What is the best approach for managing a wound from an excision of a benign vascular proliferation that is open and draining?

Management of Open and Draining Wounds Following Excision of Benign Vascular Proliferation

For an open and draining wound following excision of a benign vascular proliferation, sharp debridement of necrotic tissue followed by moist wound dressing and appropriate pressure offloading is the optimal management approach. 1

Initial Assessment and Debridement

• Sharp debridement with scalpel, scissors, or tissue nippers is the preferred method for removing devitalized tissue, as it is more definitive and controllable than hydrotherapy or topical debriding agents 1
• The goal of debridement is to physically excise dead and unhealthy tissue, enabling wound healing and removing potential pathogen reservoirs 1, 2
• All necrotic tissue must be removed as it provides an excellent medium for bacterial growth 3
• Only remove devitalized/infarcted tissue and spare normally perfused skin; if skin viability is questionable, preserve it and reassess at subsequent evaluations 1
• Wound irrigation is necessary to remove foreign matter, hematoma, and decrease bacterial contamination 3

Wound Dressing and Care

• The wound should be dressed in a manner that allows daily inspection and promotes a moist wound-healing environment 1
• No specific type of dressing has proven superior; convenience and cost are important considerations 1
• For open draining wounds, negative pressure-assisted wound management (vacuum-assisted closure) may be beneficial to manage drainage, eliminate dead space, and promote healing 1
• Superficial incisional wounds that have been opened can usually be managed without antibiotics if there are no signs of systemic infection 1

Antibiotic Considerations

• Antibiotics are generally unnecessary if there is less than 5 cm of erythema and induration, and minimal systemic signs of infection (temperature <38.5°C, WBC count <12,000 cells/μL, and pulse <100 beats/minute) 1
• If the patient has temperature >38.5°C, heart rate >110 beats/minute, or erythema extending beyond the wound margins for >5 cm, a short course (24-48 hours) of antibiotics may be required 1
• Empiric antibiotic therapy, when needed, should target staphylococci and gram-negative bacilli 1
• If a specific microorganism is identified, therapy should be adjusted accordingly 1

Follow-up Care and Re-evaluation

• Plan the first re-examination within 12-24 hours and repeat evaluations until the wound shows clear signs of healing 1
• Re-evaluations should be performed sooner if clinical signs of worsening infection become evident or laboratory parameters worsen (particularly WBC count) 1
• Removal of pressure from the wound (off-loading) is crucial to the healing process, especially for wounds on weight-bearing surfaces 1
• Choose a device that permits easy inspection of the wound when off-loading is required 1

Special Considerations

• For wounds with significant drainage, consider vacuum-assisted closure devices to manage exudate and promote granulation tissue formation 1
• In cases where open management is needed, once the infection has cleared, the wound can be closed 1
• For vascular proliferation excision sites, careful monitoring of hemostasis is important due to the vascular nature of the original lesion 1
• Samson class II infections (open, draining wounds) may benefit from vacuum-assisted closure devices and occasionally from a muscle flap to achieve wound coverage, eliminate dead space, and promote healing 1

Adjunctive Treatments

• Evidence is insufficient to recommend routine use of adjunctive treatments such as recombinant growth factors, skin substitutes, or antimicrobial dressings for infected wounds 1
• Granulocyte colony-stimulating factors (G-CSFs) do not accelerate resolution of infection but may reduce the need for operative procedures in certain cases 1
• Enzymatic debridement agents can be considered as an alternative when sharp debridement is not feasible due to bleeding disorders or other considerations 4