VOL: 99, ISSUE: 13, PAGE NO: 55
Vivien McMurray, RGN, RSCN, DipN, was a clinical nurse specialist, palliative care team, Princess Alice Hospice, Esher and Kingston Hospital
Fungating malignant wounds are caused by the infiltration of the skin and its supporting blood and lymph vessels by a local tumour, or result from metastatic spread from a primary tumour. Without treatment, the fungation has the potential to extend and cause massive damage to the wound site, through a combination of proliferative growth, loss of vascularity and ulceration (Grocott, 1999).
Primary skin cancer such as a squamous or basal cell carcinoma and malignant melanoma can develop into a malignant fungating wound if left untreated (Naylor, 2002). Alternatively, a primary tumour can invade and erode the skin to form a malignant fungating wound. This presentation is often seen in untreated tumours or sometimes with recurrent cancer.
Overall the most common tumour sites associated with malignant fungating wounds include breast (62 per cent), head and face (24 per cent) and groin and genitals (three per cent) (Thomas, 1992).
The symptoms associated with these wounds are challenging and it is important that there is an integrated approach to care so as to provide comfort, minimise symptoms and improve the quality of life of patients with such complex wounds (Mallett et al, 1999)
Symptoms associated with malignant wounds
Every malignant fungating wound is unique, not only in appearance but also in presenting symptoms, with some patients having multiple symptoms, and others having very few (Figs 1, 2). The most common symptoms are malodour, exudate, pain, bleeding and pruritis (Naylor, 2002). Other problems include the presence of necrotic tissue, which predisposes the wound to infection. Uncontrolled heavy exudate produced by a fungating wound can also damage the surrounding skin.
The location, size and shape of the wound can give rise to considerable challenges in the fitting and retention of dressings (Naylor, 2002). This can lead to difficulties related to the frequency of, and the pain associated with, dressing changes (Bird, 2000).
Treatment of malignant wounds
A number of treatment options exist to help improve the quality of life for the patient with a malignant fungating wound.
The oncologist may be able to offer palliative radiotherapy, which can reduce exudate and bleeding. Chemotherapy can reduce the size of the tumour, reduce pain, and the risk of haemorrhage and irritation. Hormone manipulation helps reduce the symptoms associated with hormone responsive tumours such as breast cancers. Surgery may be useful to excise the tumour or to minimise the risk of fungation and to reduce the size of the tumour (Hallett, 1995).
The patient needs to be informed of the possible benefits or side-effects so that he or she can make a choice and work in partnership with the named nurse.
The impact of a malignant fungating wound on a patient’s life cannot be underestimated. It can have a devastating effect on his or her physical, psychological and social status as well as impacting on family and friends. It is apparent that many people with this type of wound never seek help or advice from health professionals, and manage the wound themselves (Pudner, 1998). This failure to seek help may arise from a fear of a diagnosis of cancer or from embarrassment due to the position of the wound.
Nurses must gain the patient’s confidence in order to find an acceptable wound management product. Finding a dressing regime to manage all the symptoms of malignant wounds is a challenge in itself and it is important for professionals to share their experiences. When offering support and advice to the patient, the nurse needs to have a working knowledge of the capabilities of the available products.
Inappropriate wound cleansing can result in considerable trauma to the wound with associated pain and bleeding. It is, therefore, recommended that malignant wounds are cleaned by gentle irrigation with warmed 0.9 per cent sodium chloride or water. Cotton wool should be avoided because of the risk of fibre-shedding, as should cold irrigation fluid or high-pressure irrigation, which can be painful or unpleasant for the patient (Naylor, 2002).
Wound malodour is caused mainly by bacteria, both aerobic and anaerobic, which colonise moist areas of necrotic tissue. Initial treatment may involve debridement, although mechanical debridement is not usually advocated because of the propensity for malignant wounds to bleed at the slightest trauma (Young, 1997). Using hydrogel dressings is the most gentle method of debridement as they soften the necrotic tissue to facilitate its separation from the wound bed. Metronidazole is a commonly accepted treatment for wound malodour and can be given systemically or topically, but the latter is expensive and is usually prescribed for a five to seven-day course (Clark, 2002).
Activated charcoal dressings can be useful for the containment of malodour (Kelly, 2002). Developments in silver-impregnated dressings and hydropolymer dressings have meant that bacteria at the wound surface can be significantly reduced by the anti-microbial action of these products (Ballard and McGregor, 2002).
A high level of exudate can cause anxiety and discomfort and may result in the breakdown of the skin. Leakage through the dressing may be distressing for the patient because it may soil clothing and be malodorous (Fletcher, 2002). Infected wounds or those with a large surface area can produce high levels of exudate. Equally, necrotic tissue that is attached to the wound bed and is being debrided will also produce increased exudate. Some dressings which are designed for highly exuding wounds rely on simple absorbency, for example cellulose fibre or some foam dressings. However, such dressings can become saturated and pull away from the wound resulting in poor management of exudate or malodour (Grocott, 1999).
Exudate management depends on conformable materials being fitted to the wound and to the body’s natural curves (Grocott, 1999; 1998).
Developments in wound dressing products have resulted in a variety of fluid handling designs, such as vertical or lateral wicking, which maximise the amount of absorbent surface area (Anderson, 2000). Dressings that have a high moisture vapour transfer rate, appear to vent excess fluid as opposed to allowing it to accumulate (Grocott, 1998).
Naylor (2001a) described the use of a hydropolymer dressing in a case study that considered the problems of exudate and malodour in the management of a fungating wound. He was able to provide a high level of comfort for the patient with a much less bulky dressing. Alternative product choices for the management of exudate include hydrocolloids and alginate dressings.
Thomas (1997) observed that a hydrocolloid dressing that creates an airtight seal over the surface of the wound can reduce exudate production by 50 per cent. It is suggested that the dressing forms a chamber over the wound surface which becomes filled with exudate that is under pressure. This in turn exerts back pressure on the capillaries and inhibits the production of further fluid.
Fungating malignant wounds are fragile and are prone to bleeding, which is characteristically a slow capillary ooze. Bleeding can occur more readily when the dressing is changed. However, the use of non-adherent dressings and gentle wound irrigation will reduce the risk (Naylor, 2002).
Measures to reduce the risk of bleeding include:
- Oral tranexamic acid for up to 10 days;
- Topical sucralfate paste;
- Topical adrenaline can be applied to areas that are bleeding heavily to induce local vasoconstriction, but excessive use can cause ischaemic necrosis;
- Haemostatic surgical dressings can be used for heavier bleeding. They are often used in the operating theatre, but are not readily available in the community.
Malignant growth may erode a major blood vessel and a serious haemorrhage may occur, necessitating referral to a surgeon for cauterization or ligation.
Control of pain should be achieved by using appropriate analgesia and a wound dressing that does not adhere to the wound (Pudner, 1998). A dose of the patient’s usual analgesic 20 minutes before a dressing change is advised. A breakthrough dose of morphine sulphate or a fentanyl lozenge may be prescribed. Topical analgesia such as gels have been successfully used (Grocott, 1999).
Symptomatic relief of pruritis may be obtained by using hydrogel sheets. Menthol in aqueous cream, which is recommended by the Royal Marsden Hospital, has a cooling and soothing effect as long as the itchy area of skin is intact (Naylor et al, 2001b).
Protecting the skin around the wound from enzymes in chronic wound exudate may be achieved through a variety of simple measures. Regular applications of soft paraffin or zinc oxide cream can be useful. Alcohol-free barrier films can provide protection for up to 72 hours before reapplication is necessary.
Fungating malignant wounds pose a considerable challenge to nurses. However, research by tissue viability specialists and those involved in cancer and palliative care, has led to a greater sharing of knowledge to assist the practitioner in finding an acceptable wound management solution and to help provide symptom control and psychological support.