Management of Wound Undermining

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 2
Sharp debridement with scalpel, scissors, or tissue nippers is preferable to hydrotherapy or topical debriding agents, as it is more definitive and controllable 2

Select dressings primarily based on exudate control, comfort, and cost rather than for antimicrobial properties 1
The American Diabetes Association recommends selecting dressings based on exudate control, comfort, and cost rather than for antimicrobial properties, according to the Diabetes/Metabolism Research and Reviews 1
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 4
The wound should be cleaned regularly with water or saline to remove debris from the wound surface 5
Dress the wound in a manner that allows daily inspection and encourages a moist wound-healing environment 2

Removal of pressure from a foot wound (off-loading) is crucial to the healing process, especially for diabetic foot ulcers 2

Consider negative pressure wound therapy (NPWT) for wound care after complete removal of necrosis in complex wounds with undermining 6
NPWT may help wound healing by increasing blood supply, improving tissue perfusion, reducing edema, absorbing fluids and exudates, and promoting granulation tissue formation 6

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

Failing to address the underlying cause of excess exudate will result in continued undermining despite appropriate dressing selection 3
The American College of Clinical Wound Specialists recommends against using dressings containing surface antimicrobial agents with the sole aim of accelerating healing of an ulcer, according to the Diabetes/Metabolism Research and Reviews 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