For a healthy adult or child with a clean dog bite wound less than 8 hours old on the face, scalp, or non‑weight‑bearing hand, should I perform primary closure (suture) or allow healing by secondary intention?

Dog Bite Wound Closure: Suture vs. Secondary Intention

For facial dog bites presenting within 8 hours, perform primary closure after copious irrigation, debridement, and prophylactic antibiotics—infection rates remain below 1% and cosmetic outcomes are superior; for hand wounds, avoid primary closure entirely due to significantly higher infection risk. 1, 2

Decision Algorithm by Anatomic Location

Facial Wounds (Face, Scalp, Ears)

• Primary closure is strongly recommended even though the general rule advises against suturing bite wounds, because facial tissues have excellent blood supply and infection rates remain <1% with proper technique. 1, 2
• Close within 8 hours of injury when possible, though facial wounds may be closed even after this window with appropriate antibiotic coverage. 3
• The superior cosmetic results and minimal infection risk make primary closure the standard of care for facial dog bites. 1, 4

Hand and Finger Wounds

• Never perform primary closure because hand wounds carry significantly higher infection rates than other body locations. 1, 2, 5
• Hand bites frequently penetrate periosteum, tendon sheaths, or joint capsules, creating high risk for deep infections including septic arthritis and osteomyelitis. 1
• Approximate wound edges with adhesive strips (Steri-Strips) only—formal suturing must be avoided. 1, 2

Non-Facial, Non-Hand Wounds

• Primary closure is generally not recommended for wounds on extremities or trunk. 2
• Use Steri-Strips for approximation and allow healing by delayed primary or secondary intention. 3

Essential Pre-Closure Wound Preparation

Inadequate irrigation and debridement represent the most common preventable errors in dog bite management. 1, 2

• Irrigate copiously with sterile normal saline using a ≥20 mL syringe to generate sufficient mechanical pressure for bacterial removal. 1, 2
• Mechanical cleansing is as critical as antibiotic prophylaxis for infection prevention. 1, 2
• Debride only devitalized tissue while preserving maximum viable tissue, especially on the face and ears. 1, 2
• Continue irrigation until no visible foreign material or contamination remains. 3

Mandatory Antibiotic Prophylaxis

• First-line: Amoxicillin-clavulanate 875 mg/125 mg orally twice daily for 3–5 days to cover Pasteurella multocida, Staphylococcus aureus, streptococci, Eikenella corrodens, and anaerobes. 1, 2
• Penicillin allergy: Doxycycline 100 mg orally twice daily for excellent Pasteurella coverage. 1, 2
• Prophylactic antibiotics are essential for all facial wounds being closed primarily and for any wound with contamination or tissue damage. 3, 1

Critical Pitfalls to Avoid

• Never use first-generation cephalosporins, macrolides, clindamycin, or aminoglycosides alone—they lack activity against Pasteurella multocida and Eikenella corrodens, the most common pathogens in dog bites. 1, 2
• Never close hand or finger wounds primarily—the infection rate is significantly elevated compared to all other anatomic sites. 1, 2, 5
• Never close wounds with purulent discharge or established infection—defer closure and treat infection first. 1
• Never skip copious irrigation—mechanical cleansing is as important as antibiotics for preventing infection. 1, 2
• Avoid suturing when possible per rabies prevention guidelines—primary closure should be avoided when feasible to allow drainage and reduce rabies transmission risk, though this must be balanced against cosmetic needs for facial wounds. 6, 1

Additional Management Considerations

• Administer tetanus prophylaxis (Tdap preferred) if last dose was >5 years ago or wound is heavily contaminated. 1
• Consult local public health authorities regarding rabies post-exposure prophylaxis; if indicated, give both rabies immunoglobulin and vaccine series on days 0,3,7, and 14. 1
• Schedule follow-up within 24 hours to assess for infection signs (increasing pain, erythema, swelling, purulent discharge). 1
• Elevate the injured area to reduce edema and accelerate healing. 1

Nuances in the Evidence

While older studies suggested leaving dog bite wounds open universally 5, contemporary guidelines from the Infectious Diseases Society of America clearly distinguish facial wounds as an exception where primary closure is superior. 1, 2 The key differentiator is anatomic location: facial tissues tolerate primary closure exceptionally well due to rich vascular supply, whereas hand wounds consistently demonstrate higher infection rates regardless of closure technique. 1, 2, 5 Recent case series confirm that even deep facial lacerations can be safely closed primarily with zero infections when proper technique is followed. 7