is a warning sign. Certainly any wound that starts draining pus, has a foul odor, or gives you a fever is an immediate warning sign that warrants prompt medical evaluation.
The last detail is redness. Unfortunately, several days after the injury, all wounds develop some redness around the edge. This is actually part of the normal healing process as your blood vessels open up to lay down new tissue.
There’s no hard and fast way to evaluate redness (and its associated warmth). Sometimes you just need a doctor to look at it. I have found though that the “Rule of Thumb” (seriously, I didn’t just make that up for this newsletter) works pretty well. If the area of redness is more than the width of your thumb outside the wound edge, it may be the concerning redness of infection rather than the normal redness of healing.
Takeaways:
All wounds follow the same healing progression (open → closed → scar), but the amount of moisture they need changes dramatically along the way.
"If it dries, it dies" - keep raw, open wounds moist with Vaseline/Aquaphor, but once they're closed, less is more.
Watch the trend - while all healing wounds have some pain, redness, and swelling, any sudden worsening of these symptoms needs medical attention.
Remember: healing is a progression. While most wounds follow this predictable path to recovery, knowing these care principles - and warning signs - helps ensure the best possible outcome.
