Malignant / Fungating Wounds - Wound Care Nursing · Primary skin cancer such as a squamous or basal cell carcinoma and malignant melanoma can develop into a malignant fungating wound

Malignant / FungatingWounds A Clinical Perspective

F. Alex Khan, APRN ACNS-BC MSN

2018

Email: [email protected]

Malignant wounds are caused by the metastatic spread from a malignant tumor. Cancerous cells cause massive damage to the localized tissue, through a combination of proliferative growth, ischemia and ulceration. These Wounds are non-healable due to co-existing untreatable medical life limiting conditions.

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Malignant WoundsMalignant Wounds

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Malignant WoundsMalignant Wounds

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Primary skin cancer such as a squamous or basal cell carcinoma and malignant melanoma can develop into a malignant fungating wound if left untreated. The most common malignant / fungating wound sites include breast 62%, head and face 24% and groin and genitals 3%.

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StatisticsMalignant Wounds

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Malignant wounds are usually polymicrobic, containing both aerobic and anaerobic bacteria causing foul odor and purulent drainage from the tissue necrosis. Anaerobic bacteria emit putrescine and cadaverine, which results in foul odors and some aerobic bacteria such as Proteus and Klebsiella can also produce foul odors. Each wound is unique but pain, foul odor, bleeding, and tissue necrosis is common in malignant wounds .

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CharacteristicsMalignant Wounds

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Radiation TherapyMalignant Wounds

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• As a result of radiation therapy (3) three types of skin problems are commonly seen:

• Erythema (Redness)

• Dry Desquamation

• Moist Desquamation

• Skin Ulcers

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Primary Site Metastatic Cutaneous Sites

Lung and Breast Head, neck, anterior chest

Gastrointestinal Upper abdominal wall, suture lines

Genitourinary Lower abdominal wall and external genitals

Stomach Umbilicus, suture lines

Melanoma Extremities

Oral Cavity Face

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Malignant DegenerationMalignant Wounds

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Chronic wounds may exhibit chronic inflammation that can undergo malignant transformation. A Marjolin ulcer may develop in an area of chronic inflammation.

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Marjolin UlcerMalignant Wounds

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Kennedy Terminal UlcerMalignant Wounds

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•A pressure ulcer some people develop at end of life .Sudden onset•Associated with imminent death•Pear, butterfly, or horseshoe shaped•Often on coccyx or sacrum•Skin Failure: Occurs when skin and underlying tissue develops necrosis due to lack of tissue perfusion associated with severe dysfunction or failure of other organ systems.

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Management StrategiesMalignant Wounds

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In some malignant/fungating wounds; treating oncologist can perform palliative radiotherapy, which can reduce drainage and bleeding. Further, Chemotherapy can be used to reduce the size of the tumor, reduce pain, and bleeding. Hormone therapy can be used to reduce the symptoms associated with hormone responsive tumors such as breast cancers. Surgical excision of the malignant tissue is also useful in reducing the size of the wound and allows better wound management options.

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• Managing malignant wounds is frequently based on expert opinion and the experiences of the clinicians.

• The assessment of a malignant wound requires clinician to gain insight into the patient’s perception of the wound and its consequent impact on his/her life.

• Nursing care requires counseling skills and knowing how to provide care that is based on an awareness of and insight into the patients’ experience

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• Treatment selections should include those that provide minimum side effects and maximum benefit to the client.

• Establish goal of care Healing vs Palliation• Wound bed preparation will vary based on the goal. If

palliation is the goal, tissue debridement and management of bacterial overload is required to minimize odor and decrease risk of infection.

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• The impact of a malignant/ fungating wound on a patient’s life cannot be underestimated. It can have a devastating effect on physical, psychological and social wellbeing as well as on the family and friends.

• Treatment plan shall include the management of; Pain, Comfort, Psychological factors, Aesthetics, odor, drainage, and quality of life.

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Pain ManagementAlthough many patients experience debilitating pain at the end of life, there are many options to improve analgesia and quality of life. Appropriate pain assessment with attention to patient needs and specific goals, helps tailor individual treatment plans. Medications: Morphine, Hydromorphone, Oxycodone, Methadone, Fentanyl

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Exudate / Drainage ManagementFor wounds with mild to moderate drainage; use of super absorbent pads is recommended. For copious drainage, Negative Pressure Wound Therapy is ideal; only if patient is able to tolerate it.

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Exudate / Drainage ManagementFor wounds with frequent bleeding issues can be managed with:- Hemostatic dressings- Surgifoam/Gelfoam to fill the cavity- Silver Nitrate sticks- Topical Tranexamic acid (TXA)

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Odor ManagementWound malodor causes serious physical and psychological effects on the client. Management may include:- Removal of necrotic tissue- Sharp Wound Debridement - Wound Culture – Antibiotics & Antifungals- Topical Antimicrobials / Antifungals: Dakin’s Solution, Gentian

violet, Methylene Blue, Polyhexanide solution, Cider, Baxedin. Vinegar,Metronidazole Powder, Nystatin Powder, Charcoal dsg.

- Malodor Concealers – Lavender Oil, Chamomile Oil

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References

• Bergstrom, K. Assessment and Management of Fungating Wounds. Source: Journal of Wound, Ostomy and Continence

Nursing. 38 (1): 31-37, 2011 Jan/Feb

• Bryant, R. (2000). Acute and Chronic Wounds: Nursing Management,

Second Edition (pp. 374-379). Mosby Inc.

• Barton, P., & Parslow, N, (1998) Caring for Oncology Wounds.

Management Guidelines

• Krasner, D, Rodeheaver G, Sibbald G. (2001) Chronic Wound Care Third Edition Chapter 10 (pp. 79-90)

• Kohr, Rosemary. Sawhney, Mona. Advanced practice nurses' role in the treatment of pain. [Review] [23 refs] Source: Canadian

Nurse. 101(3): 30-4, 2005. March

• Reddy, M., Kohr, R., Queen, D., Sibbald, R Gary. Practical treatment of wound pain and trauma: a patient-centered approach.

An overview. Ostomy Wound Management. 49(4 Suppl):2-15, 2003 Apr

• Sibblad, G., Woo, K. & Goodman, L. Update on Wound Bed Preparation 2011: A review of the principles of treating the

root cause of wounds, pain and wound healing, and local wound care. Wound Care Canada, vol. 10, number 10, pp18-22

• Woo, K. & Sibbald, G. (2010). Local Wound Care for Malignant and Palliative Wounds. ADV SKIN WOUND CARE 2010;23:417-

28; quiz 429-30

• www.woundcarenurses.org

Malignant / Fungating Wounds - Wound Care Nursing · Primary skin cancer such as a squamous or basal cell carcinoma and malignant melanoma can develop into a malignant fungating wound

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