Management of Tender Scalp Laceration After 7 Days
Tenderness alone at 7 days post-staple closure does not warrant antibiotic initiation—you must first assess for actual signs of infection before starting antibiotics.
Clinical Assessment Required
The key distinction is between normal healing tenderness versus true wound infection. You need to evaluate for:
- Purulent drainage from the wound 1
- Erythema extending beyond the wound edges 1
- Warmth and induration surrounding the laceration 1
- Wound dehiscence or breakdown 1
- Systemic signs: fever, lymphadenopathy, or constitutional symptoms 1, 2
Decision Algorithm
If NO Signs of Infection (Tenderness Only)
Do not start antibiotics. 1, 3
- Tenderness at 7 days can represent normal healing, especially with staples creating local tissue reaction 4
- The Infectious Diseases Society of America explicitly recommends against antibiotic therapy for clinically uninfected wounds 1
- Consider staple removal if at appropriate timeframe (typically 7-10 days for scalp) 4, 5
- Reassess in 24-48 hours if tenderness persists or worsens 2
If Signs of Infection ARE Present
Start therapeutic antibiotics immediately. 1, 3
First-line antibiotic choice:
- First-generation cephalosporin (e.g., cephalexin 500mg PO QID) for Staphylococcus and Streptococcus coverage 1, 3
- Alternative for penicillin allergy: Clindamycin 3
Duration: 3-5 days of therapeutic antibiotics 1, 3
Additional considerations:
- If fresh water contamination occurred at time of injury, consider coverage for Aeromonas hydrophila, which may not respond to standard cephalosporins 6
- Remove staples if purulent drainage present to allow adequate drainage 1
Critical Timing Considerations
- Reassessment is mandatory if no improvement after 3-5 days of antibiotics 2
- Clinical deterioration at any point requires immediate re-evaluation for alternative diagnosis, resistant organism, or inadequate source control 2
- Patients showing no response after 5-7 days of appropriate therapy likely need antibiotic change rather than continuation of the same regimen 2
Common Pitfalls to Avoid
- Do not reflexively start antibiotics for tenderness alone—this represents antibiotic overuse for normal healing 1, 3
- Do not delay antibiotic initiation if true infection signs are present, as delay beyond recognition significantly increases complications 1
- Do not continue ineffective antibiotics beyond 5-7 days without reassessment—the problem is likely wrong antibiotic choice, resistant organism, or alternative diagnosis 2
- Ensure tetanus prophylaxis was addressed at initial presentation if not vaccinated within 10 years 1