Is it safe to remove black eschar on the heel?

Management of Black Eschar on the Heel

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

Initial Assessment

When evaluating black eschar on the heel, you must systematically assess several critical factors before making any intervention decisions:

• Check for signs of infection including erythema, warmth, swelling, purulent drainage, and odor surrounding the eschar 1
• Assess arterial perfusion by palpating dorsalis pedis and posterior tibial pulses; if palpable, arterial supply is generally adequate 2
• Determine eschar stability by evaluating whether it is dry versus wet, and adherent versus loose 1
• Monitor the eschar characteristics including whether it remains stable or shows signs of softening or loosening 1

Management Strategy

When to Leave Eschar Intact

The stable, dry eschar on the heel should be left in place as it serves as a natural biological cover. 1 This approach is particularly important for the heel, which has unique anatomical considerations compared to other body sites.

• Allow the eschar to auto-amputate naturally over time, especially in patients who are poor surgical candidates 1
• Provide pressure relief from the affected area through appropriate off-loading techniques, such as pressure-redistributing devices or specialized footwear 1
• Monitor regularly for any signs of infection development or changes in eschar stability 1

The rationale for this conservative approach is supported by clinical evidence showing that 94 of 95 heel wounds with eschar healed after an average of 11 weeks when managed with offloading and keeping the eschar dry, without premature debridement 3

When Debridement Becomes Necessary

Debridement should only be performed under specific circumstances:

• Evidence of infection beneath or surrounding the eschar requires urgent intervention 1
• The eschar begins to soften and loosen naturally, making removal safer and more appropriate 1
• Need to assess wound depth when clinical evaluation suggests deeper tissue involvement 1

If debridement is indicated, sharp debridement is the preferred method as it is more definitive and controllable, and should be performed only by clinicians with appropriate training 1

Special Considerations

For Ischemic Limbs

• Debridement may be relatively contraindicated in wounds that are primarily ischemic 1, 2
• Refer to a vascular surgeon if the infected limb appears ischemic before attempting any debridement 1

For Diabetic Patients

• Evaluate for underlying osteomyelitis, especially with deep or chronic wounds 1
• Ensure appropriate pressure off-loading devices are in place 1

For Infected Eschar

• Obtain urgent surgical consultation if infection is present 1
• Initiate systemic antibiotics targeting both aerobic and anaerobic organisms if infection develops 2

Critical Pitfalls to Avoid

• Never prematurely remove stable, dry eschar on the heel, as this can lead to unnecessary tissue damage and complications 1
• Do not perform aggressive debridement of ischemic wounds without first obtaining vascular assessment 1
• Avoid delaying necessary surgical intervention when there are signs of spreading infection or progressive tissue destruction 1
• Do not mistake the stable eschar for requiring immediate intervention simply because it appears necrotic; the heel eschar specifically benefits from conservative management 1

Monitoring Protocol

• Document wound size and extent of any surrounding cellulitis at each assessment 1
• Track quality and quantity of drainage if present 2
• Reassess regularly for any changes in eschar stability or development of infection signs 1