How would you stage a wound with all eschar that fell off, revealing dermis exposure?

Wound Staging After Eschar Removal Revealing Dermis

When eschar falls off a wound revealing dermis exposure, you cannot definitively stage the wound as Stage II based solely on dermis visualization—you must assess the actual depth of tissue loss present. The key principle is that wounds previously covered by eschar were "unstageable" until the eschar was removed, and the true depth must now be determined by what tissue layers were actually destroyed, not just what is currently visible 1.

Understanding the Staging Framework

The Unstageable Category

• Wounds covered by eschar or slough are classified as "unstageable" because the extent of tissue damage is obscured by the necrotic tissue 1.
• Once the eschar is removed (whether it falls off spontaneously or is debrided), the wound reveals its true depth and can then be staged as either Stage III or Stage IV 1.

Critical Distinction: Visible vs. Destroyed Tissue

• The staging system is based on the depth of tissue LOSS/DESTRUCTION, not simply what tissue layer is currently exposed or visible 1.
• Seeing dermis does not automatically mean Stage II—you must determine whether deeper structures (subcutaneous fat, muscle, bone) were destroyed even if they are no longer present in the wound bed 1.

Staging Algorithm After Eschar Removal

Step 1: Assess the Wound Depth

• Probe the wound with a sterile, blunt metal probe to determine actual depth and identify any deeper structures 2.
• Look for exposed or palpable subcutaneous fat, muscle, tendon, ligament, or bone 1.

Step 2: Apply Staging Criteria

Stage II (Partial-Thickness):

• Partial-thickness loss of dermis presenting as a shallow open ulcer 1.
• Viable red-pink wound bed without slough 1.
• No subcutaneous fat, muscle, or bone visible or was destroyed 1.

Stage III (Full-Thickness to Fat):

• Full-thickness tissue loss exposing subcutaneous fat 1.
• Bone, muscle, and tendon are NOT visible or exposed 1.
• Slough or eschar may have been present before removal 1.

Stage IV (Full-Thickness to Muscle/Bone):

• Full-thickness tissue loss with exposed or palpable bone, muscle, ligament, or tendon 1.
• Slough or eschar may have been present before removal 1.

Step 3: Consider the Clinical Context

• Assess the wound location—pressure ulcers over bony prominences (sacrum, ischium, trochanter, heel) are more likely to have deeper tissue destruction 1.
• Evaluate the chronicity of the wound—chronic wounds with eschar are more likely to have progressed to deeper stages 1.

Common Pitfalls to Avoid

Pitfall 1: Assuming Dermis Exposure = Stage II

• Do not automatically classify as Stage II just because you see dermis—the wound may have had full-thickness destruction with the deeper tissues already lost or debrided 1.
• The dermis you see may be the base of a much deeper wound that has partially healed or been debrided 1.

Pitfall 2: Failing to Probe the Wound

• Always probe to assess true depth, especially in pressure injuries where tunneling or undermining may be present 2.
• Palpable bone indicates Stage IV regardless of what is visible on the surface 1.

Pitfall 3: Ignoring the Pre-Eschar History

• If the wound had significant depth before eschar formation, it likely remains Stage III or IV after eschar removal 1.
• Eschar formation does not reverse the underlying tissue destruction—it merely obscures it 1.

Practical Approach

For most wounds where eschar falls off revealing dermis:

• If the wound is shallow with only partial-thickness skin loss and no evidence of deeper tissue involvement → Stage II 1.
• If there is evidence of subcutaneous fat loss (even if not currently visible) or the wound extends beyond the dermis → Stage III 1.
• If bone, muscle, or tendon is exposed or palpable → Stage IV 1.

When in doubt, probe the wound and assess for deeper involvement before assigning a stage 2.