The Undermining Wound: What’s Now and What’s Next

Have you seen those cross-sectional pictures of icebergs? The ones that show what appear to be a collection of icicles sticking above the water, but under the surface is the remainder of the structure that’s much larger than you’d expect.

If you have, then you know how closely this image often aligns with that of an undermining wound—in which tissue beneath the skin has been damaged or destroyed, causing the edges of the wound to become eroded or sunken. The result is a wound that can be much larger and deeper than it appears to be on the surface.

Not to be confused with the similar but distinct tunneling wound, where damage extends deeply and narrowly into underlying tissue like a tunnel, undermining wounds are shallower but can spread wide under the surface of the skin—much like an iceberg under the surface of the water.

If you’re a practitioner who’s dealt with undermining wounds before, you know they can be difficult to treat due to hidden tissue damage, infection risk, and certain underlying conditions, among other health factors.

Whether you’re treating pressure ulcers—which is likely, given that one meta-analysis found that they have a prevalence rate of 12.8% worldwide—or infected wounds or burns, staying in the know about current undermining wound treatments can help you deliver the best care for your patients. Continue reading to learn about several of these treatments, as well as emerging technologies to keep on your radar.

8 Current Top Treatments for Undermining Wounds

1. Debridement

Debridement is the process of removing dead or damaged tissue from a wound. It’s one of the most common treatments for undermining wounds. It’s also a crucial step in treating these wounds as it helps to promote healing and prevent infection. Debridement can be performed using a variety of techniques, including sharp debridement, mechanical debridement, and enzymatic debridement.

2. Negative Pressure Wound Therapy

Negative pressure wound therapy (NPWT) involves applying a vacuum to the wound, which helps to remove fluid and debris, promote tissue growth, and reduce swelling. This treatment is often used for complex wounds, including undermining wounds, as it can help to improve healing rates and reduce the risk of infection.

Notably, studies on different wounds suggest that NPWT may be more economical in the long term compared to conventional wound care methods—despite the dressings being more expensive—as it requires fewer dressing changes and lesser reconstructive options for wound healing.

“Wound healing is faster and [there is an] overall short duration of treatment and hospitalization,” says the authors in a review of NPWT literature published in the National Library of Medicine (NLM).

3. Moisturized Wound Care

Keeping the wound moist is essential for promoting healing and preventing infection. A variety of moist dressings, such as hydrocolloids, hydrogels, and alginates, can be used to maintain a moist environment. These dressings can also help to absorb exudate and protect the wound from bacteria.

4. Antibiotics

Antibiotics may be prescribed to treat infections associated with undermining wounds. The choice of antibiotic will depend on the type of bacteria causing the infection. Of course, it’s important to stress to patients that they complete the full course of antibiotics to ensure that the infection is completely eradicated.

5. Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) involves exposing the patient to high concentrations of oxygen in a pressurized chamber. This treatment can help to improve blood flow to the wound and promote healing. It’s often used for wounds that are resistant to other treatments, such as those associated with diabetes or vascular disease.

An interesting study on HBOT published in 2020 in the NLM found that out of 248 patients referred to a treatment center for nonhealing, chronic wounds across various surgical specialties, 81% of all wounds were near complete healing or completely healed after adding a minimum of 20 HBOT sessions to standard wound care protocols.

“Even highly complicated wounds that had existed for more than 18 months showed accelerated wound healing (79%),” notes the authors of the study.

6. Skin Grafting

Skin grafting may be necessary in some cases to cover large or deep undermining wounds. This involves transplanting healthy skin from another part of the body to the wound site. Skin grafts can help to promote healing and improve the appearance of the wound.

7. Growth Factors

Growth factors are naturally occurring proteins that play a crucial role in regulating cellular growth, differentiation, and migration. They are essential for tissue repair and regeneration, including the healing of wounds. Specifically, growth factors help to promote healing, reduce swelling, and improve blood flow to the wound.

8. Surgical Debridement

In severe cases of undermining wounds, surgical debridement may be necessary to remove large amounts of dead or excessively damaged tissue. For example, necrotizing soft tissue infections, or NSTIs, typically call for “aggressive” surgical debridement of all necrotic tissue and the “delay of definitive debridement is the most critical risk factor for death,” notes the authors of a book on wound assessment.

10 Emerging Technologies for Undermining Wound Treatment

1. Electronic Health Records with Wound Care Modules

Electronic health records (EHRs) equipped with advanced wound care modules can significantly improve the management of undermining wounds. These modules can track wound measurements, document treatment plans, and monitor patient progress over time. They can also integrate with other medical devices and systems, such as NPWT machines, to provide a comprehensive view of patient care.

2. Artificial Intelligence for Wound Image Analysis

AI algorithms can be trained to analyze wound images and identify potential complications, such as infection or tissue necrosis. This can help healthcare providers detect and address issues early, preventing further deterioration of the wound. For example, AI-powered wound imaging platforms can accurately measure wound size without a physical ruler, assess tissue viability, and identify signs of infection based on visual cues. Some can provide recommendations for diagnosis and treatment options based on comparison with thousands of other wounds at various stages of healing.

A systematic review on image-based AI in wound assessments published in the NLM in 2022 indicates that AI-based systems hold the power to help clinicians diagnose, assess the effectiveness of therapy, and predict healing outcomes. However, several issues exist that limit this potential:

• Image collection. Collecting wound images during every clinical visit is time consuming. Luckily, some platforms are adapting to images taken by phone, which may help alleviate this issue in the future.
• Data interpretation. Interpreting the large number of collected images and other data is cumbersome.
• AI capabilities. Developing AI systems for high-quality wound care that result in better patient outcomes is challenging.

Still, the authors of the review indicate hope is on the horizon:

“With increasing availabilities of massive data (wound images, wound-specific electronic health records, etc.) as well as powerful computing resources, AI-based digital platforms will play a significant role in delivering data-driven care to people suffering from debilitating chronic wounds.”

3. 3D Printing for Wound Dressings

3D printing technology can be used to create customized wound dressings that are tailored to the specific needs of each patient. These dressings can be designed to provide optimal moisture retention, support, and protection, while also incorporating antimicrobial agents or growth factors to promote healing.

4. Bioengineered Skin Substitutes

Bioengineered skin substitutes are being developed to replace damaged skin and promote healing. These materials can be derived from a variety of sources, including human cells, animal cells, and synthetic materials. They can be used to cover large, complex wounds, including undermining wounds, and can help to reduce the risk of infection and scarring.

5. Nanotechnology

Nanotechnology involves the manipulation of materials at the atomic and molecular level. Nanomaterials can be used to create wound dressings that are highly absorbent and antimicrobial, as well as promote tissue regeneration. For example, nanofiber dressings can provide a scaffold for new tissue growth, while nanoparticles can deliver growth factors or antibiotics directly to the wound site.

One 2023 review calls out research reports that show evidence of several promising developments in nanotechnology:

• Drug delivery systems. “Nanoparticulate drug delivery systems accelerate the wound healing process due to their ability to safeguard the therapeutic agents from degradation caused by specific wound environments,” the authors write.
• Therapeutic agents. According to authors of the review, “The slow and steady release of loaded therapeutic agents from nanomaterials [maintain] the effective therapeutic concentration at the wound site leading to reduced dosing frequency and an accelerated wound healing process.”
• Patents. In recent years, there have been several innovative patent applications and grants of NPs-based wound dressing systems, indicating continued development of this technology.

6. Stem Cell Therapy

Stem cells are undifferentiated cells that have the potential to develop into different types of tissues. These cells are being investigated for their potential to promote wound healing by stimulating tissue regeneration and reducing inflammation. Stem cells can be derived from various sources, including bone marrow, adipose tissue, and umbilical cord blood.

7. Wearable Sensors for Wound Monitoring

Wearable sensors can be used to monitor wound temperature, moisture levels, and other vital parameters. This can help to detect early signs of infection or tissue breakdown and allow for timely interventions. For example, sensors can be integrated into wound dressings or bandages to provide real-time data on wound healing progress.

8. Augmented Reality (AR) for Wound Assessment

AR can be used to overlay digital information on top of real-world images. This can be helpful for visualizing the extent of undermining wounds and guiding treatment decisions. For example, AR can be used to display measurements, annotations, or 3D models of the wound, providing healthcare providers with a more comprehensive understanding of the patient’s condition.

9. Gene Therapy

Gene therapy involves introducing genetic material into cells to treat diseases. It’s being investigated as a potential therapy for chronic wounds, including undermining wounds. By delivering genes that promote tissue regeneration or reduce inflammation, gene therapy could help to improve healing rates and reduce the risk of complications.

10. Photodynamic Therapy

Photodynamic therapy (PDT) involves the use of light to activate a photosensitizing agent, which can then destroy cancer cells or bacteria. This therapy is being investigated as a potential treatment for chronic wounds, including those with infection or tissue necrosis. As a result, PDT can be used to not only reduce bacterial load and promote tissue healing, but also reduce the need for surgical debridement.

Get Undermining Wounds Under Control

Chances are you’re already using several of the above treatments, but hopefully the inclusion of emerging technologies in undermining wound care give you some new methods to explore.

Standard treatments like debridement and antibiotics are great first line treatments for undermining wounds, especially when slough or the lifted edges of the wound make it difficult to tell the size and depth of the wound. But advanced treatments like NPWT and HBOT have shown promise, and many new advancements, from bioengineered skin substitutes to nontechnology to PDT, offer more options than were available in the past.