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.
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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