Assessment and management of scalp lacerations

INTRODUCTION — Scalp lacerations are a common injury. Clinical evaluation should identify associated serious head injury, laceration of the galea, or bony defect of the skull. After hemostasis is achieved and the wound is irrigated, scalp lacerations are typically closed with surgical staples under local anesthesia. Sutures may be preferred over staples for large, gaping wounds and to provide hemostasis for wounds with brisk bleeding.

The assessment and management of scalp lacerations will be reviewed here. Minor wound management, methods of suture placement, and closure of skin wounds with staples are discussed in detail separately:

●(See "Minor wound evaluation and preparation for closure".)

●(See "Skin laceration repair with sutures".)

●(See "Closure of minor skin wounds with staples".)

EVALUATION — As in all trauma patients, the initial clinical assessment should provide rapid identification of potentially fatal conditions. Evaluation should rapidly identify airway compromise (while maintaining cervical spine immobilization), impaired breathing, hemorrhagic shock, and altered level of consciousness upon patient arrival at the emergency department. Such systematic evaluation helps ensure detection of potentially life-threatening injuries. The approach to the injured child or adult is discussed in detail separately (table 1). (See "Trauma management: Approach to the unstable child", section on 'Primary survey' and "Initial management of trauma in adults", section on 'Primary evaluation and management'.)

Scalp lacerations should be identified during a vigilant and organized secondary survey. (See "Trauma management: Approach to the unstable child", section on 'Secondary survey'.)

History — The clinician should identify the following aspects of the injury:

●Traumatic force (eg, high-speed motor vehicle collision with significant likelihood of associated injuries versus fall from standing height with no other symptoms)

●Associated symptoms of head injury (eg, altered mental status, vomiting, headache) (see "Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation", section on 'History' and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation", section on 'History')

●Wound age

●Likelihood of wound contamination (eg, clean laceration from table edge with low risk of contamination versus bite wound with high risk of bacterial contamination)

●Potential presence of foreign body (eg, fall on to glass or gravel)

The history should also include a comprehensive review of past medical history (eg, diabetes mellitus, cancer, prior keloid formation), medication use (eg, immunosuppressive agents), and social habits (ie, alcohol or drug use) that may negatively affect healing and increase the risk for poor outcomes. (See "Minor wound evaluation and preparation for closure", section on 'Risks for poor outcome'.)

In addition, the clinician should also elicit allergies to any medications, especially local anesthetics, and the patient’s tetanus immunization status. (See "Allergic reactions to local anesthetics", section on 'Evaluation' and "Assessment and management of facial lacerations", section on 'Tetanus prophylaxis'.)

Physical examination — The scalp should be examined carefully to evaluate for signs of injury to the underlying structures (picture 1). The layers of concern in the scalp include the subcutaneous tissue, galea aponeurosis, connective tissue and periosteum overlying the bone. Visible or palpable bony defects warrant computed tomography of the head to determine presence of intracranial injury or penetration of the wound through the skull.

Removal of all foreign debris and blood will allow for proper assessment. Bleeding is a common problem with scalp lacerations. Hemostasis of a wound is necessary to allow for an appropriate examination. Direct pressure for approximately 15 minutes with or without local injection of lidocaine with epinephrine can often provide sufficient hemostasis. If these methods fail, the clinician should evert the edges of the scalp wound using manual manipulation, hemostats, or skin hooks. The wound is then rapidly closed with sutures. In this situation, simple interrupted sutures provide circumferential wound closure and thus better control of bleeding than noncircumferential wound closure with staples. (See "Skin laceration repair with sutures", section on 'Percutaneous closure'.)

The following attributes of the wound should be noted [1]:

●Length of laceration in centimeters

●Depth of laceration (epidermis, dermis, subcutaneous fat, muscle, or bone)

●Shape of laceration (eg, linear, curvilinear, stellate, or corner)

●Presence of gross contamination or visible foreign bodies

●The presence of skin loss

Diagnostic imaging — Patients with clinical findings (eg, laceration from broken glass, debris in the wound, visible or palpable bony defect) that suggest the presence of a foreign body or bony injury warrant appropriate imaging as follows:

●Plain radiographs can identify most radiopaque foreign bodies (eg, glass, metal, rocks) while ultrasound can often locate many nonradiopaque foreign bodies.

●Skull fractures and the potential associated intracranial injury are best evaluated by computed tomography of the head without contrast. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Diagnosis and radiologic evaluation' and "Skull fractures in adults", section on 'Diagnostic imaging'.)

INDICATIONS FOR SUBSPECIALTY CONSULTATION OR REFERRAL — Scalp wounds with significant skin loss that requires grafting or associated with penetration into the cranial vault warrant consultation with an appropriate surgical subspecialist (eg, plastic surgeon, neurosurgeon). Most other scalp lacerations do not require subspecialty consultation or referral.

WOUND REPAIR

Indications for primary closure — Primary closure (ie, wound repair at the time of presentation) is usually the preferred treatment for scalp lacerations into or through the dermis. If these wounds are not closed, they will heal by secondary intention but have increased scarring and risk for wound infection. In general, a scalp laceration with no increased risk factors for infection can be closed regardless of time from injury if appropriate cleansing is performed [2]. (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Delayed primary closure (ie, cleansing and debridement at the time of initial presentation with definitive wound closure performed electively four to five days later) may be warranted for wounds that present after 24 hours and have increased risk for infection. There is no definite time point after which wounds must be closed by delayed primary closure. In general, the decision should be based upon the time from injury, patient factors that increase the risk of infection (ie, vascular insufficiency), and wound factors (contamination or foreign body potential). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Because of the excellent blood flow to the scalp, wound infections are rare, even following repair of contaminated wounds or bite wounds.

Contraindications and precautions — Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. Scalp laceration closure should also not delay further evaluation and definitive care of more urgent traumatic injuries, including underlying intracranial injuries [3].

When closure is delayed, saline-soaked gauze packing (wet-dry closure) can be provided to enhance secondary healing. Appropriate antibiotic coverage (eg, amoxicillin-clavulanate or, in penicillin allergic patients, clindamycin) aimed at the flora of the skin and possibly upper respiratory tract can be initiated in selected patients with wounds other than bite wounds (eg, patient with diabetes mellitus, or other risks for poor wound outcome). (See "Minor wound evaluation and preparation for closure", section on 'Type of closure'.)

Indications and empiric oral antibiotic regiments for patients with animal bites (table 2) and human bites (table 3) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Preparation — Preparation for the care of scalp lacerations includes control of bleeding, provision of anesthesia and analgesia, wound debridement and cleansing, and assembly of appropriate equipment.

●Hemostasis – Bleeding may be profuse and substantial blood loss can occur with scalp lacerations [2,4]. Direct pressure for approximately 15 minutes with or without local injection of lidocaine with epinephrine can often provide sufficient hemostasis. If these methods fail, the edges of the scalp wound can be everted manually or using hemostats or skin hooks and the wound rapidly closed with sutures. In this situation, sutures provide circumferential wound closure and thus, anecdotally, better control of bleeding than noncircumferential wound closure with staples.

●Anesthesia – In children and apprehensive older patients, topical anesthesia with LET (4 percent lidocaine, 0.1 percent epinephrine, 0.5 percent tetracaine) available as an aqueous solution or methylcellulose based gel either alone or prior to infiltration of local anesthesia facilitates repair for small (<4 cm) lacerations, especially when combined with concurrent nonpharmacologic interventions that use biobehavioral and cognitive distraction techniques. The wound should be assessed for analgesia, and if incomplete, infiltration with buffered lidocaine without epinephrine should be performed. (See "Procedural sedation in children: Approach", section on 'Nonpharmacologic interventions' and "Clinical use of topical anesthetics in children", section on 'Lidocaine-epinephrine-tetracaine (LET)'.)

Alternatively, infiltration of buffered lidocaine with epinephrine provides adequate analgesia and vasoconstriction to limit bleeding with an acceptable pain of injection for most patients (table 4). Lidocaine with epinephrine (1:100,000-1:200,000) should be used with caution for large scalp tissue flaps [5-7]. Plain lidocaine (1 or 2 percent), bupivacaine, mepivacaine, or very dilute lidocaine with epinephrine (1:400,000-1:800,000) should be used instead [7]. (See "Subcutaneous infiltration of local anesthetics", section on 'Lidocaine' and "Subcutaneous infiltration of local anesthetics", section on 'Methods to decrease injection pain'.)

●Wound debridement and cleansing – Local or regional anesthesia prior to initiating irrigation and wound cleansing improves patient comfort. In young children and patients with heavily contaminated wounds, procedural sedation may also be necessary so that wound preparation can be tolerated. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications" and "Procedural sedation in children: Approach".)

Hair trimming is often necessary to appreciate the extent of the wound and determine if full thickness skin lacerations are present [8]. Hair shaving should be avoided as it may increase debris in the wound. Hair can also be patted down with petrolatum, water, or povidone-iodine ointment to allow for visualization of the wound. Disposable hair combs can be used to help remove blood clots and other foreign debris.

The volume of wound irrigation for scalp lacerations is based upon wound size and degree of contamination. Moderate sized scalp lacerations (>2.5 to 5.0 cm in length) with minimal contamination may be irrigated with 100 to 150 mL while contaminated wounds and wounds >5.0 cm in length may benefit from irrigation with 200 mL or more. (See "Minor wound evaluation and preparation for closure", section on 'Volume'.)

In general, scalp lacerations can be irrigated with isotonic 0.9 percent normal saline. For clean wounds, running tap water can be an acceptable alternative in regions where the local water supply is sanitary. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation solution'.)

Povidone/iodine surgical scrub (Betadine surgical scrub) should not be used because it contains ionic detergent that may be toxic to wound tissue. The clinician should also avoid hydrogen peroxide solution due to its potential for dermatologic irritation and hair bleaching qualities. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation solution'.)

Wound debridement and irrigation is discussed in more detail separately. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation' and "Minor wound evaluation and preparation for closure", section on 'Debridement'.)

Equipment — The following equipment should be assembled for scalp laceration repair:

●Sterile gloves

●Surgical mask

●Eye protection

●Buffered lidocaine with epinephrine 1 percent or similar local anesthetic

●Small volume syringe (eg, 3 or 6 mL) with small gauge needle (eg, 27 or 30 gauge) for infiltration of local anesthetic

●Suture material (table 5)

●Needle holder

●Hemostat

●Scalpel with handle (#10 or 15 blade)

●Tissue forceps

●Scissors

●Surgical probe

●Sterile 4 x 4 gauze

●Absorbent towels

●Sterile field drapes

●Stapler, dermal adhesive (for hair apposition technique), or sutures

Emergency departments generally are well equipped with minor surgical or suture trays that contain the instruments, sterile gauze, towels, and drapes listed above.

TECHNIQUES

Skin closure — Options for the skin closure of scalp wounds include stapling, modified hair apposition, and sutures.

Surgical staples — We suggest that scalp lacerations through the dermis undergo skin closure with surgical staples rather than sutures (figure 1). However, sutures are an acceptable option if surgical staples are not available in a timely manner and are preferred to promote hemostasis when brisk bleeding is present.

The benefits of staples relative to sutures include the following [9,10]:

●Rapid closure of wound edges

●Noncircumferential wound closure that avoids potential tissue strangulation, although this concern is much less important in the highly vascular scalp

●No cross hatch marks, although these are primarily seen in sutured wounds when suture removal is delayed

Several studies also suggest that staple closure is faster and less expensive for closure of skin wounds with similar cosmetic results and no added wound complications when compared to suturing [11-16]. Of these, the following studies limited their evaluation to scalp wounds:

●A randomized trial of 88 children with scalp lacerations found that closure with staples was six times faster than closure with nylon sutures (65 versus 397 seconds, p<0.0001) and was significantly less expensive when considering the cost of equipment and physician time [12]. No cosmetic or infectious complications were noted in either group at a one week follow-up that was completed by 91 percent of patients.

●A randomized trial of 200 adults with scalp lacerations showed that the mean time to close a scalp wound with staples was significantly less than with sutures (49 versus 380 seconds) with no difference in wound complications [11].

●A trial of 31 children with scalp wounds demonstrated that cosmetic outcomes at 6 to 18 months were similar between wounds closed by staples or sutures as measured by a visual analogue scale [16]. Time for wound closure was significantly shorter with staples when compared to sutures.

Human studies of wound closure have not documented a lower wound infection rate in scalp wounds closed with staples. However, animal studies have shown that skin wounds closed by staples are more resistant to infection than skin wounds closed with monofilament nylon suture [17-19].

Although a quick method, stapling is painful. Thus, we advise that most patients receive local anesthesia prior to skin closure with staples. Adult patients that require just one to two staples may prefer the pain of staples over the needle stick required for anesthesia. (See 'Preparation' above.)

Closure of minor skin wounds with staples is discussed in more detail separately. (See "Closure of minor skin wounds with staples".)

Modified hair apposition — Modified hair apposition (figure 2) is another technique that may be used instead of staples or sutures to close scalp lacerations. This approach is appropriate for wounds that are straight and less than 10 cm. Patients need to have hair that is longer than 1 cm and scalp bleeding must be controlled prior to the procedure [20-22]. We prefer the modified hair apposition technique over hair tying because it can be performed in patients with hair as short as 1 cm. Scalp wound closure with staples may be faster than the modified hair apposition technique with similar wound outcomes, and closure with sutures is preferred when control of bleeding is necessary.

Modified hair apposition is performed in the following manner (figure 2) [20,22]:

●Ensure that the wound is clean and is not actively bleeding.

●Using forceps or hemostats, grasp between 5 and 15 strands of hair directly opposite and on each side of the wound.

●Cross the strands once without knotting until the wound edges are apposed.

●Maintain the strand closure by having an assistant place one drop of glue where the strands cross.

●Avoid getting glue into the wound. If glue is introduced into the wound during hair apposition, wide scarring with a bald spot can occur [22].

Patients should not let the wound get wet for 48 hours after repair and should be informed that the glue will come out with time.

Limited evidence suggests that modified hair apposition may permit faster scalp wound closure with fewer complications than sutures. For example, in a randomized study of 189 patients with scalp lacerations, wound healing after modified hair apposition was similar to sutured wounds with a significantly lower risk for complications (eg, infection, scarring, bleeding, or wound breakdown [7 versus 22 percent]) [20]. Hair apposition was less painful and quicker than wound closure with sutures (median closure time 5 versus 15 minutes). However, the complication rate for sutures in this study was higher than reported in other scalp wound studies, thus limiting the generalizability of these results.

Modified hair apposition is obviously not a suitable technique for bald patients or those with short hair (<1 cm). Profusely bleeding scalp wounds and those with gross contamination may require close clipping of hair to achieve hemostasis, proper wound cleansing, and debridement and also preclude the use of the hair apposition technique. In addition, the modified hair apposition technique requires an assistant to apply glue to the hair strands.

Although modified hair apposition appears to have advantages when compared to suture placement in patients with the appropriate wound and hair characteristics, the benefits when compared to closure of scalp wounds with staples is less well studied. Modified hair apposition takes approximately 5 to 10 minutes [20] to perform while staple closure typically takes approximately 1 minute [11,12]. However, modified hair apposition avoids the need for staple removal which requires a special instrument and can be painful. Both methods provide good cosmetic results with few complications. (See "Closure of minor skin wounds with staples", section on 'Aftercare'.)

Simple interrupted sutures — If staples are not rapidly available, when brisk bleeding requires hemostasis by wound closure, or if the wound type or hair length make hair apposition difficult or impossible to perform, scalp lacerations may be closed with 3-0-or 4-0 nonabsorbable or absorbable (eg, coated polyglactin 910 [Vicryl Rapide]) simple, interrupted sutures [23]. When compared to nonabsorbable sutures, closure with Vicryl Rapide has added convenience, in that the patients do not need to return for suture removal. (See "Skin laceration repair with sutures", section on 'Percutaneous closure'.)

Mattress sutures — These suture techniques are beneficial to approximate the thin, fragile skin of the older patient, and, especially in bald patients, for scalp lacerations subject to tissue loss or debridement. Horizontal and vertical mattress sutures reduce tension and provide optimal eversion of the wound edges by incorporating large amounts of tissue and improve cosmesis:

●Although not commonly performed for most simple lacerations, horizontal mattress sutures permit tension to be dispersed along the length of the laceration during initial placement (figure 3). (See "Skin laceration repair with sutures", section on 'Wounds under tension'.)

●Vertical mattress sutures also utilize larger amounts of tissue to promote wound closure and eversion of the edges. The suture is a combination of deep and superficial suture placement, and is threaded in a far-far, near-near manner (figure 4) . (See "Skin laceration repair with sutures", section on 'Wounds under tension'.)

Galeal lacerations — Galeal lacerations larger than approximately 0.5 cm can be approximated with 3.0 or 4.0 absorbable simple interrupted sutures (eg, Polyglactin 910 [Vicryl] and Poliglecaprone 25 [Monocryl]) regardless of the method of skin closure. Repair of a galeal laceration prevents subgaleal infections, spread of potential infections to the remainder of the scalp and underlying connective tissue, subgaleal hematoma, increased scarring, and other poor cosmetic outcomes [2]. The galea is a key anchoring structure of the frontalis muscle. If the frontalis loses its anchoring point, contraction of that muscle can become asymmetric and noticeable. (See "Skin laceration repair with sutures", section on 'Suture selection'.)

Deep scalp lacerations may also benefit from the placement of a pressure dressing for the first 24 hours to prevent hematoma formation (figure 5).

OTHER CONSIDERATIONS

Tetanus prophylaxis — Tetanus prophylaxis should be provided for all scalp wounds as indicated (table 6). Pregnant women should receive immunization with tetanus and diphtheria toxoids. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

Prophylactic antibiotics — Most scalp wounds do not warrant empiric antibiotic treatment. Prophylactic antibiotics may decrease the risk of wound infection in patients with animal or human bites or those with excessive wound contamination, vascular insufficiency (eg, peripheral artery disease), or immunodeficiency.

Recommendations for the use of prophylactic antibiotics after the closure of skin wounds other than bite wounds are discussed in more detail separately. (See "Skin laceration repair with sutures", section on 'Prophylactic antibiotics'.)

Indications and empiric oral antibiotic regiments for patients with animal bites (table 2) and human bites (table 3) are discussed separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management", section on 'Management' and "Human bites: Evaluation and management", section on 'Antibiotic prophylaxis'.)

Bite wounds — Bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in the skin all can transmit rabies. Early wound cleansing is an important prophylactic measure, in addition to timely administration of rabies immune globulin and vaccine (table 7). Indications for rabies prophylaxis are discussed separately. (See "Indications for post-exposure rabies prophylaxis" and "Rabies immune globulin and vaccine".)

Any unvaccinated patient or individual negative for anti-HBs antibodies who is bitten by an individual positive for HBsAg should receive both hepatitis B immune globulin (HBIG) and hepatitis B vaccine (table 8). In addition, although the risk for transmitting HIV through saliva is extremely low, infection is of concern if there is blood in the saliva. Counseling regarding post-exposure HIV prophylaxis is appropriate in this setting. (See "Epidemiology, transmission, and prevention of hepatitis B virus infection", section on 'Post-exposure prophylaxis' and "HIV infection: Risk factors and prevention strategies", section on 'Bloodborne transmission risk factors'.)

AFTERCARE — Scalp wounds should be left open to air unless they require a pressure dressing (figure 5) to prevent hematoma formation. After 24 to 48 hours, wounds closed with staples or nonabsorbable sutures can be left open to air and cleansed gently with soap and water. (See "Skin laceration repair with sutures", section on 'Topical antibiotics and wound dressing' and "Closure of minor skin wounds with staples", section on 'Aftercare'.)

Staples or nonabsorbable sutures should be removed after 7 to 10 days. Small, superficial wounds with few staples or sutures are good candidates for staple or suture removal at 7 days. Larger or deeper wounds warrant removal of staples or sutures at 10 to 14 days.

Most clean scalp wounds do not need to be seen by a physician until suture removal, unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 48 to 72 hours. It is imperative that all patients or caregivers receive discharge instructions regarding the signs of wound infection.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Human bites" and "Society guideline links: Minor wound management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education topics are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest in the UpToDate search box.)

●Basics topic (see "Patient education: Stitches and staples (The Basics)").

SUMMARY AND RECOMMENDATIONS

●Evaluation – Patients with scalp lacerations require careful evaluation to determine the presence of life-threatening injuries; historical features that increase the risk of serious injury and complications after wound repair; and wound characteristics including extent, degree of contamination, presence of foreign bodies, and visible or palpable bony defects. (See 'Evaluation' above.)

●Wound preparation

•Bleeding may be profuse and substantial blood loss can occur with scalp lacerations. Direct pressure for approximately 15 minutes with or without local injection of lidocaine with epinephrine can often provide sufficient hemostasis. If these methods fail, the edges of the scalp wound can be everted manually or using hemostats or skin hooks and the wound rapidly closed with simple, interrupted sutures. In this situation, sutures provide circumferential wound closure and thus better control of bleeding than noncircumferential wound closure with staples. (See 'Preparation' above.)

•Local anesthesia typically provides adequate analgesia for the management of simple scalp lacerations in children and adults.

•Wound irrigation should be performed with normal saline or tap water (if the local water supply is sanitary) for most clean wounds. Hair trimming is often necessary to appreciate the extent and depth of scalp wounds. Hair shaving should be avoided as it may increase debris in the wound. Hair can also be patted down with petrolatum, water, or povidone-iodine ointment to allow for visualization of the wound.

●Primary closure – Scalp lacerations that extend through the dermis should undergo primary closure. Wounds with obvious signs of inflammation (redness, warmth, swelling, pus drainage) should not be closed primarily. (See 'Indications for primary closure' above and 'Contraindications and precautions' above.)

•We suggest that scalp lacerations through the dermis undergo skin closure with surgical staples rather than sutures (figure 1) (Grade 2B). Although outcomes from either method are similar, staples are much more quickly placed. (See 'Surgical staples' above.)

•Sutures are an acceptable option if staples are not rapidly available or when brisk bleeding requires hemostasis by wound closure. (See 'Simple interrupted sutures' above.)

•Modified hair apposition (figure 2) is another technique that may be used instead of staples or sutures to close scalp lacerations. This approach is appropriate for wounds that are straight and less than 10 cm. Patients need to have hair that is longer than 1 cm and scalp bleeding must be controlled prior to the procedure. (See 'Modified hair apposition' above.)

•Galeal lacerations larger than approximately 0.5 cm should be approximated with 3.0 or 4.0 absorbable simple interrupted sutures (eg, Polyglactin 910 [Vicryl] and Poliglecaprone 25 [Monocryl]) prior to skin closure, regardless of the method used. (See 'Galeal lacerations' above.)

●Tetanus and antibiotic prophylaxis – Patients should receive tetanus prophylaxis, as needed (table 6). Most scalp wounds do not warrant empiric antibiotic treatment. (See 'Other considerations' above.)

●Aftercare – Scalp wounds should be left open to air unless they require a pressure dressing (figure 5) to prevent hematoma formation. After 24 to 48 hours, wounds closed with staples or nonabsorbable sutures can be left open to air and cleansed gently with soap and water. Staples or nonabsorbable sutures should be removed after 7 to 14 days. (See 'Aftercare' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Martin Camacho, MSN, CRNP, ACNP-BC, ENP-BC, who contributed to an earlier version of this topic review.