What is the definition and management of a stage 3 (full-thickness skin loss) ulcer?

Definition and Management of Stage 3 Ulcers

A stage 3 ulcer is defined as a full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, presenting as a deep crater with or without undermining of adjacent tissue. 1

Characteristics of Stage 3 Ulcers

• Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but not extending to muscle, tendon, or bone 1
• These ulcers typically present as deep craters that may contain slough (yellow, tan, gray, green, or brown tissue) in the wound bed 1
• Slough is commonly found in Stage 3 pressure injuries and presents as a layer of dead tissue in the wound bed 1
• Stage 3 ulcers may have undermining or tunneling into surrounding tissues 2
• In diabetic foot ulcers, a Stage 3 equivalent (Wound Grade 3 in the WIfI system) is described as an "extensive, deep ulcer involving forefoot and/or midfoot; deep, full thickness heel ulcer with calcaneal involvement" 3

Assessment of Stage 3 Ulcers

• Documentation should include size, location, presence of slough and granulation tissue, exudate amount and characteristics, odor, presence of sinus tracts, undermining, and signs of infection 2
• Evaluate vascular status, especially in lower extremity ulcers, considering ankle pressure or ABI measurements 4
• Assess for signs of infection such as increasing pain, erythema, warmth, or purulent drainage 4
• Inspect the ulcer thoroughly to determine the extent of tissue damage and necrosis 4

Management Approach

Debridement

• Sharp debridement is the preferred method for removing slough and necrotic tissue from Stage 3 ulcers 1, 4
• Urgent sharp debridement should be performed if advancing cellulitis or sepsis occurs 2
• Alternative debridement methods include:
  • Autolytic (using hydrogels) for cases where sharp debridement is contraindicated 1
  • Biological (larval therapy) 1
  • Enzymatic (collagenase) 1
• Repeat debridement as needed until all necrotic tissue is removed 4

Wound Cleansing and Dressing

• Cleanse wounds preferably with normal saline 2
• Select appropriate dressings based on wound characteristics:
  • Alginates or foams for moderately exudative wounds 4
  • Continuously moistened saline gauze or hydrogels for dry wounds 4
  • Avoid silver or antimicrobial agent-containing dressings unless specifically indicated 4
• Dressings should be selected based on exudate control, comfort, and cost after slough removal 1

Infection Management

• Bacterial load can be managed with proper cleansing 2
• Consider topical antibiotics if there is no improvement in healing after 14 days 2
• Use systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection 2
• If infection is present, empiric antibiotic therapy should target S. aureus and streptococci for superficial infections 4

Pressure Offloading

• Ensure complete offloading of pressure from the affected area 4
• Follow a patient repositioning schedule 2
• Keep the head of the bed at the lowest safe elevation to prevent shear 2
• Use pressure-reducing surfaces 2
• For heel ulcers, consider shoe modifications, temporary footwear, or orthoses 4

Nutrition

• Assess nutrition status and provide supplementation if needed 2
• Optimize glycemic control in diabetic patients 3

Advanced Therapies for Non-Healing Stage 3 Ulcers

• Consider vascular assessment and possible revascularization if healing is delayed 4
• Evaluate for systemic hyperbaric oxygen treatment for poorly healing wounds 4
• For recalcitrant ulcers, dermal substitutes including skin from cadaver donors may increase healing rates 5
• Complex wound reconstruction may be required for extensive Stage 3 ulcers, particularly in the sacrococcygeal region 6

Clinical Pitfalls to Avoid

• Mistaking slough for biofilm can lead to inappropriate treatment strategies 1
• Failing to remove slough can result in increased risk of infection and delayed wound healing 1
• Aggressive debridement in patients with severe ischemia requires careful consideration of risks versus benefits 1
• Neglecting to assess for and treat underlying causes (e.g., pressure, poor circulation) will result in poor healing outcomes 2
• Underestimating the importance of nutrition in wound healing 2