Caring for a patient with a fungating malignant wound is challenging. The science of palliative wound care is still in its infancy, with little research to guide care for this type of wound. This article examines fungating wounds and recommended methods of care and symptom management.
SpecialtiesOncologyArticle
A fungating (malignant) wound is a mass of cancerous tissue that is spreading under the skin and eventually infiltrates the outside layer of cells, breaking through the skin surface to create a wound. There is the potential for massive skin damage, with gross disfigurement and loss of function.
As the cancerous tumor grows, it blocks the supporting blood and lymph supply, starving the area of oxygen. This causes the skin and underlying tissue to die due to lack of blood flow (necrosis). Fungating wounds present as either a raised nodule or as an ulcerated crater with a defined margin. The raised nodules often resemble a cauliflower or fungus protruding from the skin. The necrosis can lead to inflammation and infection. Usually there is a strong smelling discharge, bleeding, and pain.
Thankfully, fungating wounds are rare, occurring in just 5 to 15 percent of cancers. These malignant lesions tend to develop in elderly patients, primarily those aged 70 or older, who are in the advanced stages of metastatic illness. They may develop during the last few months of life or be present for years.
Fungating wounds rarely heal and often require palliative management. Nearly two-thirds of these wounds develop in the breast area and a quarter develop in the head and neck area. Other common sites are the kidney, ovary, lady parts, colon, member, and bladder. Head and neck fungating tumors can distort the face, while these growths in the genitourinary tract can cause fistulas involving the bladder, lady parts, and bowel.
Not surprisingly, these destructive wounds can have a devastating impact on the patient's overall quality of life. The most common symptoms of a fungating wound include copious exudate, an offensive smell, pain, bleeding, and itching. These symptoms can cause embarrassment, social withdrawal, and isolation. Wound bleeding is common in fungating wounds. This occurs because the cancerous cells damage the tiny blood vessels, making the tissue very fragile, and platelet function is impeded within the tumor as well.
The profuse, spontaneous bleeding can be distressing to patients and families. Should bleeding occur, pressure to the area should be applied immediately with a moist or non-stick dressing to avoid damaging the tissue further.
Meticulous skin care is imperative for comfort, cleanliness, and odor control. To avoid drying and irritating the skin, soaps should be avoided. A mild pH-balanced skin cleanser such as Aloe Vesta or Sensi-Care should be used instead.
Dressings should facilitate maintenance of a moist wound bed, to prevent irritating delicate nerve endings. Hydrogels, hydrocolloids, foams, composite dressings, and calcium alginates are recommended. These type dressings also help control leakage or discharge. Wet-to-dry dressings are not recommended, as these can damage the periwound. A barrier cream such as Cavilon can be applied around the wound to protect surrounding skin. The dressings should be changed as often as necessary to control discharge and odor, but too frequent changes can exacerbate bleeding. Nonadherent dressings should be used to protect the fragile skin. Gentle irrigation of the wound with warm saline, as opposed to swabbing, can reduce pain and tissue damage with dressing changes.
What have been your experiences with these types of wounds?
