Management of Non-Opened Heel Deep Tissue Injury (DTI)
For a non-opened heel DTI or pressure injury, you should apply a prophylactic multilayer foam dressing as a skin protectant rather than betadine, as povidone-iodine is indicated for infected wounds with broken skin, not intact skin overlying deep tissue injury. 1
Rationale for Foam Dressing Over Betadine
Why Foam Dressings Are Preferred
Prophylactic multilayer foam dressings applied to heels significantly reduce the development of pressure injuries when used in conjunction with an evidence-based pressure injury prevention program (Level 1 evidence). 1
Multilayered silicone foam (MSF) dressings reduce the combined force generated by internal shear force and pressure more effectively than other dressing types, which is critical since DTI originates in deep tissue layers closest to bone. 2
The foam dressing acts as a mechanical barrier that redistributes pressure and reduces friction/shear forces at the heel interface, addressing the underlying pathophysiology of DTI progression. 1, 2
Why Betadine Is Not Appropriate Here
Povidone-iodine is an antimicrobial agent indicated for infected wounds with broken skin or open ulcers, not for intact skin overlying suspected deep tissue injury. 3
In studies of venous leg ulcers, topical povidone-iodine was effective for superficial infected ulcers (82% healing rate with compression), but your patient has intact skin without surface infection. 3
While povidone-iodine does not significantly delay wound healing in most studies, it provides no mechanical protection against the pressure and shear forces that drive DTI progression in intact skin. 4
Clinical Assessment Priorities
Identifying the DTI
DTIs characteristically appear as purple or maroon discoloration of intact skin or blood-filled blisters, most commonly over the coccyx, sacrum, buttocks, or heels. 5
The hallmark of DTI is rapid deterioration despite appropriate preventive interventions, as the injury originates in deep muscle tissue near bone before becoming visible at the skin surface. 5
Patients who develop DTI are typically older with lower body mass index compared to those developing other pressure injury stages. 5
Complete Management Algorithm
Immediate Interventions
Apply a prophylactic multilayer silicone foam dressing to the heel to reduce pressure, friction, and shear forces. 1, 2
Completely offload the heel using pillows or specialized heel suspension devices to eliminate pressure on the affected area. 5
Reposition the patient every 2 hours to prevent additional pressure injury development. 5
Ongoing Monitoring
Inspect the dressing and underlying skin daily for signs of deterioration, including increased discoloration, blister formation, or skin breakdown. 5
If the skin opens and infection develops (increased warmth, purulent drainage, erythema extending beyond the wound margin), then transition to antimicrobial therapy including consideration of povidone-iodine for local wound care. 3
Change foam dressings every 5-7 days or as needed based on adherence and skin condition. 6
Common Pitfalls to Avoid
Do not apply antiseptic solutions like betadine to intact skin overlying DTI, as this provides no mechanical protection and is not indicated without open infection. 4, 3
Do not assume the injury is superficial based on initial appearance—DTI originates deep and may rapidly progress despite intact skin initially. 5
Do not rely solely on dressings without complete pressure offloading, as continued pressure will cause progression regardless of dressing type. 5, 1
Do not use detergent-containing povidone-iodine surgical scrubs on any wound without thorough saline irrigation afterward, as the detergent component delays healing. 4