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Part 1: Symptom control in the management of fungating wounds

Author(s)

Wayne Naylor
BSc(Hons), RN, Dip Nursing, Onc cert

Wound Management Research Nurse
Directorate of Nursing, Rehabilitation and Quality Assurance
Royal Marsden Hospital, Sutton, Surrey, SM2 5PT, UK
Email: Wayne.Naylor@rmh.nthames.nhs.uk

Contents
Published: Feb 2002
Last updated: Feb 2002
Revision: 1.0

Keywords: fungating wounds; sympton control; malodour; exudate; pain; bleeding.

Key Points

  1. For a significant minority of cancer patients the presence of a malodorous, exuding, necrotic skin lesion can be a constant physical reminder that their disease is both progressive and incurable.

  2. Fungating wounds may develop from a primary skin tumour, an underlying tumour or metastatic disease. Sometimes a chronic wound may undergo malignant transformation to produce a fungating wound, although this is rare.

  3. The most frequently reported symptoms related to a fungating wound are malodour, exudate, bleeding and pain.

Abstract

Fungating malignant wounds are a distressing problem for a significant number of patients with advanced cancer. They may develop during the last few months of life or be present for a number of years. Fungating wounds rarely heal and often require palliative management. In treating patients with fungating wounds, the goal of care is to maintain or improve quality of life through symptom control. This article reviews the management of the four most common symptoms associated with fungating wounds: exudate, malodour, bleeding and pain.


Introduction

Many cancer patients live with the knowledge that their disease is both progressive and incurable. For a significant minority of these people this reality may be present in the form of a malodorous, exuding, necrotic skin lesion, which can be a constant physical reminder of disease progression [1], [2]. These lesions are commonly known as 'fungating wounds', the term 'fungating' referring to a malignant process of both ulcerating and proliferative growth [3], [4]. Lesions that have a predominantly proliferative growth pattern may develop into a nodular 'fungus' or 'cauliflower' shaped lesion, whereas a lesion that is ulcerating will produce a wound with a crater-like appearance [5], [6]. Sometimes a lesion presents with a mixed appearance of both proliferating and ulcerating areas [7], [8].

A fungating wound may develop in the following ways:


image
Figure 1 - A fungating wound which has developed from a malignant melanoma


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Figure 2 - Fungating wound on the breast, chest wall and upper arm arising from recurrent breast cancer


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Figure 3 - Fungating lesion on the forearm caused by metastatic breast carcinoma

Although rare, malignant changes may develop in chronic wounds (Marjolin's ulcer). This condition is most commonly associated with burn scar ulcers, but can develop in other chronic wounds such as pressure and venous stasis ulcers, as well as osteomyelitis [9], [10]. This type of malignancy usually occurs as an aggressive squamous cell carcinoma with a high rate of metastatic spread and local recurrence. In most cases, patients will be over the age of 50 and will have lived with the ulcer for between 25-40 years before any malignant changes occur. The condition is more common in women than men [11]. Signs of malignant change in a chronic wound include onset of pain or a change in the type or intensity of pain experienced, malodour and a change in the character, volume or appearance of exudate. A mass in the wound may be obvious, but a diagnosis of Marjolin's ulcer can only be confirmed following biopsy of the wound [9].

Fungating wounds tend to develop in elderly patients (>70 years) with metastatic cancer, who are in the terminal stages of their illness [12], [13]. Approximately 62% of fungating wounds will develop in the area of the breast and 24% in the head and neck area [14]; a fungating wound can, however, arise anywhere on the body. Although fungating wounds occur more frequently in people with advanced cancer, it is possible for people to live many years with a fungating wound if the disease is localised [5], [12], [15], [16]. For most patients, healing of the wound is unlikely unless there is a good response to anti-cancer therapy, such as radiotherapy or chemotherapy, or the wound can be surgically excised. Most fungating wounds will, however, continue to deteriorate over time [17], [18], [19] and commonly have a devastating effect on a person's physical and emotional well-being [5], [20], [21].

In treating patients with fungating wounds, the overall goals of nursing care are to promote patient comfort, confidence and a sense of well-being, to prevent isolation and maintain or improve a patient's quality of life (QOL) [12], [18], [22], [23]. Therefore, management is focused on controlling and/or eliminating the distressing symptoms associated with these wounds [7]. To achieve these goals accurate assessment is vital as a means of determining patient needs and evaluating the effectiveness of symptom management interventions [24].

The patient's experience

A review of the literature has identified many physical, psychological and social problems associated with fungating wounds (Table 1). The most frequently reported wound symptoms are exudate, malodour, bleeding and pain.
Table 1: Physical and psychosocial problems associated with fungating wounds
WOUND PSYCHOSOCIAL
Anatomical location Body image
Bleeding Communication difficulties
Comfort of dressings Cosmesis of dressing
Condition of surrounding skin Denial
Condition of wound bed Depression
Devitalised tissue Embarrassment
Exudate management Fear
Frequency of dressing changes Guilt
Infection Impact on family
Malodour Information needs
Pain related to dressing changes Restrictions due to dressing changes
Pruritis Revulsion/disgust
Size/shape Self-respect/self-esteem
Tunnelling/undermining Sexuality
Wound pain Shame
  Social isolation
  Social support/resources

Malodour

Wound malodour is probably the most distressing symptom for patients [7], [19], [25], [26], and is caused by bacterial infection in devitalised tissue within the wound. This can also be devastating for the patient's family and caregivers, as wound malodour may be constantly detectable and can trigger gagging and vomiting reflexes [15], [27], [28]. The presence of a pervasive malodour can lead to embarrassment, disgust, depression and social isolation and may have a detrimental effect on sexual expression causing relationship problems [18], [19], [21], [28].

Exudate

Fungating wounds often produce excessive amounts of exudate which can be difficult to manage [20], [21]. Increased permeability of blood vessels within the tumour and secretion of vascular permeability factor by tumour cells are the most likely causes of high exudate levels [12]; exudate production may also be increased if infection is present. Large volumes of uncontrolled exudate may cause leakage from the dressing [3] and staining of the patient's clothes [29], [30], [31]. This again can cause significant psychosocial problems for patients and carers. Effective management of wound exudate is likely to increase both patient confidence and comfort.

Pain

There are a number of mechanisms that can cause fungating wounds to be painful. The tumour, for example, may be pressing on nerves and blood vessels (Figure 4), or there may be exposure of the dermis [32]. Patients often describe their pain as a superficial stinging or painful ulceration [5]. Painful procedures such as the use of an inappropriate cleansing technique or removal of a dressing which adheres to the wound bed may also impact on the pain experienced by the patient [21].


image
Figure 4 - A fungating wound on the back with neighbouring tumour mass which has developed from a recurrent peripheral nerve sheath tumour. The wound and associated tumour were very painful due to pressure on surrounding tissues

Bleeding

Wound bleeding is common in fungating wounds. This occurs because malignant cells erode blood vessels, and may be compounded by decreased platelet function within the tumour. Profuse, spontaneous bleeding can be distressing for both patients and their carers [12], while damage to fragile tissues during dressing changes may exacerbate bleeding (Figure 5).


image
Figure 5 - Bleeding in a fungating malignant melanoma due to trauma from an adherent dressing

Cosmetic appearance

The position of the wound may be a source of embarrassment and distress for the patient especially if it is in an area such as the breast or genitals, or an area highly visible to others, for example, on the face [20]. Appropriate wound management that attends to the patient's outward appearance can have a very positive effect on self-esteem and emotional distress [12], [18]. Many patients can only continue an active social life if a socially acceptable dressing is available [31]. In some cases this may be achieved by devising a cosmetically acceptable dressing regime, for example, one that not only effectively manages odour and exudate, but also restores body symmetry. This should be carried out in an effort to boost patient confidence and improve their ability to socialise [31], [33].

Symptom management

Malodour

Debridement removes necrotic tissue and bacteria and is the primary treatment for malodorous fungating wounds. Surgical or sharp debridement, however, is not recommended because of the increased tendency of these wounds to bleed. Autolytic or enzymatic debridement is the preferred method, providing this does not significantly increase exudate production [34]. Antibiotic therapy can also be effective if this destroys the bacteria responsible for malodour [35], [36], [37], the most common treatment being metronidazole. This may be given systemically, but side effects such as nausea, neuropathy and alcohol intolerance may affect patient acceptability [38]. A poor blood supply to the wound may further reduce the effectiveness of systemic treatment [39]. Topical preparations of metronidazole gel (e.g. Metrotop®, Anabact®) have been used successfully [40], [41]. This gel is usually applied once daily for five to seven days but may need to be repeated more often to keep malodour under control.

The use of activated charcoal dressings can have an immediate effect on wound malodour. These include plain activated charcoal cloth (e.g. CliniSorb®), or charcoal cloth combined with other dressing materials (e.g. CarboFlex®, Lyofoam C®) or impregnated with silver (e.g. Actisorb Silver 220®). Activated charcoal attracts and binds the volatile odour causing molecules, preventing their escape from the local wound area [42].

Sugar paste and honey have recently come back into use, mainly due to the emergence of many antibiotic resistant strains of bacteria, and both have antibacterial and debriding properties. The high sugar content of these products produces a hyperosmotic wound environment that inhibits bacterial growth and assists in wound debridement [43], [44]. Honey may also contain bacteriocidal hydrogen peroxide, which is slowly released as the honey is diluted in wound exudate, while specific types of honey may have plant derived antibacterial properties [45], [46], [47].

Occlusive dressings may help by containing wound malodour, while daily dressing changes with the correct disposal of soiled dressings, can help prevent build-up of stale exudate. Deodorisers may mask the odour and products such as essential oils, environmental air filters or commercial deodorisers may be helpful [48]. However, on occasions these products, in particular commercial deodorisers, may make the odour worse or cause unpleasant associations with smells.

Exudate

A variety of dressings have been evaluated for the management of exudate from fungating wounds with varying levels of success [49], [50]. Where exudate is low, wounds should be managed with dressings that have a low absorbency so as not to dry out the wound, for example hydrocolloids, semi-permeable films and low adherent absorbent dressings [21]. However, care should be taken with the latter as they may stick to the wound base if this dries out too much.

More commonly fungating wounds produce moderate to high levels of exudate and it is important to choose a dressing that will absorb excess exudate, but still maintain a moist wound environment. Suitable dressings for wounds with high exudate levels include alginate and hydrofibre dressings, foam dressings and non-adherent wound contact layers, such as soft silicone (Mepitel®) or knitted viscose (NA Ultra®) with a secondary absorbent pad [5], [20]. For wounds with a small opening and high exudate, a stoma appliance or wound manager can be used [21].

Pain

Assessment of pain is vital as this will enable the clinician to understand the type of pain the patient is experiencing and determine the most appropriate treatment. Analgesic drugs should be prescribed using the World Health Organisation (WHO) guidelines for the control of cancer pain [51] and in accordance with local prescribing guidelines. It may also be useful to give the patient a pre-medication before dressing changes or a booster dose of their usual opiate, for example Oramorph® if the patient is on MST®. If dressing changes are very painful it may be worth using nitrous oxide (Entonox®) gas during the procedure [52].

To help prevent pain during dressing changes, non-adherent dressings should be used. Maintaining the wound in a moist environment will not only reduce dressing adherence but will also protect exposed nerve endings [18], [53]. If pain cannot be controlled at dressing changes then it may be worth trying a product that requires less frequent changes. Irrigation of the wound with warm saline rather than cleaning with a gauze swab will, in some cases, reduce pain [54]. Complementary therapies can play an important part in pain management; therapies such as relaxation, distraction or visualisation may help anxious and stressed patients who will have a heightened response to pain [55], [56].

Topical opioids are an interesting alternative form of pain control that can be used for painful ulcerating wounds. Although research is limited, a number of published case studies and theoretical papers support the use of topical opioids to reduce wound pain [57], [58], [59], [60], [61]. Morphine and diamorphine are most commonly used, mixed with a hydrogel (about 1 mg of morphine to 1 g of hydrogel for 0.08 to 0.1% mixture). This is usually applied to the wound once daily although some patients have used it on an 'as required' basis.

Chemotherapy, radiotherapy, hormone therapy or a combination of these anti-cancer therapies may help to shrink the wound by destroying malignant cells, reducing pressure on nerves and other structures and decreasing the area of exposed tissue [12], [18], [62]. This may have a significant effect on the level of pain experienced by the patient.

Bleeding

Preventative measures are important to reduce the risk of bleeding. Using non-adherent dressings that maintain a moist environment, and cleansing by irrigation rather than swabbing, will reduce the risk of trauma and subsequent bleeding. Oral antifibrinolytics such as tranexamic acid (Cyklokapron®) may also help [20].

For wounds that are actively bleeding, there are a number of strategies available. Sucralfate paste or an alginate may be applied to wounds with a small amount of bleeding [63], [64]. Alginates should, however, be used with caution in fragile tumours as they may cause bleeding [65]. As an alternative, haemostatic surgical sponges, such as Spongostan® or Oxycell®, can be used as these promote rapid haemostasis and can be left in place and covered with an appropriate dressing. Topical adrenaline or tranexamic acid can also be applied, but they should only be used under medical supervision and caution is advised as adrenaline may cause ischaemic necrosis due to local vasoconstriction [61]. Excessive, uncontrolled bleeding may need referral to a vascular surgeon for cautery or ligation.

Conclusion

Fungating wounds can present a major problem for both patients and healthcare professionals. Not only do they signify progressive and life threatening disease, but also significantly affect a patient's QOL by causing unpleasant and difficult to manage symptoms.

The cornerstone of effective symptom management is accurate assessment. In Part Two, the development of a new symptom assessment tool is reviewed, which allows patients to rate the severity of symptoms and problems they are experiencing, together with the level of interference their symptoms and associated problems are having on their lives.

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