What is the recommended treatment for a large stable eschar (dead tissue) on the leg?

Management of Large Stable Eschar on the Leg

For a large stable eschar on the leg, it is best to leave the adherent eschar in place, especially on the heel, until it softens enough to be more easily removed, provided there is no underlying focus of infection. 1

Assessment of Eschar

Before determining treatment approach, evaluate the eschar for:

• Signs of infection (erythema, warmth, swelling, purulent drainage, odor) 1
• Location on the leg (heel vs. other areas) 1
• Presence of adequate arterial perfusion to the site 1
• Stability of the eschar (dry vs. wet, adherent vs. loose) 1

Management Approach

For Dry, Stable, Adherent Eschar Without Signs of Infection:

• Leave the eschar in place as it serves as a natural biological cover 1
• Allow the necrotic portions to auto-amputate, especially in patients who are poor surgical candidates 1
• Monitor regularly for signs of infection or softening of the eschar 1
• Ensure pressure relief from the affected area through appropriate off-loading techniques 1

When Debridement is Indicated:

Debridement becomes necessary when:

• There is evidence of infection beneath or surrounding the eschar 1
• The eschar begins to soften and loosen 1
• There is a need to assess the depth of the wound 1

Debridement Methods:

1. Sharp Debridement:

   • Preferred method when debridement is needed 1
   • More definitive and controllable than other techniques 1
   • Should be performed by clinicians with appropriate training 1

2. Enzymatic Debridement:

   • Apply collagenase ointment directly to the wound or to a sterile gauze pad 2
   • Prior to application, cleanse the wound of debris with normal saline 2
   • Apply once daily (or more frequently if dressing becomes soiled) 2
   • When clinically indicated, crosshatch thick eschar with a #10 blade to allow better contact with necrotic debris 2

3. Autolytic Debridement:

   • Using hydrogels or hydrocolloids to soften the eschar 1
   • May be slower but less invasive 1

4. Biological Debridement:

   • Maggot therapy (larvae of Lucilia sericata) for selected necrotic wounds 1

Special Considerations

For Ischemic Limbs:

• Debridement may be relatively contraindicated in wounds that are primarily ischemic 1
• If the infected limb appears to be ischemic, refer to a surgeon with vascular expertise 1
• Ensure adequate arterial perfusion before aggressive debridement 1

For Diabetic Patients:

• Evaluate for underlying osteomyelitis, especially with deep or chronic wounds 1
• Consider the need for pressure off-loading devices 1
• Monitor closely for signs of infection, as clinical indicators may be subtle 1

For Infected Eschar:

• Urgent surgical consultation is needed 1
• Systemic antibiotics may be required 1
• Debridement should not be delayed while awaiting revascularization 1

Follow-up Care

• Regular monitoring for signs of infection 1
• Documentation of wound size, extent of surrounding cellulitis, and quality/quantity of drainage 1
• Terminate enzymatic debridement when necrotic tissue is completely removed and granulation tissue is well established 2

Pitfalls to Avoid

• Premature removal of stable, dry eschar, especially on the heel, which can lead to unnecessary tissue damage 1
• Failure to recognize underlying infection requiring urgent intervention 1
• Aggressive debridement of ischemic wounds without vascular assessment 1
• Delaying necessary surgical intervention when there are signs of spreading infection 1