What is the appropriate treatment for a patient with a boggy eschar on the heel?

Treatment for Boggy Eschar on the Heel

When an eschar on the heel becomes boggy (wet, soft, or non-adherent), this signals underlying infection or tissue breakdown, and you must urgently pursue sharp surgical debridement with systemic antibiotics after obtaining cultures. 1, 2

Immediate Assessment Required

A boggy eschar represents a fundamentally different clinical scenario than a stable, dry eschar. You need to evaluate for:

• Signs of infection: Look for erythema, warmth, induration, pain/tenderness, or purulent secretions (though these may be blunted by neuropathy or ischemia in diabetic patients) 3, 2
• Vascular status: Check dorsalis pedis and posterior tibial pulses; if non-palpable or if ankle pressure <50 mmHg or ABI <0.5, obtain urgent vascular imaging 3, 2
• Underlying osteomyelitis: Probe the wound with a sterile metal instrument—if you can touch bone, osteomyelitis is highly likely, especially with longstanding or deep wounds 3, 2

Treatment Algorithm for Boggy Eschar

Step 1: Urgent Surgical Consultation

• Obtain immediate surgical evaluation when eschar becomes boggy, as this indicates infection beneath or surrounding the eschar 1, 2
• Do not delay intervention—spreading infection can lead to sepsis or limb loss 1, 2

Step 2: Culture and Antibiotics

• Obtain specimens for aerobic and anaerobic culture before initiating antibiotics 2
• Start empiric systemic antibiotics for moderate to severe infection (not just topical agents) 3
• Classify infection severity: mild (superficial with minimal cellulitis), moderate (deeper/extensive), or severe (systemic sepsis signs) 3

Step 3: Sharp Debridement

• Sharp debridement with scalpel, scissors, or tissue nippers is the preferred and most definitive technique when a boggy eschar requires removal 1, 2
• Remove all necrotic tissue and loosened debris to expose viable tissue 3, 4
• Crosshatching thick eschar with a #10 blade before debridement allows better access to underlying necrotic material 4

Step 4: Post-Debridement Wound Management

• Cleanse the wound with gauze saturated in normal saline to remove debris and digested material 4
• Apply appropriate topical antibiotic powder to the wound before dressing if infection is present 4
• Select moisture-appropriate dressings based on wound characteristics after debridement 2
• Implement strict pressure offloading: Use non-removable knee-high offloading devices (total contact cast or irremovable walker) for plantar wounds, or appropriate heel protection devices for heel wounds 3, 2

Critical Distinction: Stable vs. Boggy Eschar

The key clinical principle is that stable, dry, adherent eschar on the heel should be left in place until it softens naturally, as it serves as biological cover 1, 2, 5. However, once eschar becomes boggy (wet, soft, loose), this protective barrier is compromised and infection is likely present, necessitating urgent intervention 1, 2.

A retrospective study of 179 heel eschars managed conservatively (kept dry with offloading) showed 94 of 95 healed without debridement over an average of 11 weeks, but this only applies to stable, dry eschar 5. Your patient's boggy eschar does not meet these criteria.

Special Considerations

For Ischemic Limbs

• If the limb appears ischemic (absent pulses, ankle pressure <50 mmHg), debridement may be relatively contraindicated until revascularization is achieved 1, 2
• Refer to vascular surgery urgently for revascularization before or concurrent with debridement 3, 2

For Diabetic Patients

• Evaluate for neuropathy that may mask pain and infection signs 3, 2
• Plain radiographs suffice for initial osteomyelitis screening 3
• Ensure glucose control and cardiovascular risk reduction (smoking cessation, aspirin/clopidogrel) 3

Enzymatic Debridement Alternative

If sharp debridement expertise is unavailable or patient is not a surgical candidate, collagenase ointment (Santyl®) can be applied once daily after crosshatching the eschar 4. However, this is slower and less definitive than sharp debridement for infected boggy eschar 1, 2.

Common Pitfalls to Avoid

• Delaying surgical intervention when there are signs of spreading infection can lead to sepsis or amputation 1, 2
• Aggressive debridement without vascular assessment in ischemic wounds can cause further tissue loss 1, 2
• Failure to implement adequate offloading will prevent healing regardless of debridement quality 3, 2
• Treating with topical agents alone when systemic infection is present 3, 2

Follow-Up Monitoring

• Re-evaluate daily if hospitalized, or within 3-5 days (sooner if worsening) for outpatients 2
• Document wound size, surrounding cellulitis extent, and drainage quality/quantity 1
• If no healing progress within 6 weeks despite optimal management, consider revascularization regardless of initial vascular studies 3, 2