Current treatment guidelines recommend that stable, intact heel eschar (dry, firmly attached, intact, no erythema or fluctuations) should not be removed. As a natural barrier, eschar can protect wounds from bacterial contamination. If the eschar becomes unstable (wet, oozing, loose attachment, swelling, redness), it should be debrided according to institutional guidelines.
For autoimmune and pyoderma gangrenosum wounds, when there is a clear boundary of activity, debridement with instruments will make the wound worse. This is because debridement stimulates an inflammatory response. When receiving immunosuppressive therapy and there is no active boundary, surgical debridement can be accepted.
Expanding tissue necrosis and calcium hypersensitivity wounds with violet borders should not be surgically debrided. Before debridement, the patient must complete sodium thiosulfate treatment to confirm that the area of necrotic tissue has stopped expanding and the violet border has disappeared.
Patient education can improve outcomes
The primary purpose of patient education is to reduce anxiety, manage expectations, and improve the effectiveness of treatment. Explain to the patient the procedure and any local analgesics or anesthetics that need to be used in the debridement. Anesthetics such as lidocaine (with/without epinephrine) injections, topical gels, sprays, and ointments can be used for outpatient or bedside debridement for pain relief.
