Knowing the Difference Between Scabs and Eschar Protection Status
eschar on heel pressure ulcer


Knowing the difference between a scab and eschar may not seem like a big deal. However, if you are being audited, or your facility is in survey, you might think otherwise. Here are a couple of scenarios for you to think about.

Scenario One

You have an acquired, unstageable pressure ulcer in a long-term care facility. The treatment nurse documented a suspected deep tissue injury (sDTI) dry scabbed area, measuring 4 x 4 x UTD. First, an sDTI is intact skin with no depth. The tissue level of destruction may be full-thickness, but intact skin. Secondly, a scab is found on a superficial or partial-thickness wound. This is considered a discrepancy in documentation.

Scenario Two

A physician has documented, "sharp debridement removing eschar", when it was actually a scab. This is now considered a full-thickness wound, leading to an incorrect billing code. Documentation is critical to ensure accurate reimbursement for the procedures performed.

Scab vs. Eschar

The term “eschar” is NOT interchangeable with "scab". 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.

Image Credit: Medetec (

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. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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great post, thank you!

Your description of scab and eschar at last agrees with my medical school pathology, hematology, histology, microbiology and even the out patient surgery clericals. The rational is medical and easy to understand with histology slides.

Ms. Cheryl, I must tell you this is the BEST information on wounds that I have seen! I have been in LTC for many years and I learned something new!
Thank You!

Kudos my friend. I love reading your wound source blog postings. You are one of the brightest, sincerest, and helpful wound clinicians I know. So glad we are friends!

Thank you, this was very informative.

Is it possible to develop a scab from a moisture related injury?

I developed eschars around my knee after a knee replacement. I am 4 months post op and the last of the eschars is slowly healing. I have numerous dark red. irregular 2-4 inch by 1/4 to 1/2 inch scars around this knee. What would you recommend to decrease the scar or lighten the color of the scar?

I have a patient with a pressure ulcer of a heel. It is unstageable due to 100% Escher. The patient happens to be a diabetic, and I was told this ulcer should not be "Staged", but should be "Graded" according to to Wagner Grading Scale since the patient has diabetes. What would the appropriate grade be ?

Hello Dr. Powers,
I get this question a lot actually. Determining whether the ulcer is Diabetic vs. Pressure is most important. If a diabetic patient develops a wound to their heel due to "pressure", you wouldn't automatically call it Diabetic and Grade it. If the primary diagnosis is pressure, you would stage appropriately (Unstageable).
Another example: If you have a diabetic patient with a reoccurring chronic heel wound, (originally due to pressure) you could call this diabetic. Maybe their blood sugars are uncontrolled, charcot foot noted etc. 2-3 comorbidities validate the diabetic ulcer dx.
I hope this helps you differentiate things a bit. It can be confusing if you do not know the past wound history too. The Wagner Grading Scale would be Grade 1 for eschar. Grade 2 is into exposed structure. Grade 3 is deep ulceration, possibly into joint capsule, with abscess or osteomyelitis.

Hope this helps. :)

Kind regards,

Cheryl Carver

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