Negative Pressure Wound Therapy with Multiple Drainage Holes for the Treatment of Pressure Ulcer with Undermining: Case Reports

doi:10.4236/jcdsa.2013.31015

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Journal of Cosmetics, Dermatological Sciences and Applications, 2013, 3, 107-109

http://dx.doi.org/10.4236/jcdsa.2013.31015 Published Online March 2013 (http://www.scirp.org/journal/jcdsa)

107

Negative Pressure Wound Therapy with Multiple Drainage

Holes for the Treatment of Pressure Ulcer with

Undermining: Case Reports

Hiroyuki Miura, Yumiko Ito, Tomoko Matsuda, Ayano Abe, Syun Kitaba

Department of Dermatology, Kinki Central Hospital, Itami, Japan.

Email: [email protected]

Received January 4th, 2013; revised February 7th, 2013; accepted February 15th, 2013

ABSTRACT

Noninvasive treatment of pressure ulcers with undermining is often difficult. To decrease the risk of bleeding in such

conditions, negative pressure wound therapy (NPWT) has been applied. We treated a pressure ulcer with wide under-

mining using NPWT after opening drainage holes in the undermined area. This method can reduce the risk of bleeding

and promote the rapid closure of the undermined area.

Keywords: Negative Pressure Wound Therapy; Pressure Ulcer; Undermining

1. Introduction

Negative pressure wound therapy (NPWT) is gaining po-

pularity as an acute and chronic wound management, and

can prevent bacterial infection, eliminate edema, and fa-

cilitate neovascularization [1-3].

Noninvasive treatment of pressure ulcers with under-

mining is often difficult. To decrease the risk of bleeding

in such conditions, NPWT has been applied. However,

closure of the undermined area requires a long operative

time [3,4]. Therefore, we treated a pressure ulcer with

wide undermining using NPWT after opening drainage

holes in the undermined area. This method can reduce

the risk of bleeding associated with incising the entire

undermined area and promote the rapid closure of the un-

dermined area.

2. Case Reports

2.1. Case 1

An 86-year-old woman, with right-sided paralysis due to

cerebral infarction, had been suffering from a Stage III

pressure ulcer for 3 months. Examination revealed a

pressure ulcer (4 × 3 cm) with a widely undermined area

(8 × 5 cm) on the right great trochanter. Blood tests re-

vealed a low albumin level (3.2 g/dL) and slight anemia

(Hb, 10.4 g/dL). NPWT using the polyurethane foam-

based NPWT system (RENASYS; Smith & nephew, Flo-

rida, USA) at −80 to −120 mmHg for a month neither

reduced the size of the ulcer nor improved the under-

mining (Figure 1(A)). Therefore, we opened several

drainage holes using a 5-mm punch biopsy needle on the

undermined surface under local anesthesia, instead of in-

cising the entire undermined area (Figure 1(B)). After

confirming the absence of bleeding over night, we started

NPWT again at −120 mmHg.

Twice a week, when the dressing had been changed,

basic fibroblast growth factor (bFGF) (Fiblast splay; Ka-

ken, Tokyo, Japan) was applied to the ulcer and drainage

holes.

Two weeks after this treatment, the sizes of the ulcer

and the undermining were 3 × 2 cm and 3 × 1.5 cm, re-

spectively (Figure 1(C)). During 2 weeks of additional

NPWT, no improvement of undermining was observed.

Therefore, we performed a histological examination of

the undermined area. In the specimen of the undermined

area, which closed rapidly, the tissue of the ceiling por-

tion was granular. On the other hand, in the specimen of

the remainder of the undermined area, the ceiling portion

was covered with irregular epithelium, thought to have

prevented closure of the dead space (Figure 1(D)). There-

fore, we stopped NPWT and continued bFGF and hy-

drocolloid dressing and so on, sometimes performing de-

bridement of the ceiling surface using a curet. After 2

weeks closure of the undermined area was observed, and

there was complete epithelialization of the ulcer after 5

weeks (Figure 1(E)).

2.2. Case 2

An 80-year-old woman had been suffering from stage III

sacral pressure ulcer for several years, consist of an ulcer

Negative Pressure Wound Therapy with Multiple Drainage Holes for the Treatment of Pressure Ulcer

with Undermining: Case Reports

108

(A)

(B)

(C)

(D)

(E)

Figure 1. (A) Pressure ulcer (4 × 3 cm) with wide under-

mined area (dotted line: 8 × 5 cm); (B) Drainage holes were

made with a 5-mm punch biopsy needle in the undermined

area before NPWT; (C) Two weeks after treatment, the size

of the ulcer and the undermining were 3 × 2 cm and 3 × 1.5

cm, respectively. All of the drainage holes closed and left a

slight scar. (D) Histological appearance of the ceiling of the

undermined area (H&E stain, ×40 magnification). (a) A

specimen of undermining that closed rapidly (1B, *); The

ceiling portion consisted of granular tissue (arrow); (b) The

remainder of the undermined area (1B, **). The ceiling por-

tion was covered with irregular epithelium (double arrow).

(E) Complete epithelialization of the ulcer was observed.

(3 × 3 cm) with an undermined area (3 × 3 cm) and an

ulcer (1 × 0.5 cm) with an undermined area (1.5 × 1 cm).

When we opened drainage holes on the undermining

(Figure 2(A)), we investigated the ceased piece of un-

dermining by dermoscopy and found the existence of

irregular epithelium in the ceiling portion of the under-

mining, which histologically confirmed later. After we

performed debridement using a curet, we started NPWT

with drainage holes on the undermining, in the same

method as Case 1. After two weeks of NPWT both of the

undermining were closed (Figure 2(B)).

3. Discussion

Pressure ulcers can form anywhere on the body, although

they most frequently develop in the sacral area (30% -

40%). The great trochanter is another location where

pressure ulcers occur frequently (10% - 15%) [4]. They

are caused by pressure, traction, friction, or their combi-

nation.

The treatment of a pressure ulcer with undermining is

challenging. It is recommended that an incision be made

above the undermined surface, although this is an inva-

sive approach that carries the risk of bleeding. To prevent

bleeding, NPWT has been applied to such conditions.

However, undermining closure requires a long operative

time and is sometimes unsuccessful [3,4].

To promote the closure of the undermined area, we

administered a basic fibroblast growth factor (bFGF)

(A)

(B)

Figure 2. (A) Pressure ulcer (3 × 3 cm) with an undermined

area (line: 3 × 3 cm) on the left side of scrum and an ulcer (1 ×

0.5 cm) with an undermined area (line: 1.5 × 1 cm) on the

right. The drainage holes, four on the left and one on the

right side, were opened before NPWT; (B) Closure of un-

dermining was observed after two weeks of NPWT.

Negative Pressure Wound Therapy with Multiple Drainage Holes for the Treatment of Pressure Ulcer

with Undermining: Case Reports

109

spray because bFGF has been reported to accelerate

wound healing by promoting neovascularization, granu-

lation, and epithelialization [5]. Furthermore, we hy-

pothesized that the drainage holes created in the under-

mined area may decrease the dead space below the un-

dermined area, thus allowing for strong contact between

the ceiling of the undermined area and the bottom of the

dead space during NPWT. In fact, the drainage holes

gradually reduced in diameter following NPWT, and

they were filled with high amounts of granulation tissue

after NPWT and bFGF administration. After closure of

the drainage holes, the granulation tissue likely extended

downward to the bottom, as the resultant scars seemed to

adhere tightly to the underlayer without mobility.

In both of our cases, irregular epithelialization was

observed in the ceiling of the undermined area. This ir-

regular epithelium is believed to prevent undermining

closure; therefore, this tissue must be identified by his-

tology, dermoscopy, or other methods before NPWT

with drainage holes can be performed in the undermined

area.

Thus, the granulation tissue in drainage holes may play

a role as an anchor that fixes and encloses the undermin-

ing. In addition, we believe that NPWT with drainage

holes created in the undermined area may become a

therapeutic option for pressure ulcers with undermining.

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