Back to Section 14 Selection Page

Section 10: Wound Complications - Fungating Wounds CLICK HERE for printer friendly version of this page
Fungating wounds are caused either by a local tumour infiltrating the skin, or by metastatic spread from the primary tumour. Malignant fungating lesions are an immense challenge. Management goals vary depending on the stage of the underlying cancer, the patient’s prognosis, and the individual’s own goals and wishes. In some cases, the aim is to arrest tumour growth, but in many situations fungating tumours occur at the end of life, and treatment is completed in a palliative setting that focuses on comfort and maintenance of the best possible quality of life for that patient and their family. In either case it is important to remember that the symptoms produced by a fungating wound are often as distressing as the wound itself. Management focuses on alleviation of distressing symptoms including pain, cutaneous irritation, exudate, bleeding and odour.
	Indicator/descriptor	Management aims	Treatment options
	Exudate Wound exudate is produced as a normal part of the wound healing process. In fungating wounds the exudate produced can be excessive. This is thought to be due to increased permeability of blood vessels within the tumour and secretion of vascular permeability factor by tumour cells.	Remove slough/necrotic debris Manage excess exudate Keep moist	Heavy exudate Fibrous Hydrocolloid Alginate Extra-absorbent Foam Light exudate Hydrogel Fibrous Hydrocolloid Non-adhesive Foam Soft Silicone Foam
	Bleeding Blood vessels can be disrupted by the infiltration of tumour cells which can lead to bleeding at the wound site. Traumatic dressing changes can also lead to bleeding.	Control bleeding Prevent trauma at dressing change	An Alginate may be applied to wounds with a small amount of bleeding but should be used with caution in fragile tumours as they may cause bleeding. A Silicone Wound Contact Layer should be used as a primary dressing to prevent adherence to the wound.
	Malodour Malodour is associated with necrotic tissue that supports the growth of anaerobic bacteria, and the presence of volatile fatty acids in the wound. Stagnant exudate, infection and fistula formation are also contributing factors. Malodour is reported to be the most distressing symptom from the patients perspective.	Reduce odour Check for infection via swab	Metronidazole gel - apply to clean wound 1-2 times daily and cover with non-adherent dressing. CarboFlex^® should be used for moderately exuding wounds and CliniSorb^® for lightly exuding wounds.
	Skin irritation	Protect from maceration/breakdown Control itching	Cavilon^®, Diprobase^® or Dermol^® may provide relief. Zinc oxide paste can be used to prevent peri-wound maceration. A Hydrogel Sheet can also reduce itching and promote comfort.
	Pain - Assessment provides a means to determine the underlying cause of the pain, e.g. infection, pressure on structures, heightened anxiety, invasion of nerves. There are several types of pain associated with malignant wounds: deep pain, neuropathic pain and superficial pain related to procedures. Dressing removal has been found to be the time of greatest pain for those with chronic wounds.	Analgesic drugs should be prescribed using the World Health Organisation (WHO) guidelines for the control of cancer pain and in accordance with the Tayside Area Formulary (TAF) - CLICK HERE	A short-acting analgesic such as Oramorph^® may be given 20-30 minutes prior to dressing changes. Where nerve pain exists, adjuvant therapies may be of benefit. Please see TAF section 4.7.3 for more information. The use of morphine or diamorphine mixed with a hydrogel (to form a 0.08–0.1% mixture) and applied topically to the wound has been found to be an effective method of pain relief in ulcerating wounds, including fungating wounds.

Other considerations

Exudate
- In selected wounds with high exudate either stoma appliances or absorbent pads over a non-adherent contact layer may be the most appropriate dressing method.
Bleeding
- Bleeding may be controlled by careful removal of dressings moistened first with warmed normal saline.
- Local ice packs can be used to control bleeding.
- Haemostatic surgical sponges Spongostan® or Oxycell®
- Adrenaline 1:1000 - only under medical supervision and caution is advised as adrenaline may cause ischaemic necrosis due to local vasoconstriction.
- Referral to a vascular surgeon for cautery/ligation.
Malodour
- Natural live yoghurt
- Sugar paste
- Honey
- Larval therapy
- Good ventilation, and essential oils on clothing or in the room.
Skin irritation
- Advice to the patient regarding the use of light, cool clothing and bathing may be of some benefit.
- Irritation caused by radiotherapy may respond to topical hydrocortisone.
Pain
- Chemotherapy, radiotherapy, hormone therapy or a combination of these anti-cancer therapies may help to shrink the wound by destroying malignant cells, reducing pressure on nerves and other structures and decreasing the area of exposed tissue. This may have a significant effect on the level of pain experienced by the patient.
Dressing choice
- Dressing choice for fungating wounds should not only be based on the wound characteristics but also should have minimum bulk, prevent leakage, be conformable and cosmetically acceptable to the patient.

References:

Dunford, C. (2000) The use of honey in wound management. Nurs Stand, 15(11); 63-8
Bergstrom, KJ. (2011). Assessment and Management of Fungating Wounds, J Wound Ostomy Continence Nurs, 38(1); 31-37
Grocott, P et al (2012). Malignant Wound Management in Advanced Illness: New Insights. Current Opinion in Supportive and Palliative Care. Review, 7(1); 101-105.
Naylor, W., Laverty, D & Mallet, J. (2001) The Royal Marsden Hospital Handbook of Wound Management in Cancer Care. Blackwell Science, Oxford
Da Costa Santos, CM et al (2010). A Systematic Review of Topical Treatments to Control the Odor of Malignant Fungating Wounds, Journal of Pain and Symptom Management, 39(6); 1065-1076.
Graves, LM. (2013). Providing Quality Wound Care at the end of Life. Journal of Hospice and Palliative Nursing, 15(2); 66-74.
Alexander, S. (2009). Malignant Fungating Wounds: Epidemiology, Aetiology, Presentation and Assessment. Journal of Wound Care, 18(7); 273-280.
Seaman, S. (2006). Management of Malignant Fungating Wounds in Advanced Cancer. Seminars in Oncology Nursing, 22(3); 185-193.
Chrisman, CA. (2010). Care of Chronic Wounds in Palliative Care and End-of-Life Patients. Interantional Wound Journal , 7(4); 214-235.
Schulte, M. (1993) Yoghurt helps to control wound odour. Oncol Nurs Forum, 20(8), 1262
Thomas, T., Jones, M., Wynn, K. & Fowler, T. (2001) The current status of maggot therapy in wound healing. Br J Nurs, 10(22), (Suppl S5-12).
Topham, J. (2000) Sugar for wounds. J Tissue Viability, 10(3), 86-9.
Zeppetella G, Ribeiro MD. (2005). Morphine in intrasite gel applied topically to painful ulcer. J Pain Symptom Manag, 29; 118-119.
Healthcare Improvement Scotland Best Practice Statement: Skincare of Patients Receiving Radiotherapy (2010)

Back to Main Page

Skin irritation

Cavilon®, Diprobase® or Dermol® may provide relief.

Zinc oxide paste can be used to prevent peri-wound maceration.

Where nerve pain exists, adjuvant therapies may be of benefit. Please see TAF section 4.7.3 for more information.

Cavilon^®, Diprobase^® or Dermol^® may provide relief.