Standard postoperative wound care practice may be all wet

By Warren R. Heymann, MD, FAAD
July 9, 2025
Vol. 7, No. 27

Dermatologists perform procedures throughout the day, including straightforward skin biopsies, electrodesiccation, curettage, cryosurgery, laser treatments, etc. Postoperatively, many of these wounds are dressed, and patients are given instructions for caring for them.

The following, entitled “After the Skin Biopsy,” is from the Mayo Clinic website discussing skin biopsies. (1) You probably have a handout with similar information.

Your health care provider may instruct you to keep the bandage over the biopsy site until the next day. Sometimes the biopsy site bleeds after you leave the clinic. This is more likely in people taking blood-thinning medicine. If this occurs, apply direct pressure to the wound for 20 minutes, then look at it. If bleeding continues, apply pressure for another 20 minutes. If bleeding still continues after that, contact your health care provider.

All biopsies leave scars. They tend to fade with time. The scar's permanent color will be set 1 to 2 years after the biopsy.

Some people develop a thick, raised scar. This type of scar, also called a keloid scar, is more common in people with brown or Black skin. The risk of a keloid scar is also higher when a biopsy is done on the neck, back or chest.

Avoid bumping the area or doing activities that stretch the skin. Stretching the skin could lead to bleeding or a bigger scar. Don’t soak in a bathtub, swimming pool or hot tub until your health care provider says it's OK — usually about seven days after the procedure.

Healing can take several weeks. Wounds on the legs and feet tend to heal slower than those on other areas of the body.

Clean the biopsy site two times a day unless it's on your scalp. Scalp wounds can be cleaned once a day. Follow these steps:

• Wash your hands with soap and water before touching the biopsy site.

• Wash the biopsy site with soap and water. If the biopsy site is on your scalp, use shampoo.

• Rinse well and pat dry with a clean towel.

• Apply a thin layer of petroleum jelly. Use a new container of petroleum jelly the first time you do wound care. Use a new cotton swab each time you apply the product.

• Cover the site with a bandage (Band-Aid, Curad, others) for 2 to 3 days after the procedure.

If you have stitches, continue wound care until they're removed. If you don't have stitches, take these wound care steps until the skin is healed.

If your wound is sore, ask your health care provider if you can apply ice wrapped in a thin towel.

Why do we do what we do? I have been instructing patients to keep the dressing on until the next day and recommending Vaseline for 30 years. It was not always this way — the seminal work by Smack et al. changed the postoperative wound care paradigm. (2) In the late 1980s and early 1990s, standard practice was to use topical antibiotics such as neomycin or bacitracin after clean cutaneous surgery to prevent infection. Both could cause allergic contact dermatitis (3,4), contact urticaria, and rarely anaphylaxis. (5) Smack et al. performed a randomized, double-blind, prospective trial comparing white petrolatum (440 patients) with bacitracin ointment in post procedure wound care (444 patients). The incidence of infection and allergic contact dermatitis were measured during a follow-up period of 4 weeks. Healing characteristics were secondary outcomes. The two treatment groups had comparable baseline characteristics. Thirteen patients developed a post procedure infection (1.5%), 9 (2.0%) in the white petrolatum group vs 4 (0.9%) in the bacitracin group (95% confidence interval for difference, -0.4% to 2.7%; P=.37). Eight infections (1.8%) in the white petrolatum group were due to Staphylococcus aureus vs none in the bacitracin group (P=.004). No patient in the group using white petrolatum developed allergic contact dermatitis vs 4 patients (0.9%) in the group using bacitracin (P=.12). Additionally, there were no clinically significant differences in healing between the treatment groups on day 1 (P=.98), day 7 (P=.86), or day 28 (P=.28) after the procedure. The authors concluded, “White petrolatum is a safe, effective wound care ointment for ambulatory surgery. In comparison with bacitracin, white petrolatum possesses an equally low infection rate and minimal risk for induction of allergy.” (6)

Despite my assurances to patients that topical antibiotics are not needed postoperatively for clean procedures, patient attitudes may be mired in habit and disbelief. I can recite the benefits of Vaseline ad infinitum and select patients will apply Neosporin no matter what.

How many of us advise patients as they do at the Mayo Clinic — Your health care provider may instruct you to keep the bandage over the biopsy site until the next day. The phrase “leave the dressing on until tomorrow” rolls off my tongue, bypassing my cerebral cortex. I never thought about the science behind this caveat. As stated by Samaan et al., “Patients are often advised to keep the initial postoperative dressings dry and undisturbed for 24 to 72 hours. However, these requirements may result in significant disruption of patients' activities of daily living, such as bathing, leisure, and exercise.” The authors sought to compare standard management of keeping wounds dry and covered (48 hours) with early (6 hours) postoperative water exposure by performing an Investigator-blinded, randomized (1:1), controlled trial evaluating the rate of infection and additional outcomes of interest. A total of 437 patients were randomized to either the early (6-hour) water exposure (n = 218) intervention group or the standard cohort (n = 219). The incidence of culture-proven infection in the intervention group (1.8%) was similar to the standard group (1.4%) (P > .99). There was also no difference in rates of bleeding or bruising. Scar assessment using the Patient and Observer Scar Assessment Scale revealed similar scar outcomes. The authors concluded, “Surgical wounds can be allowed to get wet in the immediate postoperative period with no increased incidence of infection or other complications and with similar cosmesis.” (6) It may seem trivial, but allowing patients to resume their daily hygiene practices within hours will make many patients happy.

I revere articles that examine mundane workday situations, challenge the status quo, and set a new standard. More studies are needed to determine when wounds can be exposed to water without any detrimental effects. I applaud the teams of Smack et al. and Samaan et al. for setting the record straight on postoperative wound care.

Point to Remember: Water exposure in the immediate postoperative period does not increase the risk of infection and allows the patient to continue their water-related hygiene routines.

Our experts’ viewpoints

William D. James, MD, FAAD
Emeritus Professor CE of Dermatology

Being a regular reader of Dr Heymann’s Insights and Inquiries, I was pleased to be asked to write a commentary on this article. I agree that I love articles that challenge the status quo, especially when addressing common everyday situations that negatively impact our patients.

Not getting an incision wet for days or longer impacts the daily routine of many patients. I recently had a neighbor who was told to not get a wound wet until it was completely healed and was planning to cancel a Caribbean vacation as it was within the specified two-week time frame. Samaan et al’s study is a simple but impactful patient-centered work. It reminds me of how atopic patients are told to limit showers to a few minutes or to only bathe infrequently, even though they are also told to moisturize afterwards. I don’t know of any study addressing showering time, and the expert panel who wrote the atopic dermatitis guidelines for our Academy apparently did not either stating “there is no standard for the frequency or duration of bathing appropriate for those with AD.” (7)

In the mid-1990s the use of topical bacitracin after clean cutaneous surgery was the “standard operating procedure.” At the time, the North American Dermatitis Group listed topical neomycin and bacitracin to be the number 5 and 7 most common allergens in the country. (8) I had also witnessed two patients who developed contact anaphylaxis to bacitracin applied topically. (9) Residents and faculty at Walter Reed decided to test if the routine antibiotic use in clean cutaneous surgery, whose infection rate generally ran between one and two percent, was necessary. We showed it was not needed. (2) Since then, these results have been verified in many studies and two systematic reviews and meta-analyses. (10, 11) I am happy that the latter reference included surgical incisions that included spinal, orthopedic, and cardiothoracic operations in addition to dermatologic procedures.

I had thought that a change in practice would soon follow since our JAMA article showed antibiotic prophylaxis was not necessary to prevent infection, that cosmesis was similar, and it would save money. I was advised by a senior mentor that in this situation it would take about 10 years to see significant changes to common practice. As I continued to see topical antibiotics used, I kept writing to call attention to new studies verifying our results and surveys still showing their common use. (3, 4) Our American Academy of Dermatology highlighted to not routinely use topical antibiotics on surgical wounds in their initial Choosing Wisely list in 2013. (12) Over the years practice did change! Now neomycin and bacitracin are number 11 and 15 on the North American Group’s top allergen list. (13)

What’s new? Lauck et al call attention to the fact that 75% of Mohs surgeons routinely use perioperative empiric antibiotic therapy (PEAT). (14) This despite the data from the TriNetX Analytics network platform showing in an analysis of 321,863 patients that the wound infection rate for Mohs surgery without PEAT was 0.12% and with it 0.11%. and that one in 321 Mohs patients will experience an adverse event from their use. (15, 16) It also costs more. While more studies are needed to better define if there are locations or situations where PEAT may be needed, it seems that the current situation mimics that seen in the mid-1990s regarding antibiotic use to lower infection rates that hover below one percent. Stay tuned!

Naomi Lawrence, MD, FAAD
Director, Micrographic Surgery and Cutaneous Oncology
Center for Dermatologic Surgery
Cooper Hospital/Rowan University

Tara Jennings, MD, FAAD
Dermatologic Surgeon
Cooper Hospital/Rowan University

This is a high-quality prospective trial in which the authors investigate a common postoperative instruction, that is to keep the wound dry in the immediate postoperative period. Knowing that most recent evidence supports moist wound environment (17), it makes sense that getting a wound wet should not affect healing. What we didn’t know before this study is whether it would increase risk of infection or bleeding. The strengths of the study include true randomization, blinded investigator assessment, use of validated outcome instruments (POSAS and Skindex-16), assessment of adherence, and low attrition rate. It is reassuring that the infection rate was not increased. The rate of hematoma was also quite low with hematoma being associated with antiplatelet medications and chronic obstructive pulmonary disease in the multivariate analysis. More complicated reconstruction and 2nd intention wounds were excluded as they would certainly have a higher risk of bleeding.

I really like that this study advances the science of everyday practice and improves the patient experience. We usually let patients wash the morning after surgery (typically about 12 hours later), so I’m not sure it will change my practice significantly as I do think that even patients not on anticoagulants / antiplatelet drugs need a few hours to clot. In addition, we often use tissue adhesive as our top layer, which theoretically needs to stay dry longer.

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References

1. https://www.mayoclinic.org/tests-procedures/skin-biopsy/about/pac-20384634

2. Smack DP, Harrington AC, Dunn C, Howard RS, Szkutnik AJ, Krivda SJ, Caldwell JB, James WD. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial. JAMA. 1996 Sep 25;276(12):972-7. PMID: 8805732.

3. James WD. Use of antibiotic-containing ointment versus plain petrolatum during and after clean cutaneous surgery. J Am Acad Dermatol. 2006 Nov;55(5):915-6. doi: 10.1016/j.jaad.2006.02.060. PMID: 17052511.

4. Jacob SE, James WD. Bacitracin after clean surgical procedures may be risky. J Am Acad Dermatol. 2004 Dec;51(6):1036. doi: 10.1016/j.jaad.2004.05.022. PMID: 15583617.

5. Goh CL. Anaphylaxis from topical neomycin and bacitracin. Australas J Dermatol. 1986 Dec;27(3):125-6. doi: 10.1111/j.1440-0960.1986.tb00307.x. PMID: 3632508.

6. Samaan C, Kim Y, Zhou S, Kirby JS, Cartee TV. Early postoperative water exposure does not increase complications in cutaneous surgeries: A randomized, investigator-blinded, controlled trial. J Am Acad Dermatol. 2024 Nov;91(5):896-903. doi: 10.1016/j.jaad.2024.05.098. Epub 2024 Jul 14. PMID: 39004350.

7. Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS,et al: Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71:116-32.

8. Marks JG, Belsito DV, DeLeo VA, Fowler JF, Fansway AF, et al: North American Contact Dermatitis Group patch test results for the detection of delayed-type hypersensitivity to topical agents. J Am Acad Dermatol 1998; 38:911-918.

9. Farley M, Pak H, Carregal V, Engler R, James WD: Bacitracin anaphylaxis. Am J Contact Dermatitis 1995; 6: 28-32.

10. Saco M, Howe N, Nathoo R, Cherpelis B: Topical antibiotic prophylaxis for prevention of surgical wound infections from dermatologic procedures: a systematic review and meta-analysis. K Der,atp;pg Treat 2015; 26: 151-158.

11. Lin W-L, Wu L-M, Nguyen T-H-Y, Lin Y-H, Chen C-J. et a;: Topical antibiotic prophylaxis for preventing surgical site infections of clean wounds: a systematic review and meta-analysis. Surg Infect (Larchmt) 2023; 25: 32-38.

12. Coldiron BM, Fischoff RM: American Academy of Dermatology Choosing Wisely list: Helping dermatologists and their patients make smart decisions about their care of patients. J Am Acad Dermatol 2013; 69: 1002.

13. DeKoven JG, Warshaw EM, Reeder MJ, Atwater AR, Silverberg JI, et al: Noarth American Contact Dermatitis Group Patch Test Results: 2019-2020. Dermatitis 2023; 34: 90-104.

14. Aizman L., Barbieri JS, Lukowiak TM, et al: Attitudes on prophylactic antibiotic use in dermatologic surgery: a survey study of American College of Mohs surgery Members. Dermatol Surg. 2021; 47:339-342

15. Lauck, KC, Malick H, Tolkachjov SN: Trends and efficacy of empiric antibiotic administration in Mohs micrographic surgery: a global, propensity matched, retrospective cohort study. J Am Acad Dermatol. 2023; 89:1302-1305.

16. Lauck KC, Cho SW, Rickstrew J, Tolkachjov SN: Adverse events after empiric antibiotic administration in dermatologic surgery: A global, propensity-matched, retrospective cohort study. J Amer Acad Dermato 2024;,90: 1065-1067.

17. Eaglstein, William. Moist Wound Healing with Occlusive Dressings: A Clinical Focus. Dermatol Surg 2001; 27: 175-181.

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