Ask the Treatment Expert about ... eschar

Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC
Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC

When eschar is present, what are the best practices for treating pressure injuries that occur on the heel?

Approximately one-quarter of all pressure injuries (ulcers) are located on the heel. Pressure is sustained directly to the posterior aspect of the heel and concentrated directly over the bone. There is only a small amount of subcutaneous tissue in this area of the body, resulting in a very small surface to bear the weight of the foot and leg, and thus the susceptibility to pressure ulcers. 

A question that frequently arises is this: Exactly how is one to treat heel pressure injuries if they are covered with hard, black, dry eschar? The first intervention one should implement is pressure redistribution. This is accomplished by using pillows, positioners or devices to “float the heels” — in other words, heels are not in contact with any surface. 

A complete assessment is essential. In other anatomical locations, debridement of devitalized material or eschar is usually recommended to optimize the wound bed for healing. This is not necessarily true for pressure injuries of the heel, and in fact, caution must be used with debridement in such cases. If the individual has compromised blood flow, eschar that is stable and dry may provide protection against bacterial invasion. In many cases, the tissue under the eschar and the wound will heal, after which the body will release the eschar.

Daily observation, periwound skin cleansing, and pressure redistribution are essential to ensure healing without complications. Observe for signs and symptoms of infection: redness extending from under the eschar, increase in temperature, firmness, discoloration, pain and purulent drainage. If these symptoms are noted in the area around the eschar, infection should be suspected. Report the change in status to the physician immediately, as debridement may be indicated.