Fast Fact and Concept #046: Malignant Wounds

2nd Edition

Author(s): Frank Ferris, MD and Charles von Gunten, MD 

Few things can worsen a patient’s quality of life greater than an oozing, odorous, painful, and bleeding malignant skin wound. The pathology of a primary or metastatic cancer to the skin leading to an open wound is a combination of neovascularization, necrosis and inflammation, leading to pain, bleeding, odor and exudate.

As with other chronic wounds, a fundamental decision needs to be made about whether the wound can eventually heal or not (See Fast Fact 41). The choice of dressing is generally the same as with pressure ulcers (Fast Fact #41). However, malignant wound management raises additional issues that deserve comment. Note: for any complex wound, it is recommended that you seek professional consultation from a wound care expert.

Exudates can be substantial from malignant wounds. The overall goal is to prevent exudate macerating other normal tissues or dripping off the patient into clothes and bedclothes. This serves both an infection control issue as well as a cosmetic goal. You can use absorbent foams to minimize the frequency of dressing changes and maximize absorption. Typically a gauze pad (such as an ABD pad) is placed on top of the foam. Alginate dressings have a role in wounds that have exudates and/or are bleeding, they are hemostatic, control infection, as well as being absorptive. They don’t have to be pulled off; they can be washed off in the shower.

Malignant wounds carry a high risk of superficial infection, especially with anaerobic or fungal species. Odor is frequently the first sign of anaerobic infection along with a purulent exudate. If the infection is only superficial, topical treatment (metronidazole, silver sulfadiazine) may be sufficient. However, if there is evidence of deeper tissue infection, then systemic metronidazole should be used. If the wound is determined to be non-healing, then topical agents like povidone can be used; note some patients find it irritating and painful. Povidone is cytotoxic to bacteria and will help keep the wound clean; Povidone should not be used for wounds that are expected to heal because it is cytotoxic to normal granulation tissue.

Managing odor can be accomplished by using odor absorbers; kitty litter or activated charcoal can be placed on a cookie tray underneath the bed. In addition, there are charcoal dressings that can be used to cover a particularly malodorous wound. Additional approaches include putting a burning flame (such as a candle) in the room in an attempt to combust the chemicals causing the odor. One can also introduce a competing odor; bowls of vinegar, vanilla, or coffee. Fragrances and perfumes are often poorly tolerated by patients and should be avoided.

Bleeding is common; the surface of a malignancy may be friable and predispose to bleeding. It may either present as oozing (microvascular fragmentation) or vascular disruption from necrosis or sloughing leading to “a bleeder”. Any dressing that comes into contact with the surface may adhere and tear the surface when it is pulled off (e.g. saline wet-dry). This can be prevented by using a mesh synthetic polymer non-stick, non absorptive dressing (e.g. Mepitel). Other options to control bleeding are alginate dressings, topical low dose (100u/ml) thromboplastin can also be used, silver nitrate or cautery.

In addition to systemic treatments for pain (e.g. oral or parenteral opioids), local anesthetics may also be helpful.

References

Barton P, Parslow N. Malignant wounds: holistic assessment and management. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A clinical source book for healthcare professionals. Third Edition. Wayne, PA: HMP Communications, 2001:699-710.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Fast Facts and Concepts #46 Ferris F and von Gunten C. Malignant Wounds; 2nd edition, August, 2005. End-of-Life Palliative Education Resource Center www.eperc.mcw.edu.

Creation Date: 7/2001; 2nd edition, August, 2005.

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Cancer

Specific Disease and Organ System Category(s): Cancer