Management of Facial Eschar
Debride the eschar down to a clean ulcer base before initiating any definitive treatment. 1
Initial Assessment and Preparation
The underlying etiology must guide your approach, as facial eschars arise from distinct pathologic processes requiring different management strategies:
For cutaneous leishmaniasis lesions with eschar: Debridement to a clean ulcer base is mandatory before local therapy (heat treatment, cryotherapy, or intralesional antimony) can be effective 1
For thermal burn eschars on the face: Early excision within 72 hours reduces bacterial colonization, infection risk, and hospital stay, while improving functional and cosmetic outcomes 2
For anthrax-related eschars: Do not squeeze or manipulate the lesion; obtain cultures by rotating moist swabs beneath the eschar's edge, then initiate systemic antimicrobial therapy (ciprofloxacin or penicillin depending on susceptibility) 1
Debridement Techniques
Surgical Debridement
- Primary excision at 10 days post-burn for facial burns not essentially healed yields superior appearance and function compared to allowing spontaneous eschar separation 3
- Tangential excision preserves viable dermis and reduces scar-related complications when performed early 2
- Aggressive initial surgical debridement removes non-viable tissue and is critical for preventing infection 4
Enzymatic Debridement
- Bromelain-based enzymatic debridement (Nexobrid®) effectively removes eschar while reducing blood loss, need for autologous skin grafting, and surgical excision requirements 2
- Apply within 72 hours of injury for optimal outcomes 2
Post-Debridement Wound Care
Topical Antimicrobial Therapy
- Silver sulfadiazine 1% cream applied once to twice daily is the standard topical antimicrobial for facial burns after debridement 5
- Topical antibiotics and dressings are recommended for several days after heat treatment of leishmaniasis to prevent secondary bacterial infection 1
Critical Monitoring
- Assess for secondary bacterial infection, which should be treated if present 1
- Monitor for fungal proliferation below the eschar, though clinically significant fungal superinfection incidence is low 6
- Watch for transient leukopenia (maximal white blood cell depression occurs within 2-4 days of silver sulfadiazine initiation, with spontaneous recovery in 2-3 days) 6
Specialist Consultation Requirements
Obtain burn specialist consultation immediately for all facial burns to determine whether admission to a burns center is indicated and to guide ongoing management 1, 5
- Telemedicine should be utilized when burn specialists are not readily available to improve initial assessment and TBSA measurement 1
- Delaying specialist consultation for facial burns results in suboptimal functional and cosmetic outcomes 5
Common Pitfalls to Avoid
- Do not irrigate wounds under pressure, as this spreads bacteria into deeper tissue layers 5
- Do not apply topical antimicrobials to intact eschar in deep burns—these agents cannot penetrate the eschar to reach the subeschar plane where microorganisms harbor 7
- Do not use universal antibiotic prophylaxis for burn wounds; reserve systemic antibiotics for spreading cellulitis or systemic infection signs, targeting both Gram-positive and Gram-negative organisms 5
- For anthrax lesions, do not squeeze the lesion to produce material for culture 1
Definitive Coverage
After debridement and infection control:
- Split-thickness skin grafts remain the standard for rapid, permanent closure of full-thickness facial burns 4, 8
- Early wound closure (conservative treatment or skin grafting) reduces scar-related complications including functional limitations and unaesthetic scar formation 2
- Autografts should be the first choice when available; temporary coverage with barrier materials if autografts unavailable 8