A Systematic Review of Topical Treatments to Control the Odor of Malignant Fungating Wounds.pdf

Vol. 39 No. 6 June 2010 Journal of Pain and Symptom Management 1065

Review Article

A Systematic Review of Topical Treatmentsto Control the Odor of MalignantFungating WoundsCristina Mamedio da Costa Santos, RN, MsN,Cibele Andrucioli de Mattos Pimenta, RN, PhD,and Moacyr Roberto Cuce Nobre, MD, PhDScience Institute of Hospital Alemao Oswaldo Cruz, Sao Paulo, Brazil (C.M.d.C.S.); School

of Nursing of the University of Sao Paulo, Sao Paulo, Brazil (C.M.d.C.S., C.A.d.M.P.); and

Clinical Epidemiology Unit (M.R.C.N.), Heart Institute, Medical School of the University of

Sao Paulo, Sao Paulo, Brazil

Abstract
Context. Malignant fungating wounds (MFW) result from cutaneous infiltration
by carcinogenic cells. Fetid odor, profuse exudate, pain, and infection arecommon symptoms that add to the physical and psychological suffering ofpatients with MFW. The topical treatment of MFW remains controversial.

Objectives. To collect evidence about topical treatments to control the odorof MFW.

Methods. Fourteen sources of data were used, without restriction in terms oflanguage, period, or study design. The patient, intervention, comparison, andoutcome strategy for the development of research questions yielded 334descriptors related to oncology, MFW, topical treatments, medications, andsymptoms of these lesions. Data from the abstracts of these articles were extractedby two independent researchers and decisions were reached by consensus amongthem. Through an analysis of these abstracts, studies that broached the topic ofMFW odor were selected. These studies were analyzed in their entirety and wereclassified according to quality, levels of evidence, and grade of recommendation.

Results. Of 11,111 studies identified, 325 (2.93%) made reference to thecontrol of some symptoms of MFW by means of topical interventions: 12.4%related to odor, 16.8% to exudate, 17.8% to bleeding, 31.0% to pain, and 22.0% toMFW-related infection. Within the 59 studies that analyzed odor control, sevenwere clinical trials (35%), five were case series (25%), and eight (40%) were casestudies. Eleven topical treatments were identified. Topical metronidazole andMesalt� dressing yielded 2b level of evidence or B grade of recommendation.Activated carbon dressing and curcumin ointment yielded 2c level of evidence orB grade of recommendation. C and D grades of recommendation were observedfor seven topical treatments: topical arsenic trioxide, essential oils, green tea

Address correspondence to: Cristina Mamedio da CostaSantos, RN, MsN, Clinical Research Center - ScienceInstitute of Hospital Alemao Oswaldo Cruz Rua

Joao Juliao, n. 331, Paraıso, Sao Paulo, SP 01323-020, Brazil. E-mail: [email protected]

Accepted for publication: November 10, 2009.

� 2010 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

0885-3924/$esee front matterdoi:10.1016/j.jpainsymman.2009.11.319

mailto:[email protected]

1066 Vol. 39 No. 6 June 2010da Costa Santos et al.

extract, hydropolymer dressings, antiseptic solutions, hydrogels, and debridementenzymes. The variety of interventions and of the methodological quality of thestudies did not allow for meta-analysis.

Conclusion. Of the 59 studies of odor, 20 fulfilled all the criteria for inclusion.Few studies of high quality were found, and the principal methodological flawswere the design of the studies, the sample size, and the absence of scales tomeasure odor. Grade B evidence for the treatment of MFW was found with topicalmetronidazole, Mesalt� dressing, activated carbon dressing, and curcuminointment. J Pain Symptom Manage 2010;39:1065e1076. � 2010 U.S. Cancer PainRelief Committee. Published by Elsevier Inc. All rights reserved.

Key Words
Evidence-based medicine, wounds and injuries, palliative care, odor, neoplasms
IntroductionA malignant fungating wound (MFW) in-

volves the infiltration of the epithelium by tu-mor cells. It can result from primary tumorgrowth of the skin, from metastasis, from theinvasion of the skin by tumors from deeperlevels, and from the accidental implantationof malignant cells into the epitheliun duringdiagnostic or surgical procedures.1 MFWs, inmost instances, appear in patients during theterminal phase of an illness and developfrom highly malignant tumors.

The prevalence of these wounds has not beenwell-established, but it is estimated to be be-tween 0.6% and 9.0% for all types of cancer.2e8

MFWs are characterized by rapid proliferatinggrowth, fetid odor, bleeding, localized pain,profuse exudate, local infection, and a vegetat-ing appearance, that is to say, a fungal appear-ance reminiscent of cauliflower. When thereare ulcerations, they are called malignantulcerated and fungating wounds. The range ofindicators and symptoms varies considerablyand these may present themselves individuallyor collectively.4,7,9,10

MFWs are associated with bleeding, edema,a great amount of exudate, and tissue necrosis.The bleeding results from an imbalance in thehemostatic process; edema, exudate, and ne-crosis arise from irregularity in cellular perfu-sion. Necrotic tissue is an ideal environmentfor bacterial growth (infection). The meta-bolic processes of the bacteria release volatileand fetid fatty acids, which give rise to a dis-agreeable odor. The bacteria that colonizethe wound activate proteases that break down

the necrotic tissue, causing the dead tissue toliquefy and generate extensive exudate. Therapid growth of a tumor can lead to the com-pression of adjacent structures, such as soft tis-sues and nerves, leading to pain anddiminished mobility.11 The lesion will con-tinue to develop, and local damage will getprogressively worse until some sort of oncolog-ical treatment is employed successfully.12 Thediagnosis of MFW can be made after a biopsyor a histological evaluation of the wound.8,13

However, it is generally made based on clinicalhistory and the characteristics of the wound.

Patients find MFWs to be extremely distress-ing and uncomfortable, and they often causeintense physical and psychological sufferingbecause of their fetid odor, their vegetating ap-pearance, the great quantity of exudate, theintense pain, and the constant risk of bleeding.They can lead to feelings of rejection, disgust,social isolation, anxiety, sadness, and loneli-ness. The patients’ expectation that they willhave to live with the wound until death givessubstantial importance to the adequate treat-ment of these wounds.

The treatment of MFWs is a complex topic.It requires an evaluation of oncological etiol-ogy, of the characteristics of the wound, ofthe physical and emotional state of the patient,and of the stage of cancer. The aim should beto reduce fetid odor, pain, infection, andbleeding and to improve the absorption andcontrol of excessive exudate but not to curethe lesion itself.7,14e18

Recommendations for the treatment ofMFWs are controversial, and conduct in clini-cal practice varies widely. Previous narrative

Vol. 39 No. 6 June 2010 1067Topical Treatments for Malignant Fungating Wound Odor

reviews14e18 indicate a considerable lack ofpublications about MFWs. In addition, thesereviews are small in number, they fail to ob-serve the methodology of systematic review,and it is questionable whether they were ableto identify existing publications on the subject.There are difficulties worldwide with the pre-scription of local treatments for MFWs.

The aim of the present study was to obtainand organize high-quality information thatcould contribute to the improvement of topi-cal treatments for the odor resulting fromMFWs in cancer patients.

MethodsA systematic review of the literature was un-

dertaken, based on the guidelines of the Centrefor Reviews Dissemination19 and the CochraneCollaboration;20 this involved the formulationof a research question; the location, selection,and evaluation of the quality of articles; the col-lection of information; and the analysis, presen-tation, and interpretation of results.

The research question was structured ac-cording to the patient, intervention, compari-son, and outcome (PICO) strategy, and thecriteria for the inclusion of studies weredefined as follows:21e23

Patient: individuals with malignant neo-plasms who developed MFWs, withoutreference to the clinical stage or severityof the MFW;Intervention: different topical agentsand/or dressings available in the globalmarketplace;Comparison: not defined because of thelack of known treatment pattern for MFWs;Outcome: the control or improvement ofodor in MFWs.

The researchers proceeded by identifyingthe descriptors or key words to be used tosearch for articles in databases, analyzing forthat purpose all the terminology of DeCS(Health Sciences Descriptors) and MeSH(Medical Subject Headings). They opted touse broader descriptions of the componentsof the question structuring the research tomake the systematic review more encompass-ing and to reduce the possibility of selectionbias.20,24

The researchers also chose not to restrict thesearch by types of study, with the exception ofnarrative reviews, first to classify the level ofevidence present in the studies found andthen to quickly identify the gaps in knowledgeand the subsequent steps for research to guidethe topical treatment of MFWs.

The present review made use of 14 elec-tronic databases: three primarily designed toidentify dissertations and theses (ThesisBank, Capes and Digital Library of Thesesand Dissertations, University of Sao Paulo, forBrazilian publications; and Proquest Disserta-tion and Theses for international publica-tions); one database of primary sources forthe identification of reports of clinical trials(Current Controlled Trials); two databases ofprimary sources covering nursing (BDENFfor Brazilian publications and CINAHL for in-ternational ones); one general database ofprimary sources for European material (Em-base); five general databases of primary sour-ces from North America (PubMed, Ovid,PsycInfo, Scopus, and Web of Science); onegeneral Latin American database of primarysources (Lilacs); and one database of second-ary sources (EBM Reviews). Different strategieswere formulated to accommodate the specific-ities of the different databases.22

The search was undertaken in August 2006with 14 databases, without a lower limit fordata, thus, making use of the total content ofthe databases. The results were exported usingEndNote� (Thomson Reuters, New York,United States of America) and an archive foreach database was created.

The selection of studies (articles, disserta-tions, and theses) followed different steps inthe following order: the removal of duplicatedstudies, preclinical studies, studies not relatedto oncology, studies concerning benign neo-plasms, studies not related to MFWs, and fi-nally, studies that did not cover the five mainsymptoms (odor, pain, exudate, bleeding,and infection). Data from the studies were ex-tracted by means of a form especially designedfor this purpose and following the recommen-dations of Consolidated Standards of Report-ing Trials (CONSORT) and Strengtheningthe Reporting of Observational Studies in Epi-demiology (STROBE).25e27 Data from bothexperimental and observational studies wereextracted. The same process was used for


studies that were identified by means of a man-ual search of the studies listed in the biblio-graphic references of the studies included.

Codes were developed for all of the selectedstudies based on an alphanumeric sequence de-rived from the alphabetical order of theauthors’ names. These studies were organizedinto a table of characteristics containing the au-thors’ names, the year of publication, the coun-try of publication, the study’s title, the model ofstudy used, and each study’s clinical focus.

Qualitative studies and narrative reviews wereexcluded. The quantitative studies were classi-fied according to the model of study proposedby Fletcher and Fletcher,28 as follows: descrip-tive studies (case histories or case series); obser-vational studies (transversal or prevalencestudies, cohort studies, case-control studies,studies of therapeutic results); experimentalstudies (randomized clinical trials, controlledclinical trials, cross-sectional studies); andsystematic reviews with or without meta-analysis.

The studies were organized hierarchicallyaccording to levels of evidence, grade ofrecommendation, and quality. The grade ofrecommendation29 is a measure of quality at-tributable to a study’s level of evidence; itaids in the interpretation of recommenda-tions. For the analysis of the quality of clinicalstudies, the Jadad Scale was used.30

The Oxford Centre for Evidence-Based Medi-cine classifies studies in five levels of evidence ac-cording to the study design (1, 2, 3, 4, and 5),grouping them in four grades of recommenda-tion (A, B, C, and D).29 Grade A comprises levels1a, 1b, and 1c, and is used for systematic reviewsof randomized clinical trials and for randomizedclinical trials and represents the higher grade ofevidence. Grade B (2a, 2b, 2c, 3a, and 3b) is forsystematic reviews of cohort studies, cohort stud-ies, outcomes research, systematic reviews ofcase-control studies, and case-control studies.Grade B represents moderate level of evidence.Grades C (4) and D (5) represent the lowest levelof evidence. Grade C is used for case series stud-ies, and Grade D is for expert opinion.

ResultsThe research question formulated through

the PICO strategy was as follows: ‘‘What topicaltreatments and/or dressings are used for the

control of the symptoms of pain, odor, bleed-ing, exudate and infection arising from malig-nant fungating wounds in cancer patients?’’

Three hundred thirty-four descriptors or keywords were identified for the search strategy. Abibliographic search of 14 databases identified11,111 studies. Of these, only 7,890 (71.0%)were unique, or in other words, 3,221(29.0%) duplicate studies were removed.Among the 7,890 studies identified, most wereclinical studies (82.9%). Most of the publica-tions (56.8%) concerned malignant neoplasms.An analysis of the abstracts of studies of malig-nant neoplasms revealed 527 studies of MFWs,which represented 14.2% of all the woundspresent in malignant neoplasms. The targetsymptoms of MFWs manifested themselveswith the following frequency: pain (28.1%), in-fection (19.9%), bleeding (16.1%), exudate(15.2%), odor (11.2%), and other symptoms(38.3%) (Fig. 1).

Fifty-nine articles related to odor and thatmet the criteria for inclusion were identified,as set out in Fig. 2. An analysis of these articlesas a unit was undertaken. Of these, nine didnot refer to topical treatment for odor, twowere repeats, and five could not be obtained(because of the lack of availability of the scien-tific journal, a lack of response from the authorand/or the absence of cooperation from Bi-reme [Brazilian Library]). The 43 remaining ar-ticles were classified by focus. Five studies hada diagnostic focus, four studies had a prognosticfocus, and 34 studies had a therapeutic focus.Articles with a therapeutic focus were retainedfor analysis, whereas the others were excluded.

The 34 articles were classified according tostudy design. Twenty narrative reviews andone prevalence study were excluded. Of the re-maining 13 articles, five were clinical studies,five were case series, and three were case re-ports. The bibliographic references of the 13selected articles were analyzed, and a furtherseven were thereafter obtained (two clinicalstudies and five case reports), making a totalof 20 studies (Fig. 2).

The 20 studies were classified according tolevels of evidence and grade of recommenda-tion. The seven clinical studies also were classi-fied according to their quality; scales for theevaluation of quality for the descriptive studies(series and case reports) could not be identi-fied in the literature.

Fig. 1. The selection of studies about the topical treatment of odor, pain, exudate, bleeding, and infection in ma-lignant fungating wounds.


DiscussionThe small number of clinical trials

(n¼ 7)3,31e36 did not make it possible to un-dertake a meta-analysis, because interventions,measurement scales, and sample sizes were notconsistent. In addition, a number of thesestudies contained little description of theirmethods, of the interventions made, of the in-struments used to measure odor and results, orof the strategies used to analyze the data(Table 1).

Eleven topical interventions were identified,which varied from traditional treatments (the

use of metronidazole or activated carbon) toinnovative ones (the topical application of cur-cumin or green tea).

Among the instruments used to measureodor, a visual analog scale was cited in fourstudies. The other studies either reportedthat they used an instrument for the measure-ment of odor, without specifying what it was, ordid not use an instrument to measure odor.

Metronidazole was cited in 10 studies.31e33,36e42

The interventions ranged from the topicalapplication of a gel or solution of metronida-zole in concentrations of 0.75%e0.8% to the

Fig. 2. The selection of clinical studies, case series, and case reports about the topical treatment of odor in ma-lignant fungating wounds.


treatment of the MFWs with crushed metroni-dazole tablets; on average, application tookplace once a day, and treatment lasted for 14consecutive days. Metronidazole is a syntheticantimicrobial drug, which is highly effectiveagainst anaerobic bacteria and protozoa.43

The most frequent form of topical interven-tion presented a 2b level of evidence and a Bgrade of recommendation. Metronidazole gelwas either used under medical prescriptionor was made available in accordance with insti-tutional protocol, which, therefore, allowedfor it to be prescribed in nursing environ-ments. It seems that this is an interventionknown in clinical practice to be effective for

the control of MFW odor, but this review hasdemonstrated that conducting more methodo-logically refined studies could raise the level ofevidence and grade of recommendation forthis practice.

Mesalt� dressing (Molnlycke Health Care,Norcross, Georgia) is an absorbent nontissuematerial made up of viscose or polyester im-pregnated with sodium chloride and whoseaction stems from the hypertonic effect pro-duced on the lesion.3 This intervention wascited in one study and showed a 2b level ofevidence and B grade of recommendation.In addition, this was the only study that gavea measurement as to quality (Jadad Scale¼ 1).

Table 1Classification of Controlled Clinical Trials (n¼ 2) and Uncontrolled Trials (n¼ 5) Using Topical Interventions for the Control of Odor in MFWs,

by Level of Evidence, Grade of Recommendation, and Quality

Author, Year Intervention

Sample/Calculationof Sample

ControlGroup

Method ofRandomization

Methodof DoubleBlinding

Retained orAbandoned

ITTAnalysis

JadadScale Outcome

Evaluation ofOdor WithInstruments LE GR

Upright et al.,19943

Mesalt�

dressingþCWStreatments

11 patients/not stated

Yes 1:1 Ratio Notdescribed

Notdescribed

No 1 Alleviation ofpain with statisticalrelevance

Not stated 2b B

Bower et al.,199231

Metronidazolegel at 0.8%þ placebo


Yes Not stated Notdescribed

2 patients No 0 Reduction of odor VAS used by thepatient and bythe investigator

2b B

Finlay et al.,199632

Metronidazolegel at 0.75%


No N/A None,ongoingstudy

8 patients No 0 64% reduction ofodor on D0 andof 4% on D14

VAS (0e10), use bypatient, nurse,and doctor

2c B

Kalinski et al.,200533

Metronidazole gelat 0.75%



None No 0 100% improvementin odor (partialor total)

VAS enumerated 2c B

Kuttan et al.,198734

Curcuminointment



59 patients No 0 Reduction of odorin more than90% of patients

Not stated 2c B

Lund-Nielsenet al., 200535

SF 0.9%þ primarytreatment withactivated carbondressing andsecondarytreatment withan absorptivefoam


No N/A None Notdescribed

No 0 Reduction ofincidence ofodor from 67%to 42%

Not stated 2c B

Kuge et al.,199636

Metronidazole at0.8%þ placebo


No N/A None Notdescribed

No 0 Reduction of odor Analysis performedby doctor in charge,nurse, and patient

2c B

ITT¼ intention-to-treat; LE¼ level of evidence; GR¼ grade of recommendation; CWS¼ continuous wet saline; VAS¼ visual analog scale; N/A¼ not applicable.

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This treatment was used as a primary cover-ing; the dressing was changed once a day,and the treatment lasted for four consecutiveweeks.

Treatment with activated carbon dress-ing35,37 was cited in two studies and showeda 2c level of evidence and B grade of recom-mendation. This treatment is producedthrough the carbonization of cellulose, render-ing it able to promote the absorption of bacte-rial spores and molecules responsible for thefetid odor.35 This treatment was used as a pri-mary covering; the dressing was changedonce a day, and the treatment lasted for fourconsecutive weeks. Traditionally, this interven-tion is known to be effective to control theodor of wounds; conducting more methodo-logically refined studies at the present timecould raise the level of evidence and grade ofrecommendation for this practice.

Curcumin ointment was cited in one study34

and showed a 2c level of evidence and B gradeof recommendation for the control of theodor from MFW. Curcumin is the main biolog-ically active phytochemical compound of tur-meric (Curcuma longa); it is a compound thathas various anti-inflammatory properties byvirtue of its inhibition of cyclooxygenase andother enzymes that regulate the inflammatoryprocess.34 Its antineoplastic activity is currentlybeing evaluated in Phase I, II, and III clinicaltrials.44 This intervention was applied directly

Table 2Classification of Case Series (n¼ 5) Using Topical Inte

of Evidence and Grade of

Author, Year Intervention Sample

Cheng et al., 200345 Topical arsenic trioxide 2 patients

Mercier andKnevitt, 200546

Topical aromatherapy(essential oils)

4 patients

Schiech, 200237 Topical metronidazoleat 0.75%; antisepticsolutions (Dakin�

or CarraKlenz�);activated carbondressing; hydrogels;debridement enzymes

2 patients

Warnke et al., 200647 Essentialantibacterial oils

30 patients, butdiscussion ofonly 3 patients

Yian, 200550 Green tea extract 4 patients

LE¼ level of evidence; GR¼ grade of recommendation; VAS¼ visual analog

to the wounds, three times per day, over a pe-riod of four consecutive weeks.

The interventions that obtained a B grade ofrecommendation are those currently recom-mended for the control of the odor ofMFWs. However, it should be noted that thenumber of high-quality studies is small; thereis a need for studies of a higher methodologi-cal quality to confirm the effectiveness of theseinterventions.

The remaining interventions received a clas-sification of C grade of recommendation (top-ical arsenic trioxide,45 essential oils,46e49 greentea extract,50 and hydropolymer dressings51)and D grade of recommendation (antisepticsolutions,37 hydrogels,37 and debridement en-zymes37) (Tables 2 and 3). All these interven-tions were used infrequently, with theexception of essential oils, which were citedin four studies.46e49 Nevertheless, these treat-ments need to be tested by higher-quality stud-ies, as the current evidence does not allow anyrecommendation to be made concerning thecontrol of the odor from MFWs.

Conclusions and Future TrendsThis review surveyed the literature about

studies related to the control of the five princi-pal symptoms of MFWs: odor, pain, exudate,bleeding, and infection. The factors that

rventions to Control Odor in MFWs by LevelRecommendation

Outcome

Evaluation ofOdor with

Instruments LE GR

Reduction of odor,of exudate, minimalabsorption of arsenicinto the bloodstream

Not stated 4 C

Reduction of odor, onaverage, in 3 days.

Not stated 4 C

Resolution of odor within5e7 days after the start ofintervention; reduction ofodor in all interventionstested

Not stated 5 D

Improvement in odor Not stated 4 C

Improvement in odor VAS (1e5) 4 C

scale.

Table 3Classification of Case Reports (n¼ 8) Using Topical Interventions to Control Odor in MFWs by Level

of Evidence and Grade of Recommendation

Author/YearTopical Treatment

UsedSample

Size OutcomeEvaluation of OdorWith Instruments LE GR

Naylor, 200151 Treatment with hydropolymerfoam

1 patient Complete resolutionof fetid odor

Not stated 4 C

Warnke et al., 200548 Essential oilsþ systemicantibioticþ systemicchlorophyll


Not stated 5 D

Warnke et al., 200449 Essential oilsþ systemicantibioticþ systemicchlorophyll


Not stated 5 D

Bauer et al., 200038 Crushed metronidazole appliedto woundþ secondary dressingimpregnated with petrolatum

1 patient Improvement in fetidodor

Not stated 5 D

Jones, 199839 Metronidazole gel at 0.8% 1 patient Reduction of odor Not stated 5 DPrice, 199640 Topical metronidazole

gel (concentrationnot indicated)


Not stated 5 D

Shulter et al., 199741 Metronidazole gel at 0.9%þ hydrogel treatment

1 patient Improvement in fetidodor

Not stated 5 D

Dalton, 199042 Metronidazole treatment 1 patient Complete resolutionof fetid odor

Not stated 5 D

LE¼ level of evidence; GR¼ grade of recommendation.


enhanced the quality of this review include thenumber of descriptors and databases used, inaddition to the fact that there were no restric-tions as to the language in which the studieswere written or their design.

Eleven interventions for the topical treat-ment of the odor from MFWs were identified.Metronidazole and Mesalt� dressing presenta 2b level of evidence and B grade of recom-mendation. Activated carbon dressing and cur-cumin ointment yielded a 2c level of evidenceand B grade of recommendation. C and Dgrades of recommendation were observed inseven other interventions: topical arsenic

Table 4Synthesis of Evidence Regarding the Topical Treat

Topical InterventionCitations in

Studies, n (%)a E

Metronidazole 10 (50)Mesalt� dressing 1 (5)Curcumin ointment 1 (5)Activated carbon dressing 2 (10)Topical arsenic trioxide 1 (5)Essential oils 4 (20)Green tea extract 1 (5)Hydropolymer dressings 1 (5)Antiseptic solutions 1 (5)Hydrogels 1 (5)Debridement enzymes 1 (5)

aThe total percentage exceeds 100%, because some studies involved more th

trioxide, essential oils, green tea extract, hy-dropolymer dressings, antiseptic solutions, hy-drogels, and debridement enzymes (Table 4).

The goal of identifying the evidence forodor control was achieved, and in addition, itwas possible to point out the flaws to beavoided in the planning of future studies inthis area. Few high-quality studies were foundto guide the topical treatment of odor in thecase of MFWs, and the principal limitationsof existing studies were design (few controlledclinical and randomized trials), small samplesizes, and the absence of instruments or scalesto measure odor.

ment of the Fetid Odor of MFWs (n¼ 11)

Highest Level ofvidence Achieved

Highest Grade ofRecommendation Achieved

2b B2b B2c B2c B4 C4 C4 C4 C5 D5 D5 D

an one type of intervention.


Randomized clinical trials are the goldstandard for treatment studies but are hardto conduct in many clinical conditions as,for example, wound care. The research chal-lenges related to MFWs involve a number ofmethodological and ethical concerns, suchas use of a placebo group, blinding re-searchers, blinding patients, assessing levelof changes in odor, following patients fora long period, and others. To improve thelevel of evidence of future studies, we sug-gest an increase in the number of patientsand the use of standardized scales for odorassessment. These strategies could bring im-portant contribution and even supportmeta-analysis.

This study provides evidence to support theuse of metronidazole, Mesalt� dressing, acti-vated carbon dressing, and curcumin ointmentin the treatment of patients with MFWs, but ad-ditional research in this area is still necessary.The use of metronidazole has spread aroundthe world; it is inexpensive, easy to use, andeasily available. Activated carbon dressing iseasy to use, available in many countries, andwell accepted by patients, but is still expensivefor developing countries. Mesalt� dressing isnot available in many countries, and there isvery little experience with this dressing inMFWs. Curcumin ointment is a new practicenot available commercially.

The palliative care target is holistic care thatinvolves physical, social, emotional, and spiri-tual well-being. Odor causes social embarrass-ment and has a destructive psychologicalimpact on the individual with this kind ofwound, contributing even to isolation. Themainstays of the management of MFWs are an-ticancer treatments, symptom control (includ-ing pain management), and local wound care.The odor could be controlled by local care orsystemic treatment, such as radiotherapy andchemotherapy.

MFWs require palliative care, and answers asto how this care should be administered can-not be found in studies in the area of woundcare, a field which privileges research intohealing rather than symptom control. Thehighest level of evidence currently availablefor the control of odor from MFWs indicatesthe use of metronidazole, Mesalt� dressing,activated carbon dressing, and curcuminointment.

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A Systematic Review of Topical Treatments to Control the Odor of Malignant Fungating Wounds.pdf