What are the recommended wound care guidelines for a patient with stable eschar?

Recommended Wound Care Guidelines for Stable Eschar

For a large stable eschar on the leg, leave the adherent eschar in place until it softens enough to be more easily removed, provided there is no underlying focus of infection. 1, 2

Initial Assessment Algorithm

Evaluate for Infection

• Examine for at least two signs of inflammation: erythema, warmth, induration, pain/tenderness, or purulent drainage 2
• Note that inflammatory signs may be blunted by neuropathy or ischemia, and systemic findings (fever, elevated white blood count) are often absent 2
• If infection is present beneath or surrounding the eschar, urgent surgical consultation is required 1, 2

Assess Vascular Status

• Check dorsalis pedis and posterior tibial pulses—if palpable, arterial supply is generally adequate 2
• Measure ankle pressure and ankle-brachial index (ABI) 2
• If ankle pressure <50 mmHg or ABI <0.5, obtain urgent vascular imaging and consider revascularization 2
• For ischemic limbs, debridement may be relatively contraindicated, and referral to a surgeon with vascular expertise is recommended 1

Management Based on Clinical Scenario

Stable Eschar WITHOUT Infection (Primary Approach)

• Leave the eschar in place as it serves as a natural biological cover, allowing necrotic portions to auto-amputate, especially in patients who are poor surgical candidates 1
• This approach is particularly important for heel eschars 1, 2
• Monitor regularly for signs of infection or softening of the eschar 1
• Ensure pressure relief from the affected area through appropriate off-loading techniques, such as using pressure-redistributing devices or footwear 1

Stable Eschar WITH Infection

• Urgent surgical consultation is required 1, 2
• Obtain specimens for aerobic and anaerobic culture before initiating antibiotics 2
• Systemic antibiotics may be required 1

When Debridement Becomes Necessary

Debridement is indicated when:

• Evidence of infection beneath or surrounding the eschar exists 1
• The eschar begins to soften and loosen 1
• There is a need to assess the depth of the wound 1

Debridement Techniques (When Indicated)

Sharp debridement is the preferred method when debridement is needed, as it is more definitive and controllable than other techniques, and should be performed by clinicians with appropriate training 1, 2

Alternative methods include:

• Autolytic debridement using hydrogels or hydrocolloids can soften the eschar—this may be slower but less invasive 1
• Biological debridement with maggot therapy (larvae of Lucilia sericata) can be used for selected necrotic wounds 1

Wound Dressing After Eschar Removal

Once eschar is removed, select dressings based on wound characteristics 2:

• Continuously moistened saline gauze for dry wounds 3
• Hydrogels for dry wounds to facilitate autolysis 3
• Alginates for drying exudative wounds 3
• Foams for exudative wounds 3
• Silver-containing products/dressings may be applied to sloughy areas only (choice should be guided by local microbiological advice) 4

Special Considerations for Diabetic Patients

• Evaluate for underlying osteomyelitis, especially with deep or chronic wounds 1, 2
• Consider osteomyelitis as a potential complication of any infected, deep, or large foot ulcer, especially chronic wounds or those overlying bony prominences 2
• The preferred treatment for neuropathic plantar ulcers is a non-removable knee-high off-loading device 2

Follow-Up and Monitoring

• Regular monitoring for signs of infection is essential, including documentation of wound size, extent of surrounding cellulitis, and quality/quantity of drainage 1
• Re-evaluate patients at least daily if hospitalized, or in 3-5 days (or sooner if worsening) for outpatients 2
• If the wound shows no signs of healing within 6 weeks despite optimal management, consider revascularization regardless of initial vascular test results 2

Critical Pitfalls to Avoid

• Premature removal of stable, dry eschar, especially on the heel, can lead to unnecessary tissue damage 1, 2
• Failure to recognize underlying infection requiring urgent intervention can have serious consequences 1, 2
• Aggressive debridement of ischemic wounds without vascular assessment 1
• Delaying necessary surgical intervention when there are signs of spreading infection 1