This site is intended for health professionals only

Fungating malignant wounds: a guide to management

Una Adderley
RGN DN BSc BA
Research Nurse
Centre for Evidence Based Nursing
Department of Health Studies
University of York

District Nurse Scarborough and NE Yorks NHS Trust
E:una@adderleyspringfarm.fsnet.co.uk

Although the exact incidence of fungating wounds is currently unknown, most primary care nurses who practice wound management will care for patients with this condition on a regular, if infrequent, basis.
The management of fungating malignant wounds is complex and challenging,(2) and the physical and psychological distress for both patients and their carers is well documented.(3) However, at present there is little relevant research evidence to guide clinical practice.(4) The condition demands a team approach that includes expertise in oncology, palliative care and wound care. In addition, patients with tumours that involve structures such as the digestive system or genitourinary system will require input from specialists such as dietitians and stoma advisors.
Fungating wounds are usually associated with advanced cancer, particularly carcinoma of the breast, although other carcinomas, such as head and neck and genitourinary, can also lead to fungating wounds.

[[NIP11_fig1_79]]
PHOTOCREDIT DR P MARAZZI/SCIENCE PHOTO LIBRARY

Malignant cells spread between the tissue planes, along blood and lymph capillaries and into the perineural spaces, interfering with tissue oxygenation, lymphatic drainage and haemostasis. The loss of vascularity leads to the loss of tissue viability and tissue necrosis. Rapid tumour cell growth interferes with the clotting mechanism, leading to coagulation and subsequent tissue death and necrosis. The lymphatic system may be impaired, causing infarction, hypoxia and necrosis. Anaerobic and aerobic bacteria thrive on necrotic tissue, causing malodour and profuse exudate. In addition, the fragility of tumour capillaries increases the risk of haemorrhage.
Accurate diagnosis of the underlying cause of the wound is essential, and a small proportion of patients may achieve healing following surgical excision. The possibility of tumour sensitivity to radiotherapy and chemotherapy treatment should be considered as it may be possible to significantly reduce the size of the tumour or even achieve healing. Unfortunately tumours often recur, but such treatments may reduce symptoms and prolong life.
When the aim of care is palliation, treatment should try to achieve the best quality of life for patients and their families. Effective care can greatly relieve the physical and psychological impact of altered body image and reduced independence. Good practice is aimed at effective management of the physical symptoms, such as exudate, malodour, pain and the risk of haemorrhage, which will hopefully lessen the psychological burden for the patient and their family. However, it is important that aims remain realistic, and the priorities of care are jointly agreed with the patient and their family.

Managing exudate
Uncontrolled exudate swiftly leads to skin maceration and excoriation, causing pain and increasing the size of the lesion. Since the problem is predictable, barrier products should be used from the beginning. Recent advances have resulted in the availability of alcohol-free barrier products (eg, 3M Cavilon) that provide sustained protection against exudate damage.
The management of exudate also requires the development of dressings that can cope with absorption of exudate while avoiding adhesion to the wound bed, which may lead to haemorrhage. Most general wound care management aims at achieving healing through applying Winter's theory of moist wound healing,(5) but this is not the aim for palliative management of fungating wounds. However, a moist wound contact layer remains important since this prevents painful adhesion that may lead to haemorrhage.
Grocott recommends the development of dressing systems with the following three functions:(6)

  1. Conservation of surface humidity and moisture to prevent adherence and trauma (eg, low-adherent silicone dressings, foam dressings).
  2. Reservoir capacity for exudate that is excess to the purpose of point 1 (eg, foam dressings).
  3. High moisture vapour transfer through the back surface of the dressing to vent excess fluid and manage overload of exudate production.

Unfortunately, materials with high levels of moisture vapour transfer are not easily available in the UK at present. Simple, high-venting dressings such as gauze are unable to conserve the necessary amount of moisture at the wound contact interface, and strikethrough can be problematic.
The problems are compounded by lesions that present in awkward-to-dress contours of the body. Dressings need to fit the size and site of the wound, since joining several small dressings increases the risk of leakage.

Managing malodour
Malodour usually has a psychological impact and may cause nausea, loss of appetite and subsequent weight loss. Like pain, malodour is a subjective experience. Odour assessment scoring tools exist and offer the possibility of minimising subjectivity and enabling a means of comparison. (7) However, any assessment tool should be assessed and validated before use. In addition, the use of a tool may alert a patient to a symptom of which they were previously happily unaware.
Malodour is caused by a combination of infected necrotic tissue and stale exudate. When the blood supply to the skin is impaired, the subsequent wound becomes filled with debris, slough and necrotic tissue, which form an ideal breeding ground for anaerobic bacteria. Malodorous wounds usually contain at least two anaerobic bacteria in addition to aerobic bacteria. Anaerobic bacteria break down the proteins in dead tissue, leading to tissue liquefaction and the release of volatile fatty acids with pungent odour. In addition, stale exudate will become malodorous.
Gentle cleansing with an isotonic solution such as saline 0.9% will remove stale exudate and some debris. Removal of dead tissue will lessen the problem, but surgical or sharp debridement is not recommended due to the high risk of bleeding. Debridement through autolysis using a hydrogel may be helpful, but the possibility of reducing malodour must be weighed against the increase in exudate.
Systemic antibiotic therapy may reduce bacterial colonisation and thus reduce malodour. Unfortunately, impaired blood supply around the wound may mean that the antibiotic fails to reach the wound site, and many antibiotics have gastric side-effects. In particular, patients taking oral metronidazole, which is commonly prescribed for anaerobic infection, must avoid alcohol. These limitations and side-effects may have a significant impact on the patient's quality of life.
Eradication of infection is impossible since the fungating wound cannot be healed. Therefore the palliative care literature suggests that a lower dose of metronidazole may control malodour and minimise side-effects.(8)
A course of treatment will usually last 5-7 days and will need to be repeated when malodour recurs.
Topical metronidazole minimises the side-effects and ensures that the drug reaches the wound site. However, the presence of necrotic tissue may mean that the drug cannot penetrate in sufficient concentration to reduce malodour.
Activated charcoal dressings filter the pungent volatile fatty acids before they pass into the air. The dressings need to fit closely to prevent malodour leaking around the edge, and they must be changed regularly as they become less effective once saturated with exudate.
 
Managing pain
Pain can be caused by stimulation of the nerve endings (nociceptive pain) or nerve dysfunction (neuropathic pain). Different types of pain require different types of analgesia. Cutaneous pain management may be attempted with topical analgesia (topical diamorphine gel) under the advice of the local palliative care team. Choosing nonadherent dressings to minimise trauma on dressing removal and preventing maceration from excess exudate will also reduce pain.
Patients may also experience intense itching around the edge of the tumour, which may be due to cutaneous infiltration as tumour nodules emerge under surrounding skin. TENS (transcutaneous electrical nerve stimulation), sited on unbroken and healthy skin, may be helpful.(5)

Preventing haemorrhage
The friable blood vessels within fungating wounds mean that haemorrhage is a constant threat. The incidence of haemorrhage can be minimised through careful selection of nonadherent dressings, gentle cleansing and avoiding fibrous dressing materials. While alginate dressings have haemostatic properties, their fibrous nature has the adverse effect of wound adherence and subsequent bleeding. On balance, fibrous alginates are best avoided as a wound contact layer.
Heavy bleeding is a medical emergency and should be immediately referred to an oncology centre. If the patient has a high risk of haemorrhage it is very important to establish communication lines and confirm care planning as a precaution in advance of any event. Surgical haemostatic sponges (eg, Spongostan; Ferrosan) are a possible emergency measure that can be kept with the patient. They are not currently listed in the Drug Tariff but may be obtainable through liaison with the local surgical services.
 
Psychological care
A fungating wound is an unavoidable reminder of the severity of the disease and the patient's own mortality. The symptoms of the wound may cause embarrassment and lead to the patient avoiding close physical contact with loved ones. The need for frequent dressing changes may reduce independence, and patients may also experience guilt and shame.
Effective management of the physical symptoms may be the most effective way of improving the psychological wellbeing of the patient. Coping therapies, such as relaxation and aromatherapy, may also be useful.

Evaluating success
Success in wound care is usually evaluated in terms of healing, but this would be inappropriate for fungating wounds. Evaluation should be from the patient and carer's perspective. If realistic aims have been identified that meet the patient and carer's priorities, then evaluation of success should be measured against those ends.

[[NIP11_pp_84]]

References

  1. Wilkes LM, Boxer W, White K. The hidden side of nursing: why caring for patients with malignant malodorous wounds is so difficult. J Wound Care 2003;12(2):76-80.
  2. Grocott P. The palliative management of fungating malignant wounds. J Wound Care 1995;4:240-2.
  3. Fairburn K. A challenge that requires further research. Management of fungating breast lesions. Prof Nurse 1994;9:272-7.
  4. Grocott P. A review of advances in fungating wound management since EWMA 1991. EWMA J 2002;2(1):21-4.
  5. Winter GD. Formation of the scab and the rate of epithelialisation of superficial wounds in the skin of the young domestic pig. Nature 1962;193:293-4.
  6. Grocott P. The palliative management of fungating malignant wounds. Educational Booklet - Vol 8, No 2. London: The Wound Care Society; 2001.
  7. Haughton W, Young T. Common problems in wound care: malodorous wounds. Br J Nurs 1995;4:959-63.
  8. Naylor W, Laverty D, Mallet J. The Royal Marsden Hospital handbook of wound management in cancer care. Oxford: Blackwell Science; 2001. p.112.

Resources
European Wound Management Association
W:www.ewma.org

Tissue Viability Society
W:www.tvs.org.uk

Wound Care Society
W:www.woundcaresociety.org