How To Handle Black Eschar Formation

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Here you can see a pressure ulcer of nine months duration with eschar formation on the left heel. The patient has a history of prostate cancer and peripheral vascular disease. (Photo courtesy of Tamara Fishman, DPM.)
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Q: Are you concerned that by debriding the eschar, you may create a deeper wound that could get infected?
A:
Dr. Hadi says this is not a deciding factor on whether she’ll debride eschar. If you do debride eschar and create a wound, she maintains that appropriate wound care should “help minimize contamination and ultimately infection of the wound.”
To that end, Dr. Shea says you can reduce this concern by using aseptic technique; controlling the wound environment locally and systemically; and closely monitoring the wound healing process (by measuring the wound volume and surrounding tissue status) weekly until the wound has closed over adequately. On average, you’ll see a 50 percent reduction in wound volume within eight to 10 weeks and 100 percent closure within 16 to 20 weeks, according to Dr. Shea.
“With aggressive algorithmic wound care, wound healing time frames such as these (even in the most compromised patient) occur 85 to 90 percent of the time,” maintains Dr. Shea.
As he mentioned above, Dr. Reyzelman is mostly concerned about exposing the subcutaneous fat. “Since the fat is avascular and this area is poorly perfused, the fat starts to dry out and eventually will require debridement,” explains Dr. Reyzelman. He adds that in patients with more severe peripheral arterial occlusive disease, debridement of the eschar will quickly lead to another eschar.

Q: Are you concerned about arterial perfusion when you see black eschar formation?
A:
Adequate arterial perfusion is essential to the process of wound healing and the presence of persistent eschar indicates poor arterial flow to an area, notes Dr. Shea. He says this could be the result of underlying vascular problems, like arterial sclerosis or stenosis, or pressure issues which DPMs often see in decubitus-type wounds.
Dr. Shea says you obviously want to address these issues, whether it’s by altering the pressure status via offloading or increasing perfusion by medical, interventional radiology or surgical means. Combining the clinical evaluation of the patient’s vascular status (physical exam) with ancillary testing (Doppler, TCPO2, TCOM, segmental vascular non-invasive testing, and arteriography with or without angioplasty) is essential for determining the timing and extent of eschar debridement, according to Dr. Shea.
When he evaluates patients who have black eschars, Dr. Reyzelman always performs a more advanced arterial exam. He says he frequently obtains a non-invasive arterial study to get a better appreciation of the severity of arterial occlusive disease. On many occasions, Dr. Reyzelman will refer patients with black eschars to a vascular surgeon for a bypass. After the revascularization, Dr. Reyzelman says the eschar will frequently become wet and he then performs a debridement.

Dr. Reyzelman (shown on the right) is Chairman of the Department of Medicine at the California College of Podiatric Medicine (CCPM) and has a private practice in San Francisco.

Dr. Hadi is an Assistant Professor and the Director of Resident Education at the University of Texas Health Science Center in San Antonio, Texas.

Dr. Shea is a Certified Wound Care Specialist at the John Muir Wound Care Center in Walnut Creek, Calif., is an Adjunct Associate Professor at CCPM and has a private practice in Concord, Calif.

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