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Wound Management

Necrotic

Authors: Hasan Gökcer Tekin, MD, Christian Kaare Paaskesen, Med. Stud, Magnus Avnstorp, MD, Bjørn Thomas Crewe, MD and Consultant wound specialist

Definition: Non-vital, dead tissue which cannot be salvaged due to devascularization.

Description:  Usually black or brown in color but can also be white. May present as dry, thick, mummified tissue (eschar) or as wet (liquefied) necrotic tissue. Dry necrosis has often a clear demarcation and a punched out appearance. Transition from dry necrosis to wet necrosis should be given special attention, as it may cause severe infections. Dry necrosis usually separates after a period from the normal wound bed due to elasticity and mechanical resistance. Fissures between the dry necrosis and underlying layers create folds where bacteria can proliferate and cause severe infection and further liquefying the necrosis (wet necrosis).

Treatment aim:  Debridement of necrotic tissue. Avoid infection during the spontaneous evolvement from dry to wet necrosis. Vascular assessment is mandatory before debridement.

Wound dressing (dry wounds): N/A (Simple gauze dressing to prevent moistening while awaiting surgical removal and reconstruction)

Wound dressing (wet wounds): N/A (Simple absorbing dressing awaiting imminent surgical treatment)

Wound exampels:

Mummified necrosis

Posterior view of thigh and crus of pressure ulcer. Dry mummified necrosis (eschar) of epidermal and dermal layers. The dry necrosis is starting to separate from the wound edges by mechanical forces, and caution must be advised to avoid wet necrosis by bacterial colonization in the fissures/folds.

Sacral pressure wound

Posterior view of a sacral pressure wound. The dry necrotic skin hides a zone with deep tissue damage and non-vital tissue that needs surgical debridement.

Heel wound with central dry necrosis

Posterior view of a heel wound. Central dry necrosis enveloped by healthy re-epithelialized wound bed. The necrosis is kept dry to avoid moistening/maceration which allow anaerobes to develop.

Dry necrosis of the Achilles tendon

Medial and posterior view of leg ulcer with dry necrosis of the Achilles tendon. The tendon has still partial adherence to underlying structures and may be salvaged after surgical debridement. Vascular assessment is mandatory before debridement.  

Dry necrosis of toes

View of foot dorsum. Typical dry necrosis of right toes due to arterial ischemia. The necrosis is kept dry to avoid moistening/maceration which allow anaerobes to develop, and promotes autoamputation and limit surgical shortening.

Flap necrosis

Dorsal view of flap necrosis – The dry necrotic skin is demarked and starting to separate from the wound edges.
Dorsal view of flap necrosis – After surgical debridement the necrosis is surgically removed to avoid wet necrosis and infection.
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