Living with necrotic tissue is challenging for patients and requires evidence-based treatments from skilled wound care clinicians to achieve improved patient outcomes. Let’s explore what it is, how to spot it, and where to go from there.
What Is Necrotic Tissue?
First, what is necrotic tissue and necrosis? The term necrosis stems from the Greek work nekros, which means death.
“Necrosis is a loose term, and it can appear in two ways – under a microscope and grossly viewed with the naked eye,” said Brian Gastman, MD, Surgical Director of Melanoma and High-Risk Skin Cancer Program at the Cleveland Clinic in Cleveland and Professor in the Department of Surgery at Case Western Reserve University School of Medicine in Cleveland.
When tissue is necrotic, there is a loss of tissue integrity, he said. “The tissue becomes discolored, there is fluid and exudative material present, and it becomes fodder for bacterial colonization.”
Gastman said some additional traits of necrotic tissue are:
- Color: Can range from brown to grey to black
- Malodorous: Typically has a purulent smell
- Consistency: Flimsy and without its ability to granulate or bleed
Necrosis is dead tissue within the wound itself, said Don Wollheim, MD, FAPWCA, WCC, DWC, a board-certified surgeon of the American Board of Surgery, instructor with the Wound Care Education Institute (WCEI) and medical adviser of the Medical Oxygen Outpatient Center in Madison, Wisconsin.
“Necrotic tissue is dead, non-functioning, non-dividing and can no longer utilize oxygen and nutrients for normal cellular function,” Wolheim said. “It cannot become live tissue again.”
How Viable Is the Tissue?
When considering whether or not the tissue is necrotic, one needs to consider the spectrum of tissue viability, he said. “There are three categories to describe tissue viability,” he said. They are viable, ischemic, and necrotic tissue.
Viable Tissue
The tissue is still considered alive and has good blood flow to carry oxygen and nutrients for its survival. It can still produce adenosine triphosphate (ATP) for aerobic metabolism/respiration for cells to remain alive and maintain cell division.
Ischemic Tissue
Ischemic tissue is in an early phase of decreased blood flow and still has the ability to return to the viable state.
When ischemic, the tissue cannot produce enough ATP because the nutrients and oxygen are not entering at the previous, normal rate due to the decreased blood flow.
Once becoming ischemic, the tissue now enters into an anaerobic/hypoxic state, producing less ATP and now producing lactic acid, causing anaerobic fermentation.
This presence and build-up of lactic acid lowers the pH in the tissue and makes the tissue more acidic. This produces pain in the patient.
One example of this process is angina pectoris: A patient experiencing a decreased blood flow into the heart muscle (aka myocardium) develops chest pain without dead heart muscle having yet developed.
Necrotic Tissue
Necrotic tissue is a result of ischemic tissue (ischemia) occurring for a long enough time to cause tissue death. The tissue is dead and will not become viable again even if blood flow is increased and returned to the area.
Illustrating the concept of necrosis once again with a heart attack patient: Think of a person who had an MI (myocardial infarction) with not only pain, but additionally resulted in dead heart tissue (myocardium).
Non-viable, necrotic tissue can present as moist and may have a slimy consistency. This is called slough. Or it can have a dry and leather-like appearance. This is called eschar.
Causes of Necrotic Wounds and Tissue
There are several causes of necrotic wounds and tissues, said Gastman.
“As a plastic surgeon, I see cases of necrosis related to surgery,” he said. “There can be problems with wound and/or tissue closure, wound infections, infections in underlying structures or as a result of decreased vascularity to the area affected.”
Sometimes tissue necrosis develops because of necrosis present at the deepest level, such as necrosis that results from an implant or necrotic bone, he said.
“The more common cause of necrotic wounds and tissues are pressure injuries (PIs),” Gastman said.
Two examples of patients at risk for the development of PIs are those that are bedridden and in wheelchairs, he said.
Wollheim pointed out that anything that leads to decreased blood flow (hypoperfusion) and/or decreased oxygenation (hypoxia) in tissue can lead to necrosis.
The list of common causes of necrotic tissue and wounds, according to Wollheim and Gastman include:
- Surgery
- Bone necrosis
- Trauma
- Radiation
- Burns
- Lymphedema (The build-up of lymphatic fluid can crush the arterial and/or venous blood supply.)
- Malignancy
- Embolism
- Cold environments (frostbite)
- Internal pressure (burns and capillary leakage, electrocution, and compartment syndrome due to swelling below the fascia)
- External pressure (PIs)
Necrotic Tissue Treatment
Identifying the cause of the ischemia and/or necrosis, then working to remove that cause is essential, said Gastman.
“If you don’t remove the cause, the wound and tissue won’t heal,” he said. “Prevention is key. If ischemia or necrosis is a result of pressure, you need to remove the cause of the pressure by using tools like specialized beds, wheelchairs, padding/cushioning, body suits that stimulate movement and moving the patient more frequently.”
Another example is necrosis due to venous and/or arterial insufficiency – you’ll want to help the patient lower their cholesterol and stop smoking if they smoke, he said.
Wollheim said the foundation of treatment of necrotic tissue is to remove it by debridement techniques such as:
- Autolytic
- Enzymatic
- Biological (maggots)
- Mechanical and/or sharp debridement
Other treatments include:
- Off-loading – if due to external pressure
- Embolectomy – if due to a vascular embolism
- Adjusting serum calcium level to low normal – if due to deposition of calcium in the microvascular system (calciphylaxis)
- Warming the tissue – if due to extreme cold (frostbite)
- Escharotomy – if due to a circumferential burn
Other adjunctive therapies to use if indicated are:
- Antibiotic therapy – if a bioburden is present
- Surgical revascularization
- Hyperbaric oxygen therapy
Wollheim said if clinicians find themselves challenged when necrosis returns after debridement or other treatments, circle back to the fundamentals and consult with other disciplines as indicated.
Living with these wounds can be challenging for patients, said Gastman.
“Many times, multiple factors led to developing necrotic wounds and tissues. Many patients experienced traumatic events, lost their jobs due to their illnesses and injuries, and some find themselves socially isolated due to living with a chronic, a malodorous wound or wounds.” This constellation of causes lends itself to some patients living with this for a long time and requiring serial treatments, he said. “As a society, we need to take care of these patients.”
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