In a 31-year-old adult with a cut from two months ago that still has a scab, no signs of infection, normal glycemic control, and up-to-date tetanus immunization, what is the appropriate next step in management?

Management of Persistent Scab After Minor Laceration

This persistent scab at 2 months post-injury warrants clinical evaluation to rule out delayed healing complications, with consideration for gentle debridement and reassessment of local wound factors that may be impeding normal healing. 1

Initial Assessment Priorities

Your first step should be examining the wound for specific features that indicate abnormal healing:

• Assess for underlying infection signs including surrounding cellulitis extending >2 cm from wound edges, purulent drainage, increased warmth, or progressive erythema—even without systemic symptoms like fever 1
• Evaluate the scab characteristics: thick, adherent eschar may harbor bacteria underneath and mechanically prevent epithelialization 1
• Document wound dimensions and photograph if possible to track any changes 1
• Probe gently to determine if there is underlying fluid collection, foreign body retention, or deeper tissue involvement 1

Why This Scab Persists

At 2 months, normal wound healing should be complete. Several factors may explain persistence:

• Retained necrotic tissue or debris under the scab acts as a mechanical barrier to healing and provides a nidus for bacterial colonization 1
• Repeated trauma or picking at the scab restarts the inflammatory phase
• Subclinical infection with biofilm formation can occur without overt signs of infection 2
• Inadequate initial debridement may have left devitalized tissue that prevents closure 1

Management Algorithm

If No Signs of Active Infection

Perform gentle mechanical debridement:

• Remove the scab and any underlying callus, necrotic tissue, or debris to fully visualize the wound bed 1
• Use sharp debridement with scissors or scalpel to excise non-viable tissue 1
• Irrigate copiously with warm sterile saline until no visible foreign material remains—avoid high-pressure irrigation as it forces bacteria deeper 1

After debridement:

• Apply thin layer of antibiotic ointment (if no allergy) 1
• Cover with clean occlusive dressing 1
• Instruct patient to keep wound moist and covered, changing dressing daily 3

If Signs of Infection Present

Obtain wound culture from the debrided wound base (not from superficial swab) before starting antibiotics 2

Initiate oral antibiotics covering skin flora:

• First-line: amoxicillin-clavulanate or cephalosporin 1
• For β-lactam allergy: clindamycin plus gentamicin 1
• Duration: 5-7 days for mild-moderate infections 2

Critical Pitfalls to Avoid

• Do not leave the scab in place indefinitely—it prevents wound assessment and may conceal underlying problems 1
• Do not assume absence of fever/leukocytosis excludes infection—chronic wounds can harbor significant bacterial burden without systemic signs 2
• Do not use hydrogen peroxide or alcohol—these damage healing tissue 3
• Do not keep the wound completely dry—moist wound healing is superior 3

Tetanus Considerations

While your tetanus is up-to-date, this case highlights an important nuance:

• Standard teaching: tetanus booster needed if >10 years since last dose for clean wounds, >5 years for contaminated wounds 4
• Your situation: at 2 months post-injury with intact scab and no infection, tetanus risk is negligible—the anaerobic environment needed for C. tetani spore germination is unlikely 4, 5
• However: chronic wounds can rarely serve as tetanus portals, particularly in elderly or immunocompromised patients 5

Follow-Up Plan

• Reassess in 5-7 days after debridement to ensure healing progression 1
• If no improvement: consider wound culture, rule out foreign body with imaging if mechanism suggests retained material, or refer to wound care specialist 3
• Expected timeline: properly debrided simple wounds should show epithelialization within 1-2 weeks 1

When to Refer

Refer to wound care specialist or dermatology if:

• No healing progress after 2 weeks of appropriate management 3
• Wound enlarges despite treatment 1
• Suspicion of underlying pathology (malignancy, vasculitis, pyoderma gangrenosum) 3
• Recurrent infection despite appropriate antibiotics 2