Malignant Ulcers or Wounds

KEYPOINTS

  • Malignant ulcers or wounds can be caused by direct invasion of the skin by a primary tumour or by metastasis to the skin
  • These wounds can have both ulcerative and fungating features
  • Odour and discharge are common problems with malignant wounds
  • Pain, infection and bleeding can also occur
  • The psychological distress to the patient or caregivers caused by these wounds should also be addressed
  • These wounds rarely heal but the symptoms can usually be controlled with good assessment and management
  • Malignant wounds occur in 5-10% of patient with metastatic disease, most commonly in breast cancer and melanoma
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  • Rare in children
  • Can occur with rhabdomyosarcomas

ASSESSMENT

(see Foreword)

  • A clinical assessment is usually all that is required
  • It is important to review the symptoms of odour, discharge, pain, bleeding and psychological impact when assessing the wound
  • Swab cultures can sometimes be helpful to determine the need for antimicrobial treatment. Local bacterial colonization of the wound is expected and should be treated with topical cleansing, debridement as appropriate, and antimicrobial creams. If there are signs of systemic infection, the use of oral or intravenous antibiotics may be considered
  • Wound location, size, appearance, exudate, odour, condition of surrounding skin and pain should all be assessed
  • The potential for serious complications, such as haemorrhage, vessel compression or airway obstruction should be evaluated and a plan developed for management

MANAGEMENT

Cleaning the Wound

  • Wound cleansing reduces odour by removing necrotic tissue and decreasing bacterial counts
  • Gentle irrigation of the wound with normal saline is helpful and can be done as often as needed
  • Good handwashing is very important in caring for malignant wounds
  • Local debridement can be performed by very gently scrubbing the necrotic areas with gauze saturated with saline or wound cleanser. This must be done carefully and gently to avoid bleeding or pain
  • Topical antimicrobial ointments or creams can be helpful

Exudate/Discharge

  • The inflammation and oedema of malignant wounds can cause significant exudate (drainage)
  • Dressings should be selected that can best conceal the wound, absorb exudate and reduce odour
  • Dressings are generally changed 1-2 times per day based on the amount of exudates and odour
  • Menstrual pads can be especially effective because of their good absorption and availability

Odour Control

  • Wound odour is caused from bacterial overgrowth and necrotic tissue
  • Managing odour is extremely important for the well-being of the patient and family
  • Wound cleaning and dressings for exudates/discharge (as mentioned above) is important to reduce odour
  • Metronidazole (orally or topically) can be very helpful
    • Metronidazole 500 mg bid or tid PO/IV
    • Gel or injectable metronidazole can be applied (not injected) on the wound with each dressing change
    • Metronidazole capsules/tablets can also be broken and the powder contents sprinkled onto the wound with each dressing change
  • Activated-charcoal dressings or a basket of charcoal placed under the bed or table can help absorb and reduce odour
  • Peppermint or other oils placed in the room can be helpful. Incense may be helpful but strong scents can sometimes cause difficulties in breathing for patients or may induce nausea

Pain

  • It is important to help control pain by using morphine and other medications as mentioned in the section on pain (some malignant wounds can cause neuropathic pain)
  • Topical morphine can be helpful for the wound for some patients. One ampoule of injectable morphine (10 mg/ml) can be mixed in most gels and applied over the wound
  • Dressing changes can be particularly painful. Giving a breakthrough or rescue dose of morphine prior to the dressing change can often be helpful

Control of Bleeding

  • The viable tissue in a malignant wound may be very friable and bleed with minimal manipulation
  • Prevention is the best method to avoid bleeding. Care must be taken when removing dressings to avoid bleeding. Use warmed normal saline irrigation to moisten the dressing and prevent trauma during dressing changes. Use non-adherent dressings and moist wound products when possible
  • If bleeding does occur, apply direct pressure for 10-15 minutes. Local ice packs can also assist in controlling bleeding
  • Radiotherapy can be considered if appropriate for the patient and the tumour is thought to be radiosensitive
  • Haemostatic dressings or pressure dressings are sometimes required if the bleeding is severe
  • If a patient is at the end of life and having uncontrolled bleeding from a large wound, using dark towels/ blankets to mask the blood can decrease anxiety for the patient and family. Pain control and sedation with a benzodiazepine would be important considerations in this situation
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  • Metronidazole 15-35 mg/kg/24h in divided doses q8h PO or 30 mg/kg/24h in divided doses q8h IV

PITFALLS/CONCERNS

  • Ensure that the dressing used is not “too dry” and therefore causes more pain and bleeding at the time of dressing changes
  • Perfumes used sometimes become associated with the unpleasant odour rather than “hide” the smell and do not necessarily help
  • Healthcare providers can become “desensitized” to the smell and so must listen to the patient or family if they complain about the smell from the wound rather than rely on their own observations

PALLIATIVE TIPS

  • It is very important to pay particular attention to the emotional impact of these wounds on the patient and family. Medical staff can help reduce social isolation that can often occur

SOURCES/REFERENCES

  1. Collier M. Management of patients with fungating wounds. Nursing Standard 2000;15(11):46-52.
  2. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliat Med 2006;9(2):285-293. http://www.ncbi.nlm.nih.gov/pubmed/16629558
  3. NHS Clinical Knowledge Summaries. Palliative - malignant ulcer. [Online]. Available from: URL:http://cks.library.nhs.uk
  4. Regnard C, Allport S, Stephenson L. ABC of palliative care: mouth care, skin care, and lymphoedema. BMJ 1997;315(7114):1002-1005. http://www.bmj.com/cgi/content/extract/315/7114/1002
  5. Seaman S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs 2006;22(3):185-193. http://www.ncbi.nlm.nih.gov/pubmed/16893748
  6. Trent J, Kirsner R. Wounds and malignancy. Advances in Skin and Wound Care 2003;16(1):31-34.

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