Malignant Wounds

Providing wound care and psychosocial support

Managing malignant wounds can be challenging for nurses, especially in terms of implications for patients and their quality of care. These wounds can spread rapidly, either as a primary, metastatic, or recurrent malignancy, and are often associated with breast or head and neck cancers.

Definition

Skin manifestations of cancer which arise from local progression of a primary tumour or from cutaneous metastases; they are particularly associated with breast cancer, malignant melanoma and mucosal tumours of the head and neck. Malignant wounds may present as proliferative, ulcerative or fistulae.

Approximately 5-10% of people with metastatic cancer develop malignant/fungating wounds. These wounds rarely heal fully, and the focus is often on comfort and reducing their impact on the person’s quality of life.

Related Resources

CareSearch Nurses Hub – Skin failure and pressure injuries
CareSearch Review Collection – Skin / wound care
palliAGED Tip Sheet – Skin and wound care

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What you can do

Nurses have an important role in recognising, assessing, and managing symptoms related to fungating wounds. They can also help patients and families with sensitive and culturally appropriate education and support.

Recognise
- Advanced malignant wounds often do not heal and are associated with poor prognosis.
- The physical and psychological impact of the wound on day-to-day living can be substantial. They can limit independence and cause emotional distress, impacting the person’s overall quality of life.
- A malignant wound and its visual appearance can cause a very strong sense of isolation, loss of sexual identity, fear, anxiety, and distress. Trying to bring the wound under control can demand a significant amount of effort and mean that activities of daily living or social interactions are changed or cancelled according to the needs of the wound.
- Physical symptoms such as pain, odour, bleeding, and exudate, all negatively impact on the person and their relationships with family and friends. Carers and family members may need help with the impact that the wound and its management have on their wellbeing, their relationship with the person, their social life, and capacity to provide care.
Assess
Continually assessing these wounds is important because they can change frequently.

To understand the wound history ask about:
- how long they have had the wound
- previous treatments or dressings for the wound and how well they worked
- any allergies/sensitivities to dressing products and/or adhesive tape
- other diseases or health problems such as diabetes, a bleeding disorder, a loss of sensation
- current medications to manage symptoms (e.g. pain, infection, depression)
- the current dressing plan.
Ask about the associated symptoms: pain, pruritus (itchiness), odour, exudate (drainage), bleeding, lymphoedema, and infection.

To understand the psychological impact of the wound, ask:
- what their concerns are
- if the wound affects their walking, sitting and/or lying down
- how the wound affects their day-to-day activities and how they feel about themself
- how the wound affects their relationships with family or friends
- if the wound makes it difficult for them to go out or socialise with others.
Ask family and carers:
- how the wound and wound management is affecting them and what resources and support they need
- how the wound is currently being managed and if they have easy access to dressing supplies.
Manage
A photographic record of the wound, with the person’s consent, can illustrate the progression of the wound. It can be useful for providing the rationale for the choice of local wound management products, the frequency of dressing changes and the volume of products used.

Treatment is generally directed at managing wound-related pain and symptom issues.

Working to develop a care plan with the person and their family is important. Key symptoms requiring management include:

Pain

Use of an opioid is widely recommended for pain management including prior to changing a dressing. Establishing if pain is due to infection or the actual wound dressing process is an important first step.

Infection

Wounds are often contaminated with bacteria. Management of local infection includes taking a swab to identify the organisms involved and use of appropriate antimicrobial agents to control signs of infection (redness, pain, swelling, increased odour or discharge; fever, chills, and sweats).

Bleeding

Causes of bleeding include changes in blood clotting capacity or blood vessel structure. Medications taken by the person, such as anticoagulants, could contribute to bleeding and should be discussed with prescribers. Wound dressings themselves can also contribute to bleeding through physical abrasion or adhesion.

Exudate

As the tumour grows, changes to blood vessels and disruption of the lymphatic system often lead to a large volume of exudate at the wound site. This can degrade the extracellular matrix and affect healing.

Management to remove saturated dressings is important and if very moist may require specialist input.

Consider:
- using a high absorbency dressing (e.g. hydrocolloid), with further packing on top and a protective layer to shield the person’s clothing
- changing the top dressing layer as often as necessary but avoid frequent changes of the dressing placed directly over the wound or use a non-adherent dressing over the wound
- covering the wound with a bag (as with a colostomy) to collect secretions and contain odour
- protecting the surrounding good skin with barrier cream or barrier film spray.
Malodour

Malodour can be one of the most distressing symptoms of these wounds. It may affect the person’s relationships and interaction with others and be equally distressing for family and carers.

Malodour can be caused by moist necrotic tissue, infection, unchanged or saturated dressings, or old dressings that have not been properly disposed of.

There are many approaches including dressings containing charcoal, medical-grade honey, or silver. If debridement to remove necrotic tissue is considered, then an assessment of how this might impact on the person’s quality of life is essential. Sealing the wound dressing to contain odour or covering the wound with a bag (as with a colostomy) to collect secretions and contain odour may also help.

External odour absorbers (tray of clay kitty litter or activated charcoal) and room ventilation can help reduce the odour. Masking environmental odours using air scents (peppermint oil, vanilla, coffee), an infuser or similar may also be helpful.

Surrounding skin integrity

Care of the skin surrounding the malignant wound is important. To promote skin hydration, it may help to moisturise the skin with hydrophilic creams and encourage the person to increase their fluid intake where possible.

To care for the skin surrounding a malignant wound it can help to:
- avoid using adhesive tape
- avoid using products that contain alcohol
- apply an alcohol-free skin barrier film to coat the skin and protect it from breakdown
- picture-frame wound with hydrocolloid wafers/strips to prevent recurrent stripping of skin – watch that the exudate does not seep under the hydrocolloid and become trapped as this can lead to erythema and skin damage
- encourage the person to avoid scratching.
Psychosocial wellbeing

The person’s comfort and quality of life remains the goal in managing malignant wounds. This includes finding the dressing that best suits them while minimising any symptoms. It also includes support for quality of life and social interaction where this is important to the person.

Care for staff who provide wound dressings for patients can include sharing care, taking time out and reflecting on practice with colleagues.

Allied health professionals who can help

A social worker, counsellor, or spiritual care provider can offer counselling and emotional support.

References
This information was drawn from the following resources:
1. Leadbeater M. Assessment and treatment of fungating, malodorous wounds. Br J Community Nurs. 2016 Mar;21 Suppl 3:S6-S10. doi: 10.12968/bjcn.2016.21.Sup3.S6.
2. Probst S, Arber A, Faithfull S. Malignant fungating wounds: the meaning of living in an unbounded body. Eur J Oncol Nurs. 2013 Feb;17(1):38-45. doi: 10.1016/j.ejon.2012.02.001. Epub 2012 Mar 27.
3. Reynolds H, Gethin G. The psychological effects of malignant fungating wounds (290kb pdf). EWMA Journal. 2015 Oct;15(2):29-32.
4. Tandler S, Stephen-Haynes J. Fungating wounds: management and treatment options. Br J Nurs. 2017 Jun 22;26(12 Suppl):S6-S14. doi: 10.12968/bjon.2017.26.12.S6.
5. Therapeutic Guidelines Limited. Dermatological symptoms in palliative care [Internet]. 2016 [cited 2022 Sep 22].
6. Tilley CP, Fu MR, Lipson JM. Palliative Wound, Ostomy, and Continence Care. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing [Internet]. 5th ed. Oxford: Oxford University Press; 2019.
7. Tsichlakidou A, Govina O, Vasilopoulos G, Kavga A, Vastardi M, Kalemikerakis I. Intervention for symptom management in patients with malignant fungating wounds – a systematic review. J BUON. 2019 May-Jun;24(3):1301-1308.
8. Skin problems in palliative care. In: Watson M, Ward S, Vallath N, Wells J, Campbell R, editors. Oxford handbook of palliative care [Internet]. Oxford: Oxford University Press; 2019.
9. Winnipeg Regional Health Authority (WRHA). Malignant Fungating Wounds – Clinical Practice Guideline. Winnipeg, MB: WRHA; 2021 Apr.