Our staff is having difficulty with the definitions of tissue types seen in pressure ulcers. Can you help? There are four basic types of skin tissue seen in pressure ulcers: slough, eschar, granulation, and epithelial tissue. Slough: soft moist avascular, devitalized dead tissue. It may be white, yellow, tan, gray or green, and it may be loose or firmly adherent. Slough may be seen in clumps, scattered, or completely covering a wound base. Its presence indicates tissue injury of stage III or higher pressure ulcers.
Slough will never be present in a stage II ulcer. Eschar: thick leathery black or brown devitalized tissue. It can be loose or firmly adherent, hard, soft, dry or wet. It reflects deep damage to tissues and is more severe than slough. To distinguish between a scab and eschar, remember that a scab is a collection of dried blood cells and serum and sits on top of the skin surface.
During wound healing, granulation tissue usually appears during the proliferative phase. Angiogenesis is the process by which new blood vessels form, bringing in tiny capilarry buds that appear as granular tissue. Granulation tissue sets the stage for epithelial tissue to be laid down on top of the wound bed.
Pale, unhealthy granulation tissue, as noted above, can result from lack of good blood supply and angiogenesis. Pale granulation tissue needs to be freshened up with debridement to stimulate new ingrowth of blood vessels. Pictured on the left is a necrotic sacral ulcer. The necrosis can be best visualized to the left of the wound in the photograph. Necrosis is usually dark tissue, which is completely devitalized.
Necrotic tissue forms as a result of tissue death from damage. For pressure ulcers, the underlying pressure causes occlusion of blood vessels blocking vital oxygen delivery to tissues. This occlusion results in tissue death and subsequent bacterial overgrowth.
In order for wounds to heal, all necrotic tissue should be debrided from the wound, a process that may take multiple attempts over months to achieve the desired outcome of good healthy granulation tissue.
Documentation is critical to ensure accurate reimbursement for the procedures performed. Eschar is dead tissue found in a full-thickness wound. You may see eschar after a burn injury, gangrenous ulcer, fungal infection, necrotizing fasciitis , spotted fevers, and exposure to cutaneous anthrax.
Current standard of care guidelines recommend that stable intact dry, adherent, intact without erythema or fluctuance eschar on the heels should not be removed. Blood flow in the tissue under the eschar is poor and the wound is susceptible to infection. The eschar acts as a natural barrier to infection by keeping the bacteria from entering the wound.
If the eschar becomes unstable wet, draining, loose, boggy, edematous, red it should be debrided according to the clinic or facility protocol. The term "scab" is used when a crust has formed by coagulation of blood or exudate. Scabs are found on superficial or partial-thickness wounds.
Scab is the rusty brown, dry crust that forms over any injured surface on skin, within 24 hours of injury. Whenever our skin is injured due to any cut or abrasion, it starts bleeding due to blood flowing from the severed vessels.
This blood containing platelets, fibrin and blood cells, soon clots to prevent further blood loss. The outer surface of this blood clot, dries up dehydrates to form a rusty brown crust, called a scab, which covers the underlying healing tissues like a cap.
The purpose of a scab is to prevent further dehydration of the healing skin underneath, to protect it from infections, and to prevent any entry of contaminants from the external environment. Scabs generally remain firmly in place until the skin underneath has been repaired and new skin cells have appeared, after which it naturally falls off. About the Author Cheryl Carver is an independent wound educator and consultant.
Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues.
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