How Do I Know if a Cut Needs Stitches?

Posted on June 15, 2020August 18, 2020

Posted by Dr. Monica Wonnacott | June 15, 2020

One of the most common questions I get is, “Does this need stitches?” Here are a few tips that might help. (Note: When I say “stitches,” that simply means the wound needs closure by a doctor — see types of closures below).

Wounds that need stitches are:

Gaping open. If a wound is in a high tension area (think body areas that bend, pull, or move a lot) it is not likely to heal up on its own very well. Also, if the wound is quite deep, the edges will pull apart and need to be stitched closed.
Deep. Wounds that involve just the top layer of skin don’t usually need stitches. If the cut is deep enough to be where the tissue changes color (the dermis) or you can see fat layers, muscle, or bone, you certainly will need stitches. Deep enough to need stitches is roughly 1/8 – 1/4 inch (2-4 mm) deep.
Most wounds that are more than a ½ inch long, (1/4 inch for faces) will need to be stitched (unless it’s just a long stratch).
Bleeding a lot. Typically, superficial wounds don’t bleed that much. It’s the deeper, more involved wounds that do. If you can’t get the cut to stop bleeding after a few minutes, you probably need medical care.
Cosmetically tricky areas. Usually a wound that is professionally cleaned out and perfectly closed will heal with less scarring than a wound that is allowed to heal up on its own. So if scarring is a huge concern (say on a face), you may want to have a doctor address it.

Wounds that don’t need stitches:

If the wound is a little deeper than a scratch, there’s no need for stitches.
Puncture wounds. These injuries happen from accidents like stepping on a nail or a dog bite (with the canines). These wounds are really deep, but very small at the surface. The risk with these injuries is infections. Often these wounds will require medical care (e.g., a tetanus shot or antibiotics), but not stitches.
Wide abrasions or scrapes. If the skin has been scraped off or injured so badly that there are no edges to sew together, you won’t need stitches. The biggest problem with these sorts of wounds is getting them properly cleaned out and preventing infection. Usually these sorts of wounds happen from bike crashes or bad trip and fall moments. These types of wounds might get lots of dirt, rocks, and road (road rash) in them, but there’s nothing to stitch.

Kinds of closures:

Sutures. These are traditional stitches. Now there are lots of different materials designed for different circumstances (e.g., fine, thin stitches for faces and big, thick hardy stitches for knees).
1. Absorbable (dissolvable): These are used when cuts are so deep that they need a layer on the inside. The body breaks them down and they don’t have to be removed.
2. Non-absorbable (not dissolvable): These are used on the outside/top layer of the skin. They have to be cut and taken out.
Staples. This method of closure uses a staple gun (not unlike a stapler you’d have in your office). The materials are a bit different though (designed for skin). It is quick and easy for a doctor to use. Ideal for use where scarring isn’t such a big deal and won’t be seen (e.g., will be used on a child’s head, covered by the hair). It requires a special device/remover to get them out (it bends the staple in half and the edges pull up and out).
Glue. Imagine sterile super glue designed for skin and you’ve got the right idea. Glue can be wonderful (since you don’t have to numb the area first to fix it), but it has a lot of limitations. It can only be used in areas where there isn’t tension (otherwise it pulls apart easily) and the wound is a clean line. It also won’t work for big, deep cuts (it simply isn’t strong enough).
Steri-strips. These can be used independently (in relatively small, shallow wounds) or as an added layer of strength to help hold another type of closure together. Steri strips are kind of like an extra strong, sterile piece of tape.

How long can I wait to get stitches?

The general rule of thumb is 6 hours (especially if it was a dirty wound). The worry about waiting a long time is risk of infection. Additionally, the wound starts healing in a different way when open for a long time. When a big, deep cut doesn’t get sewn up, it will eventually heal from the inside up (called secondary intention). This sort of healing has more risk of infection and scarring. Some wounds (especially if well cleaned), will still qualify for stitches up to 24 hours after the injury. The rule of thumb is close wounds as soon as possible. If circumstances prevented an immediate closure, see your doctor to see what your options are.

What if it the wound reopens?

This gets tricky. Depending on the location and what it looks like, sometimes they qualify for re-closure. If the cut is on the face, it is more likely to get re-glued or re-stitched. If it’s on the body, it depends on how long (48 hours is often the cut off) and how involved the wound is. Either way, it is a good idea to talk to your doctor in this circumstance.

The Best Way To Treat Scars

Posted on February 27, 2017August 18, 2020

Posted by Dr. Monica Wonnacott | February 27, 2017

I had a beautiful kiddo come into my office this week after falling and splitting her forehead open. Naturally, the parents had concerns about scarring. Even though the repair went perfectly, she is going to have some amount of scarring. The question remains, what can the parents do to reduce the scar?

Types of scars

Keloids: Have scar tissue that extends beyond the original injury. More common in people with dark skin. Do not get better with time.
Hypertrophic or pathogenic scars: Grow really fast the first 6 months (but never go beyond the original boundary of the injury) and can gradually regress over 1-3 years. More common in areas with lots of tension on the skin (chest, knees, shoulder, etc.)
Atrophic Scars: Collagen is lost in the skin (think divots and “ice-pick” scars like from acne)

Prevention

I wouldn’t be a good doctor if I didn’t at least mention prevention of scars in my discussion. One of the major reasons kids develop big scars (especially after seemingly small wounds) is development of infection. So when your child gets a cut/scrape, make sure you thoroughly clean it right away. The time to properly clean a wound is right after it has happened (i.e., when it’s still bleeding). After you clean the wound and get it to stop bleeding (by applying pressure), put some antibacterial ointment on it (to keep the wound moist) and cover it.

Treatments (what works and what doesn’t)

The science basics to scar prevention and treatment centers around keeping the area covered and moisturized. This basic tenant helps you see why some treatments work better than others.

Silicone Sheeting (or gels). Studies show it works. It improves color, elevation (how raised the scar is) and hardness of pathogenic scars. There may be some place for prevention of scarring as well. They are supposed to be used for 12 + hours a day.
Pressure bandages. This type of therapy aims at prevention. The problem is that the pressure dressings (think gauze and wraps) need to be on for 23 hours a day for at least 6 months while the scar is still forming in order to work. As for me, that sort of commitment is far too involved.
Massage therapy. This type of therapy works by increasing collagen maturation. Ideally, it is done 10-15 minutes a night (starting a few weeks after the wound is healing). It reduces scar thickness, pain, and itching.
Perpendicular taping. Works especially well for post op wounds in areas of high tension. In this method, paper tape is applied in the opposite direction of the wound to relieve the tension on the wound. This decreases the risk of scarring. Amazingly, this method still works even when started up to 3 months after the initial wound.
Onion extract (a popular ingredient in many OTC scar treatments, known for its anti-inflammatory properties). Unfortunately, science doesn’t support that this works at that well.
Vitamin E (also a popular ingredient in many OTC scar treatments. It is an antioxidant with anti-inflammatory properties). Sorry mom (this was her method), science also doesn’t support that this works. There have been a few studies showing minimal effect, but many that don’t support it at all. Unfortunately, skin irritation is a common side effect of Vitamin E.
Topical corticosteroids. Not commonly used and scientifically shown to have little effect. One study showed that a high potency steroid used with tretinoin was effective (only by prescription).
Corticosteriod shots. Unlike the topical treatment, shooting the medicine into the scar (especially keloids) is highly effective. Typically treatment is 3-4 injections every 4 weeks. The major limitation is that it hurts and is only done in a doctor’s office.
Autologous Fat Transfer (AFT). Essentially taking fat from one part of your body to fill in an atrophic scar (the divot type scar). Clearly this is an involved treatment option, but has a lot of scientific promise.
Surgical Revision. In extreme scarring (or those where other methods haven’t helped), sometimes a revision is helpful. Essentially, you’re trading one big, ugly scar, for a smaller, controlled surgical scar.
Laser therapy. This is the Cadillac of scar treatment. In general, it is highly effective, but expensive and painful.

Wow that’s a lot, break it down!

In short, do the cheap, easy stuff first. Prevent infection in new wounds. Keep the wound clean, moist, and covered. If it’s in a high tension area, consider perpendicular (90 degree) paper taping. Once it’s healing consider massage and silicone sheeting. If it’s still ugly later (and you have money), consider fancier interventions like lasers. Hope this helps.

Cutting: The Secret Epidemic

Posted on November 5, 2016August 18, 2020

Posted by Dr. Monica Wonnacott | November 5, 2016

Back in February, I wrote an article about cutting for ModernMom.com. At the time, it was something I was just starting to see in my office. Since then, I’ve started to see multiple teens every day who are cutting. The behavior is exploding. It’s a true epidemic. It seems that teens hear about it and then decide to try it out. Don’t assume your teen is immune (I’ve seen straight A, “good kids” doing it as well as teens who are struggling). It affects everybody, so become educated. Much of the information below is from my article in ModernMom, but because the behavior seems to affect so many teens these days, I’m recovering the topic here as well, with a few updates, etc.

What is cutting?

If you’re not familiar with it, “cutting” is exactly what it sounds like. It is a form of self-harm (SH) or self-injury (SI). It is the act of actually cutting the skin with some object (usually razor blades, knives, pins). It is most commonly done on the arms or thighs, but can be other places, like the belly. The cuts are usually very linear, small, and superficial (deep enough to bleed, but rarely needing sutures). To be clear, it is not a suicide attempt. Kids who cut are not trying to kill themselves.

Why teens cut?

This is the million dollar question. Generally, psychiatrists teach that cutting is done to blunt emotional pain. It can also be highly addictive, as the act of cutting can release endorphins to create a feel-good feeling. People who cut often have other underlying psychiatric disorders (e.g., depression, bipolar, anxiety, eating disorders), but not always. I saw a “straight A” student this week who heard about it on social media and decided to try it. The reasons kids cut are complex. I always ask “Why do you cut?” when I see a kid in clinic who is cutting, and I usually get an answer akin to: “So I can feel something.” That phrase tells me that there is more involved than just blunting emotional pain. There seems to be a component of control playing into the pain (both when and how).

Everyone’s doing it?

Ask any teen or preteen if they know someone who cuts and the answer seems to be, “yes.” In my patients, 100% of the kids who cut have friends or know people who cut. One of my patients claims he only started doing it because his friends did. Is that a peer pressure thing or a curiosity thing? While social dynamics are involved, most kids cut when they are by themselves. Because it is an act that kids are often doing by themselves, they hear about it or discuss it on social media.

How did I not know?

All of my patient’s parents were horrified when they found out that their kids cut. Most kids had been doing it for months before parents found out. Kids lie about it, and hide it. “The cat scratched me,” is a common, believable excuse. It’s easy to wear long sleeves and pants to cover it up. Pay attention if your kid is wearing long sleeves in 100 degree weather. Many of my savvy patients cut on their upper thighs so parents won’t see the lines. I’m not suggesting that you make your kids stand in their underwear while you inspect their bodies (your kid won’t appreciate the violation of privacy), but be aware. Know what you’re looking for (multiple fine linear marks/scars often in various stages of healing and usually more numerous on the opposite side than your child’s handedness). And here’s yet another reason to be aware of your kid’s media: many of my parents discovered kids’ actions via media means (e.g., Facebook postings, texts).

What do I do?

Your kid needs help, long-term help. Involve your doctor. Are there underlying psychiatric issues or bigger problems that need to be addressed? I had one patient who was brought in for cutting and discovered the patient was being sexually abused. That case required I call DCFS (the Department of Child and Family Services) and law enforcement. Your child may need psychotherapy. Goals of therapy include improving self-esteem, gaining self-respect, and learning healthy coping mechanisms. Your child will definitely need lots of support and love. Don’t think that cutting is just a phase. Kids that cut (who have underlying issues) and don’t get help, turn into adults who have issues. With some help, intervention, and especially love, kids can gain the tools they need to overcome this, and future problems thrown their way.