Is wound packing necessary for all wounds?

Wound Packing Is Not Necessary for Most Wounds

Wound packing is not routinely necessary for most wounds and should be avoided in many clinical scenarios, as current evidence shows it increases pain and healthcare costs without clear benefit to healing outcomes. 1, 2, 3

Specific Recommendations by Wound Type

Anorectal Abscesses

• Do not routinely pack anorectal abscesses after drainage 1, 2
• A Cochrane review found it "unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence, or other outcomes" 1, 2
• A multi-center observational study of 141 patients concluded that packing is costly, painful, and does not add benefit to the healing process 1, 2
• Alternative approach: Place a catheter or drain into the abscess cavity that drains into an external dressing, leaving it in place until drainage stops 1, 2

Superficial Wounds and Abrasions

• Cover clean superficial wounds with an occlusive dressing rather than packing 1
• Occlusive dressings (film, petrolatum, hydrogel, cellulose/collagen) result in better wound healing than dry dressings 1
• Thoroughly irrigate wounds with running tap water or sterile saline until no debris remains 1
• No indication exists that antibiotic or antibacterial dressings improve wound healing or decrease infection rates in clean wounds 1

Skin Abscesses (Non-Anorectal)

• Packing is not necessary after incision and drainage of uncomplicated skin abscesses 3
• Three randomized controlled trials demonstrated no difference in treatment failure rates, recurrence rates, or need for secondary interventions between packed and non-packed wounds 3
• Packing groups consistently experienced more pain 3
• All studies demonstrate high rates of clinical cure following incision and drainage alone 3

Bite Wounds (Human and Animal)

• Do not pack bite wounds; infected wounds should not be closed 1
• Cleanse wounds with sterile normal saline (no iodine or antibiotic solutions needed) 1
• Superficial debris should be removed, but deeper debridement is usually unnecessary 1
• Wounds should be approximated by Steri-Strips with subsequent closure by delayed primary or secondary intent 1

When Packing May Be Considered

Necrotizing Soft Tissue Infections

• After complete removal of necrosis, consider negative pressure wound therapy (NPWT) rather than traditional packing 1
• NPWT improves local wound environment, increases tissue perfusion, reduces edema, and promotes granulation tissue formation 1
• Traditional gauze packing is outdated for these complex wounds 4

High-Risk Scenarios Requiring Special Consideration

• Wounds with heavy microbial contamination may benefit from antimicrobial gauze if packing is deemed necessary 5
• Immunocompromised patients may require individualized approaches, though evidence remains limited 3

Key Clinical Pitfalls to Avoid

Pain and Cost Burden: Traditional gauze packing causes significant pain during dressing changes and increases healthcare expenses through prolonged use 1, 2, 3

Premature Closure Prevention: The traditional rationale that packing prevents premature skin closure is not supported by evidence showing equivalent or better outcomes without packing 2, 3

Probing for Fistulas: In anorectal abscesses, avoid probing to search for a fistula if one is not obvious, as this causes iatrogenic complications 1, 2

Wound Contamination: For wounds requiring ongoing management, focus on maintaining a moist wound environment with occlusive dressings rather than repeated packing 1

Practical Algorithm for Decision-Making

1. Identify wound type: Abscess, superficial wound, bite wound, or necrotizing infection
2. For abscesses: Perform adequate incision and drainage alone; place drain if needed but avoid packing 1, 2, 3
3. For superficial wounds: Irrigate thoroughly, then apply occlusive dressing 1
4. For bite wounds: Irrigate, remove superficial debris, leave open or approximate with Steri-Strips 1
5. For necrotizing infections: After complete debridement, consider NPWT rather than traditional packing 1
6. Monitor for infection: Remove dressing and obtain medical care if redness, swelling, foul drainage, increased pain, or fever develops 1