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).
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.
A number of treatment options exist to help improve the quality of life for the patient with a malignant fungating wound.
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.
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).
Exudate management depends on conformable materials being fitted to the wound and to the body’s natural curves (Grocott, 1999; 1998).
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).
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).