You’re in the middle of a skin assessment on a patient who is 3-days post CVA, and you notice a black, leathery patch on their sacrum. This isn’t a bruise; this is eschar. Understanding what this is and what it means for your Plan of Care is crucial for preventing a minor skin issue from becoming a major medical complication.
What is Eschar?
Eschar (es-KAR) is a thick, dry, leathery, and often black or dark brown layer of dead tissue (necrosis) that forms over a wound. Think of it as a biological scab, but one that is much thicker and more problematic. It is commonly seen in pressure injuries (bedsores) on the sacrum or heels, but can also form after burns or in wounds with compromised blood supply. The tissue itself is devitalized, meaning it has no blood flow and cannot heal on its own.
Why Eschar Matters in Physical Therapy Practice
This isn’t just a wound care issue; it’s a mobility issue. Eschar is a hard, rigid barrier that prevents the underlying tissue from healing and masks the true severity of the wound. Because it is dry and avascular, it’s also a prime medium for bacterial growth if it becomes moist or infected. For a PT, this directly impacts the Plan of Care (POC). It dictates your positioning strategies, your weight-bearing precautions during transfers, and your need to communicate with the medical team about appropriate offloading.
What You’ll See in the Clinic
You’ll see a firm, black/brown, leathery area of skin that is firmly attached to the wound bed. The patient may or may not have pain in the area, as the nerve endings are often destroyed. A key clinical finding is that you cannot stage a pressure injury when eschar is present because the depth of the wound is obscured.
“Patient is a 78-year-old female with a right hip fracture. Wound care notes report a 3cm x 3cm area of stable, dry eschar on the right heel. PT orders: Non-weight bearing on the right lower extremity. I will need a heel offloading boot and must ensure the heel is floated during all supine exercises and bed transfers.”
Common Pitfall & Pro Tip
⚠️ Pitfall: Attempting to debride the eschar yourself. This is outside the PT scope of practice. Aggressive manual removal can turn a stable, dry eschar into an open wound, drastically increasing the risk of infection.
💡 Pro Tip: Your primary intervention is offloading. For a heel wound, use a heel lift boot or position a pillow under the calf to completely float the heel. For a sacral wound, ensure the patient is not sitting for prolonged periods and use a pressure-relieving cushion. Your job is to protect the area and optimize the patient’s mobility within those constraints.
Memory Aid for Eschar
Think “The Crusty Cap”. The eschar is a cap that seals the wound. If the cap is hard and dry, it’s a stable protector. If the cap becomes soft, boggy, or starts to smell, it’s a danger sign—the “cap” is failing and infection is brewing underneath.
NPTE Connection
Watch for this in questions regarding integumentary system and wound care. You will be asked to identify the correct intervention (e.g., “What is the appropriate PT action for a patient with stable eschar on the heel?” The answer is typically offloading and patient education, not debridement).
Related Physical Therapy Concepts
Eschar is a specific type of necrotic tissue within the broader category of Pressure Injuries. It’s often confused with slough, which is a softer, yellow/white, moist necrotic tissue that can be gently removed by a PT if ordered. Understanding eschar also connects to Patient Positioning and the importance of Skin Integrity assessments for all patients with limited mobility.
Quick Reference
✓ Key findings: Black/brown, dry, leathery, adherent to wound bed ✓ Priority level: High – Masks wound depth, high infection risk if compromised ✓ PT Interventions/Considerations: • Offload the area (heel boots, pillows, pressure-relief cushions) • Reposition patient every 2 hours • Inspect surrounding skin for redness or breakdown • Educate patient/family on pressure relief • Document and communicate wound status to the medical team
Bottom line: Eschar is a clear signal to prioritize pressure relief and protection in your POC.