Natalie Kelly, BN (Hons), RN, DN.
District Nurse, Gospel Oak Clinic, Camden and Islington Community Health Services NHS Trust, London
It is particularly sad when a patient who knows he or she has a terminal malignant cancer also has to live and cope with a malodorous fungating wound. Such wounds are a constant reminder that the patient’s body is both infected and/or rotting (Moyle, 1998) - surely the ultimate insult to body image (Haughton and Young, 1995). Thus it was decided to review the literature and research available on the management of malodour in fungating wounds in order to gain greater understanding of what can be done to alleviate this distressing symptom.
A literature review on the topic revealed that much of the material was quite old, an indication of the paucity of available clinical research into this area of wound care and thus of the challenges involved in this area of nursing (Fairbairn, 1994). This paper will not, however, seek the explanations for this, but instead concentrate on the possible treatment modalities.
Fungating wounds are described by Mortimer (1998) as a condition of both ulcerative and proliferative malignant growth. Grocott (1999) describes their later appearance as fungus-like or cauliflower-like, although the presentations can vary immensely and shallow craters are also quite common (Collier, 1997a; 1997b). Later stages may be accompanied by sinus or fistula formation (Collier, 1997a; 1997b).
Research on the incidence of fungating wounds in the UK is scarce and somewhat confusing (Ivetic and Lyne, 1990) and the true extent of the problem has not really been identified (Collier, 1997a; 1997b). Haisfield-Wolfe and Rund (1997) estimate that it occurs in 5-10% of patients with metastatic disease, a cause of significant morbidity and a sizeable burden on NHS resources (Grocott, 1997). They may arise anywhere on the body, either as a primary tumour or metastatic disease (Naylor, 2001).
A literature review by Ivetic and Lyne (1990) and the research of Haisfield-Wolfe and Rund (1997) suggest that fungating lesions usually develop during the last six months of a patient’s life. However, recent case studies by Boon et al (2000) and Carville (1995) suggest that this is not always true and may relate to improved treatment modalities.
The cause of wound malodour in fungating wounds and, indeed, all chronic wounds appears to be a topic of hot debate, with literature described by Hampson (1996) as both limited and contradictory.
It is noticeable from the available literature that there is very little guidance to nurses in the form of either research or opinion on how to decide the causes of the malodour in any given wound. This can have a significant impact on the decision of how best to treat a malodorous wound, and reflects the lack of formal protocols for the management of such wounds (Grocott, 2000).
Malodour is sensed by the olfactory receptors located in the recess behind the nose (Van Toller, 1994) and is processed at both a conscious and subconscious level. If the odour is very foul this can lead to repulsive movements and a virtually uncontrollable reaction by the patient’s family and carers (Jacob et al, 1991). Van Toller (1994) further explains that this subconscious experience also affects the experience of taste and flavour (Van Toller, 1994). This obviously has a profoundly negative impact on the patient, diminishing his or her appetite (Benbow, 1999) and enjoyment of food at a time when quality of life is all-important (Price, 1996).
It is well documented that pleasant fragrances evoke happy feelings (Van Toller, 1994) and thus the psychological effect of malodour on patients, families and carers cannot be underestimated. Indeed, Bottomley (2000) states that nearly half of all cancer patients have clinical levels of distress that are equivalent to a psychiatric population. Other effects of malodorous wounds are illustrated in a case study by Price (1996) who found that the malodour was a constant reminder of the patient’s pain and cancer, resulting in higher levels of pain. Better pain control was achieved only when the malodour had been successfully treated.
Moyle (1998) claims that the olfactory system rapidly acclimatises to odour, and that the psychological effect of malodour on a patient comes about through the reactions of carers, family and friends (Moyle, 1998). This is illustrated by Jacob et al (1991) who describes a case where a husband was unable to sleep with his wife because of her malodorous wound. She felt he was rejecting her as a desirable and sexual person (Haughton and Young, 1995). In addition, Van Toller (1994) states that people do not become acclimatised to an unpleasant smell and so the patient is always conscious of the malodour. Van Toller (1994) further states that current social attitudes to smell put the onus of malodour onto the patient who is then held responsible, leading to a reluctance to engage in social interaction and causing a loss in quality of lifestyle. This may also heighten the sense of stigma that many patients associate with their cancer (Neal, 1991).
Treatments for malodorous fungating wounds
Managing a malodorous wound can, at its most basic level, be discussed in two broad categories: containment of the malodour and eradication of its cause. As will be discussed, both of these have their uses but neither is a complete answer.
Odour-absorbing dressings - Containment of the malodour is mostly achieved through the use of odour-absorbing dressings which, to date, means those containing activated charcoal. These were originally developed for military use, where they were incorporated into protective clothing such as air filters and gas masks (Haughton and Young, 1995). The first clinical application is described by Butcher and Maggs (1976) who incorporated activated charcoal into pads which were then placed over malodorous wounds with good effect. The activated charcoal is produced by carbonising a suitable cellulose material. This increases the effective surface area of the fibres and thus their ability to remove malodours that are held there by weak electrical forces (Thomas et al, 1998). So in theory a single dressing should prove capable of removing odour over long periods. Products available with activated charcoal now include Actisorb Plus, Carboflex, Lyofoam C, Carbonet and Clinisorb. These are all available in the community on FP10.
Nevertheless, despite the widespread clinical application of these dressings, yet again there is little objective research available to aid the nurse in his or her decision-making process. Thomas (1989) attributed this to the poor awareness of the importance of the psychological effects of malodorous wounds on patients’ lives.
Thomas’s in vitro research demonstrated clear differences in the ability of the products to contain the malodour with Carboflex performing best out of the primary dressings tested in this particular study, but showed that this was inextricably linked with the physical absorbency of the dressings. This was because, once the charcoal fabric becomes wet, other solutes compete with the volatile molecules for the active sites, making the dressing less effective (Thomas, 1998).
Another problem with charcoal dressings, as highlighted by Grocott (1998), is the significance of dressing fit. She emphasises the importance of completely sealing the edges around the dressing to prevent the escape of odiferous agents. This was easily achieved in Thomas’s (1998) research conditions, but obviously has clinical significance for fungating lesions which, as Grocott (1998) states, are extensive, eccentrically shaped and often on curved body sites, thus rendering it more difficult to seal the edges completely. The limited sizes of the various available dressings also contribute to this problem. Carboflex, for instance, is available in 10x10cm, 8x15cm and 15x20cm sizes, although Thomas (1989) suggests overlapping the dressings to achieve a larger covering. This issue of current assumptions and conventions on size is one frequently encountered in clinical practice. Grocott tackled this in her research by entering into a collaborative partnership with a dressing manufacturer. The new sizes developed are not yet available on FP10, leaving those nurses and their patients without direct access to manufacturers at a disadvantage.
Room deodorisers - Moyle (1998) describes the use of environmental deodorisers such as aerosol scent sprays to disguise malodour as a stopgap method only. The powerful scents can be nauseants (Moyle, 1998), which may leave the patient/carer with an unpleasant psychological association (Haughton and Young, 1995).
Medicated treatments - Malodour can also be managed through chemical control of the causative pathogenic micro-organisms (Moody, 1998). Past treatments have included various antiseptics such as hydrogen peroxide (Moyle, 1998), Eusol (Newman et al, 1989) and acetic acid (Carville, 1995), but these have been shown to have a limited or even adverse effect on wound healing (Ivetic and Lyne, 1990). These treatments have largely been superseded by the use of topical metronidazole gel and/or its oral preparation.
Successful reports of treatments using metronidazole gel first appeared in the late 1970s and a literature review by Hampson (1996) found a large number of articles on the topic. Metronidazole works by preventing bacterial replication through binding to their DNA (Hampson, 1996). Previous theory stated that this could happen only under anaerobic conditions but Hampson (1996) reports that it is now known that it occurs in both aerobes and anaerobes.
Research by Bower et al (1992) using metronidazole gel found that malodour was reduced on average after six days but statistical significance was reached only after 11 days. Newman et al (1989) found that the onset of effectiveness was within the range of one to 30 days, with an average of two days.
However, Hampton (1996) questions the reliability of most of this research, either because no placebo was used and it was supported by a pharmaceutical company (Newman et al, 1989) or because the numbers were too small to be statistically significant (Bower et al, 1992). Bower’s research was also said to lack true validity because the placebo arm of the trial was stopped due to the significant overall improvement in the treatment group.
Oral metronidazole no longer seems to be a popular option and many reviewers say this is due to the associated side-effects such as nausea, prevention of alcohol consumption and even difficulties swallowing the tablets (Newman et al, 1989; Fairbairn, 1994; Moody, 1998). Moreover, many reviewers state the systemic approch will not be effective due to the poor blood supply in necrotic tissue (Fairbairn, 1994; Thomas, 1989). Hampson (1996) states that this is largely supposition as no pharmacokinetic studies exist either to confirm or to deny the problem of tissue penetration.
Hampson (1996) further questions the widespread use of metronidazole on more fundamental issues. As discussed earlier in this text, the bacteriology of malodorous wounds has yet to be fully established (Hampson, 1996) and thus the indiscriminate prescribing of an antibiotic for unknown pathogens is not rational. It is also (as previously discussed) not yet known what mechanism causes the odour. Is it due to the anaerobic bacteria, or is it part of the disease process while the bacteria are circumstantial colonisers (Hampson, 1996)? Eliminating colonisers could have serious long-term consequences in terms of developing resistance towards metronidazole (Hampson, 1996).
At a more practical level, Grocott (1999) discusses the difficulty of using metronidazole gel preparation in a very large wound or in a location where the gel is absorbed onto dressings and thus loses contact with the wound. There is also no guidance from the literature on how much gel to use on any given wound surface or cavity and no research-based evidence to back up ‘once to twice daily’ applications of the gel (Moody, 1998; Fairbairn, 1994).
Alternative treatments - Sugar paste in thick or thin forms, as well as icing sugar (Thomlinson, 1980), have all been reviewed in the literature as combating malodorous wounds (Benbow, 1999; Thomas, 1989; Haughton and Young, 1995). It is said to work through its antimicrobial properties, and by absorbing fluid, thus starving the bacteria of fluid (Benbow, 1999) and therefore inhibiting their growth (Haughton and Young, 1995). The advantages are that it is cheap, self-sterilising and can mould to the shape of the wound (Haughton and Young, 1995). The disadvantages are that after three to four hours the paste is liquefied by exudate, reducing osmolarity to a level that ceases to control infection (Molan, 1999) and necessitating frequent dressing changes. Some patients also find that the sugar stings on application (Benbow, 1999). The other disadvantage is that it is not yet made commercially and is available only from hospital pharmacies, limiting its use. There is little comparative research on its use for odour control in fungating wounds.
Honey shares similar antimicrobial properties to sugar and, according to Benbow (1999), has been used since Egyptian times. However, recent research (Cooper and Molan, 1999) has confirmed its antibacterial potency (Cooper, 2000). This is thought to occur not only through reducing osmolarity but also through the slow release of hydrogen peroxide, mediated by wound exudate and through additional plant-derived chemicals that have antibacterial properties (Molan, 1999). This last compound is said to occur in varying degrees among different types of honey, with Manuka honey containing the highest (Molan and Betts, 2000). Molan (1999) also speculates that honey provides a rich source of glucose that may be used by the bacteria in preference to amino acids, resulting in the production of lactic acid rather than malodorous compounds.
Molan and Betts (2000) stress that there is little in the literature on methods used to dress wounds with honey. However, their guidelines stress the importance of not letting the honey become too diluted by exudate. This may necessitate frequent dressing changes and will involve, typically, 20ml of honey on a 10cm-square dressing. This obviously has implications in large fungating wounds, particularly as they advise the use of occlusive dressings that can be difficult to fit on large wounds and contoured body parts. An additional factor in the UK is cost, as gamma-irradiated pre-impregnated pads and tubes of honey have to be imported from New Zealand and are not yet available on FP10, limiting their use to patients in hospital programmes only.
Despite seemingly numerous disadvantages there is increasing interest in the use of alternative therapies that may have great appeal to a terminal patient for whom technology has failed.
Another alternative therapy for reducing wound malodour is the application of plain live yoghurt (Benbow, 1999). Welch (1982) speculates that the low pH of yoghurt discourages the growth of the bacteria involved in forming odour and/or encourages recolonisation of the wound by organisms found in the yoghurt which produce no smell. Haughton and Young (1995) say that this treatment is no longer recommended due to the possibility of infection from lacto-bacillus, while Schulte (1993) suggests a mixture of topical metronidazole gel and yoghurt, a combination which seems self-defeating. However, once again this is a natural, low-cost remedy that may appeal to some patients. There are no sophisticated dressing systems involved, and control can easily devolve to the patient, thereby improving self-esteem.
Larval therapy has also been investigated for use in malodorous fungating wounds (Box 1).
The recent research by Grocott (2000) is of great importance in this field although her focus is on exudate rather than odour management. Her rationale for this seems to be that only when exudate is managed optimally can treatments for odour control be evaluated (Grocott, 2000). She does, however, point out the need for further research, particularly around necrotic tissue debridement and odour (Grocott, 1999).
Grocott’s unique research enabled her to develop new wound-care materials in partnership with a pharmaceutical company. She was then able to evaluate the materials as part of her research. More importantly, she was able to develop a system of dressings that were able to manage fungating wound exudate. However, it is difficult to see how this research can be easily replicated in the community given that Grocott (2000) has not yet disclosed all the elements used in the dressing system, presumably because they are not yet available commercially. It therefore appears that this research, at least for the near future, remains of benefit only to those who were part of this research trial. There is also the much wider issue of resource allocation by health-care companies for wound dressings of a more extensive size range (Grocott, 1999).
This literature review has shown that a number of different solutions are available to treat malodorous wounds in clinical practice, all of which are useful but none of which provide a perfect solution but will continue to be used at least until we understand more about the exact mechanisms causing the odour. Care can then be individualised to the needs of each patient (Haisfield-Wolfe et al, 1997) and address not only the wound itself but also the patient’s psychological and spiritual needs (Fairbairn, 1994). Finally, we have to go back to the basic tenet of using the patient as our guide, and use both research and wound-management policies to promote quality of life as defined by the patient (Haisfield-Wolfe et al, 1997).
- Honey shares similar antimicrobial properties to sugar and, according to Benbow (1999), has been used since Egyptian times.
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