What is the recommended treatment for wound care of a Deep Tissue Injury (DTI)?

Wound Care for Deep Tissue Injury (DTI)

For a suspected deep tissue injury, maintain the wound intact with protective dressing and pressure offloading while closely monitoring for evolution—do not debride unless full-thickness tissue loss develops, as most DTIs (66%) will resolve or progress toward healing without surgical intervention. 1

Initial Assessment and Diagnosis

DTI presents as purple or maroon discoloration of intact skin with a defined border, often with surrounding erythema in light-skinned patients. 2 In dark-skinned patients, look for persistent erythema and hyperpigmentation rather than blanching to confirm pressure injury. 2

Critical differential diagnoses to exclude:

• Stage 2 pressure ulcers, incontinence-associated dermatitis, skin tears 2
• Bruising, hematoma, venous engorgement 2
• Arterial insufficiency, necrotizing fasciitis, terminal skin ulcers 2
• Blood-filled blisters (which may also represent DTI) 1

Document the patient's "time down" history—periods of immobility during which pressure injury could have occurred. 2

Primary Management Strategy: Conservative Approach

The cornerstone of DTI management is aggressive pressure offloading, not debridement. 3 Unlike other wound types, DTI requires a watch-and-wait approach because the tissue injury extends deeper than what is visible on the surface.

Pressure Offloading Protocol

• Implement a turning schedule every 2-3 hours to eliminate pressure on the affected area 3
• Provide specialized pressure-relieving mattresses to redistribute pressure 3
• Use specialized cushions when the patient must sit 3
• Ensure proper pressure offloading is individually tailored to minimize excessive or persistent pressure at the DTI site 4

Protective Dressing Selection

Maintain a moist wound environment with appropriate dressings that control any exudate while avoiding tissue maceration. 4 The American College of Cardiology recommends comprehensive wound care with appropriate dressing selection to optimize the wound-healing environment. 3

• Apply protective dressings to intact purple/maroon skin to prevent further trauma 1
• No specific dressing type has proven superior for preventing infection or improving outcomes 4
• Simple gauze dressings perform as well as silver dressings, hydrogels, alginates, or foam dressings 4

Monitoring and Evolution

Reassess the wound at least weekly to monitor healing progress and adjust treatment. 3 Average follow-up in clinical studies was 6 days, with most DTIs showing clear evolution patterns within 2 weeks. 1

Expected Evolution Patterns

Based on a 2-year retrospective study of 128 DTIs: 1

• 66.4% completely resolved or progressed toward resolution without surgical intervention
• 24.2% remained unchanged as purple-maroon discoloration or blood-filled blister
• Only 9.3% deteriorated to full-thickness tissue loss requiring debridement

When to Debride: Full-Thickness Tissue Loss Only

Debridement should only be performed if the DTI evolves to full-thickness tissue loss with necrotic tissue. 3, 5 This occurs in less than 10% of cases. 1

Debridement Techniques (if needed)

Available methods include surgical, sharp/conservative-sharp, autolytic, mechanical, enzymatic, chemical/mechanical/surfactant, and biosurgical/larval approaches. 4, 5 The choice depends on tissue type, presence of biofilm, wound depth and location, and clinician skill. 5

For infected DTI that has evolved to full-thickness loss:

• Perform complete surgical debridement first, removing all infected and necrotic tissue into healthy-looking tissue 6
• Prompt management with antibiotics and surgical debridement is recommended for infected wounds 4
• Consider negative pressure wound therapy (NPWT) only after complete debridement 6

Systemic Optimization

Optimize medical conditions that impair healing concurrently with local wound care: 3

• Achieve tight glycemic control if diabetic 4, 3
• Encourage smoking cessation 4, 3
• Address cardiovascular risk factors 4, 3
• Ensure adequate nutrition with appropriate protein intake 3
• Control edema 4
• Provide adequate pain control 4

Advanced Therapies (Rarely Needed for DTI)

If the DTI evolves to a non-healing wound after 4 weeks of standard care: 3

• Consider NPWT to promote granulation tissue formation (only after any necrotic tissue is debrided) 4, 3, 6
• Hyperbaric oxygen therapy may be beneficial if there are signs of compromised tissue perfusion 4, 3
• Biological dressings or skin substitutes for chronic non-healing wounds 3

Critical Pitfalls to Avoid

Do not debride intact DTI. The purple/maroon discoloration represents deep tissue damage that may still be viable. 1 Premature debridement removes potentially salvageable tissue and worsens outcomes.

Inadequate pressure offloading will prevent healing regardless of other interventions. 3 This is the most common cause of DTI treatment failure.

Do not apply NPWT to infected wounds until complete surgical removal of necrosis has been accomplished. 6 NPWT on infected tissue without adequate debridement can worsen infection spread.