What is the best treatment approach for undermining of a wound?

Management of Wound Undermining

Sharp debridement is the preferred treatment for undermining of wounds, followed by appropriate dressing selection based on exudate control, compression, and immobilization of the affected area. 1, 2

Initial Assessment and Debridement

• Sharp debridement should be performed to remove slough, necrotic tissue, and surrounding callus, taking into account relative contraindications such as pain or severe ischemia 1
• The goal of debridement is to physically excise dead and unhealthy tissue, enabling wound healing and removing potential pathogen reservoirs 1
• Sharp debridement with scalpel, scissors, or tissue nippers is preferable to hydrotherapy or topical debriding agents, as it is more definitive and controllable 1
• For undermined areas specifically, debridement should include thorough cleaning of all undermined areas or inside walls of wound pockets 2

Wound Management After Debridement

• Select dressings primarily based on exudate control, comfort, and cost rather than for antimicrobial properties 1, 3
• For wounds with moderate to high exudate, use absorbent dressings such as foam dressings or alginates that draw moisture away from the wound and periwound skin 3, 4
• The wound should be cleaned regularly with water or saline to remove debris from the wound surface 1
• Dress the wound in a manner that allows daily inspection and encourages a moist wound-healing environment 1

Compression and Immobilization

• Apply compression to undermined areas using multilayered compression, modified negative-pressure therapy, or both 2
• Immobilize all wound layers using a brace, removable walker, or cast to promote healing 2
• Removal of pressure from a foot wound (off-loading) is crucial to the healing process, especially for diabetic foot ulcers 1

Advanced Therapies for Complex Cases

• Consider negative pressure wound therapy (NPWT) for wound care after complete removal of necrosis in complex wounds with undermining 1, 3
• NPWT may help wound healing by increasing blood supply, improving tissue perfusion, reducing edema, absorbing fluids and exudates, and promoting granulation tissue formation 1
• For diabetic foot ulcers with undermining, ensure proper pressure offloading in addition to appropriate moisture management 3

Monitoring and Follow-up

• Monitor the wound daily for signs of infection, which can be exacerbated by undermining and excess moisture 3
• At each dressing change, assess the wound for signs of infection (increased exudate, odor, pain, surrounding erythema) 4
• For infected wounds, systemic antibiotics should be administered if clinically indicated, rather than relying on antimicrobial dressings 4

Common Pitfalls and Considerations

• Failing to address the underlying cause of excess exudate will result in continued undermining despite appropriate dressing selection 3
• Do not use dressings containing surface antimicrobial agents with the sole aim of accelerating healing of an ulcer 1
• Avoid occlusive dressings that can worsen maceration and potentially increase undermining 3
• For severely infected wounds with undermining, urgent surgical debridement in an operating theater may be indicated, particularly for gas-forming infection, abscess, or necrotizing fasciitis 1