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Assessmentand
Managementof FungatingWounds
38 Healthy Skin
By Kelli J. Bergstrom,
BSN, RN, ET, CWOCN
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Improving Quality of Care Based on CMS Guidelines 39
AbstractA fungating wound is a malignant lesion that inltrates
the skinand its supporting blood and lymph vessels. They tend
todevelop in the last few months of a patient's life, and
oftenimpair psychosocial well-being. Fungating wounds presentunique
challenges for WOC nursing management, includingprevention or
management of bleeding and control of exudateand odor. Our
knowledge of the epidemiology, etiology,assessment, and management
of these lesions is limited. Thisarticle provides an overview of
the epidemiology of fungatingwounds, their assessment and options
for management,focusing on local wound management, control of
associatedsymptoms, and psychosocial support for patient and
family.
IntroductionA cancer diagnosis can be devastating for any
patient, espe-cially when complicated by a fungating wound. A
fungatingwound can be present for years, but they usually develop
in thelast few months of a patient's life. Although fungating
woundspose a challenge for patients and caregivers, Clark1 reports
thatonly 90 research articles have been published on the topic
inthe past 30 years. Approximately 5% of patients with cancerand
10% of those with metastatic disease will develop afungating
wound.2,3 Although they can arise from any type ofunderlying
malignant tumor, the majority of metastatic cuta-neous lesions
arise from primary tumor sites involving thebreast, lungs, skin,
and gastrointestinal tract.4 Fungatingwounds require additional
research focusing on their etiologyand presentation, physical and
social impact, and management,especially as patients approach end
of life,5 and WOC nursesshould both initiate and participate in
interdisciplinary studiesaddressing these challenging wounds.
Etiology and PresentationA fungating wound, also known as a
malignant lesion, isdened as the inltration and proliferation of
malignant cells into the skin and its supporting blood and lymph
vessels.6 It mayevolve from the site of the primary cancerous
lesion or from asecondary lesion.7 Fungating malignant wounds may
be locallyadvanced, metastatic, or recurrent.8 Metastatic spread
tends tooccur along pathways of minimal resistance, such as
tissueplanes, blood or lymph vessels of the skin, or through
implan-tation of tumor cells through a surgical incision.9 They
frequentlyoccur in patients between the ages of 60 and 70 years
andoften develop during the last 6 months of life.10 Diagnosis
isbased on histological assessment and cultures from thesurface of
the wound to confirm the presence of anaerobicorganisms that ourish
on the necrotic tissue. If these organ-isms are not accurately
identied, inappropriate treatments canlead to the production of
by-products that can interact withwound drainage resulting in
periwound maceration.7
Fungating wounds have a tendency to expand rapidly, and theyshow
a propensity to become locally invasive, or form shallowcraters.7
Initially, they present as multiple nontender nodules thatare
skin-toned, pink, violet-blue, or black-brown in color, butthey go
on to develop in to papillary lesions (resembling a cau-liower
stalk) that may be complicated by an ulcer, sinus tract,or stula.8
The most common location for a fungating malignanttumor is the
breast; these lesions represent 62% of fungatingwounds. Head and
neck lesions account for 24%, the groin,genitals and back account
for approximately 3%, and all otherregions account for 8% of all
fungating wounds.10 As theselesions expand, they tend to disrupt
the local blood supply,resulting in necrosis of the malignant tumor
and underlying
Fungatingwounds presentunique challenges,
including prevention ormanagement of bleedingand control of
exudate
and odor.
Treatment
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tissue. Anaerobic organisms readily grow and proliferate in
thiswarm, moist, and oxygen-poor environment. It is the
prolifera-tion of these anaerobic organisms that create their
characteristicexudate and malodor. Tumor inltration of the local
lymphaticvessels can also affect interstitial tissue drainage
resulting inlymphedema of the affected region.7
AssessmentAssessment is an ongoing process due to the
progressivenature of the wound, and the evolving condition of
thepatient.10 It is necessary for the WOC nurse to take a
holisticapproach in assessing the interrelationship between patient
andthe wound.7 In addition to assessing local wound factors, theWOC
nurse should consider the cause and stage of the under-lying
cancer, previous and current treatment, the patientsunderstanding
of the diagnosis, nutritional status, impact of themalignancy and
wound on the patient's and caregivers psy-chosocial status and
quality of life. Assessment should alsoevaluate availability of
resources and social support networks.9
Local wound assessment includes evaluation of its
location,dimensions, depth, percentage of devitalized tissue,
degree oftissue adherence of the wound surface, volume and
character-istics of exudate, odor, history of bleeding, quality and
intensityof pain, signs of stula or sinus formation, and condition
of theperiwound skin.9 Assessment data are then used to develop
amanagement plan, taking care to ensure that the
plannedinterventions are consistent with the patient's goals and
priori-ties and do not adversely interact with other components of
themanagement plan.7
TreatmentThe management goals of a fungating tumor vary,
depending onthe stage of the underlying cancer, the patient's
prognosis, andthe individual's own goals and wishes. In some cases,
the goalis to arrest tumor growth. In these cases, a
multidisciplinaryapproach is required that may include
radiotherapy, chemother-apy, surgery, hormone manipulation, neutron
therapy, and lowintensity laser therapy.10 In other situations
fungating tumorsoccur at the end of life, and treatment is
completed in a pallia-tive care setting that focuses on comfort and
maintenance ofthe best possible quality of life for the patient and
family.11 Ineither case, it is important to remember that the
symptoms pro-duced by a fungating wound are often as distressing as
thewound itself. Therefore, management focuses on alleviation
ofbothersome symptoms including pain, cutaneous irritation,exudate,
bleeding, odor, and psychosocial support, regardlessof whether
treatment is delivered in a palliative or aggressivecare
context.
PainPain is a subjective symptom impacted by the underlying
con-dition, the wound itself, and dressing changes.10
Assessmentincludes location, nature, duration, onset, frequency,
intensity,impact on activities of daily living, aggravating and
alleviatingfactors, current analgesia use, and effects of
treatment. Stan-dardized pain scales are used to assess intensity.
Evaluationshould also differentiate nociceptive pain (caused by
stimula-tion of nerve endings when provoked by inammatory
media-tors) from neuropathic pain (caused by nerve damage
anddysfunction) because treatment differs depending on the type
ofpain. Analgesics, including opioids and nonopioid agents, areused
for nociceptive pain, while adjuvant agents, such asamitriptyline
and carbamazepine, are more effective for neuro-pathic pain.
Analgesics and adjuvant agents may be prescribedseparately or
concurrently to achieve a combined effect.According to recent case
studies, topical opioids applied to thewound surface can provide
immediate local analgesia and workindirectly to diminish the
inammatory process.10,12 When man-aging pain associated with
dressing changes, several interven-tions may be implemented, such
as a booster dose ofanalgesia prior to dressing changes, use of
nonadherent softsilicone dressings, gentle care techniques, and
reducedfrequency of dressing changes.
40 Healthy SkinContinued on page 42
Assessment is an ongoing process due tothe progressive nature of
the wound, andthe evolving condition of the patient.10
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42 Healthy Skin
Periwound Skin IrritationPatients with fungating wounds often
experience a creeping,intense itching sensation attributed to the
activity of the tumor.Because of its invasiveness, the tumor causes
severe damageto the patient's peripheral nerve supply, which is
responsible fortransmitting pruritic sensations. Typical inammatory
mediatorsare not involved; therefore, intense itching is normally
notresponsive to traditional antihistamines. Alternative options
fortreatment include cancer specic hormone therapy, chemother-apy,
tricyclic antidepressants, or Transcutaneous ElectricalNerve
Stimulation.13
ExudateFungating wounds may produce large amounts of
exudateresulting in discomfort and embarrassment for the
patient.Exudate also may lead to periwound maceration, increasing
therisk of infection.10 Several types of dressings may be used
tomanage high-volume exudate, and WOC nurses are a valuableresource
when selecting an appropriate dressing. The optimaldressing should
be nonadherent to the tumor to reduce painand trauma associated
with dressing changes. It should effec-tively absorb exudate and
toxins while maintaining a moist sur-face that supports autolytic
debridement of necrotic tissue. Ifthe wound is friable and bleeds
easily, a dressing with hemo-static properties is benecial. Control
of odor and restoration ofbody symmetry and cosmetic acceptability
with the use of lessbulky dressings are also important principles
to consider for thepatient's self-image.7 The categories of
dressings normally rec-ommended include activated charcoal
dressings for odor con-trol, alginates for bleeding wounds,
foam/hydropolymerdressings for exuding wounds, hydrocolloid sheets
for lightlyexuding wounds or protection of surrounding skin,
hydroberdressings for heavily exuding wounds, and semipermeable
lmmembranes for protection of intact skin. If the volume of
woundexudate is too high even for highly absorbent dressings
andrequires more than 2 to 3 dressing changes per day, a
woundmanager pouchmay be necessary to collect drainage and
protectsurrounding skin.9 Ointment based skin protectants or
liquidpolymer acrylate barrier lms should be considered for
patientswith exudate that compromises intact skin.10
Not only is the selection of the most effective dressing a
chal-lenge; determining the best way to secure the dressing is
oftendifcult. Some dressings are self-adhesive, but most require
aseparate product. Depending on the location and size of thewound,
traditional adhesives, such as a tape, may not beappropriate. In
addition, the patient may be more vulnerable to
skin tears and breakdown due to the underlying malignancy andits
impact on nutritional status. In some cases, standard adhe-sive
products may potentiate problems and a cling dressingwrap or a
tubular net bandage may be used to secure dressingswithout
resorting to an adhesive secondary cover.
BleedingBecause blood vessels can be disrupted by the inltration
oftumor cells, bleeding at the wound site is common in patientswith
fungating wounds.10 There are several treatment optionsto control
spontaneous bleeding, including oral antibrinolytics,such as
tranexamic acid, and radiotherapy.8 In situations wherethe bleeding
is associated with dressing changes, interventionsto prevent
bleeding include gentle technique for application andremoval of
dressings, maintaining a moist wound and dressinginterface, gentle
cleansing techniques, and use of nonbrous,nonadherent dressing
materials. Certain dressings, such as cal-cium alginates, have
hemostatic properties that exchangesodium ions for calcium ions,
promoting the clotting cascadewithin the wound bed.5 It is
important for the WOC nurse tomonitor the patient's hemoglobin
levels because if the patientbecomes anemic, a blood transfusion or
iron tablets may berequired.10
OdorThe presence and severity of odor is subjective and
inuencedby multiple factors such as the patient's ability to
perceive odor,along with the perceptions of caregivers and family
members.14
This symptom can be one of the most devastating aspects ofa
fungating wound.15 As noted previously, wound odor isassociated
with necrotic tissue that supports the growth ofanaerobic bacteria,
and the presence of volatile fatty acids inthe wound. Stagnant
exudate, infection, and stula formationare also contributing
factors.1
Treatment for odor encompasses multiple aspects of woundcare.
Systemic antibiotics may be appropriate if there is evi-dence of
clinical infection. However, excessive use of antimi-crobial agents
should be avoided because it can lead toovergrowth of resistant
organisms such as methicillin-resistantStaphylococcus aureus and
vancomycin-resistant enterococcus,and some antibiotics increase the
risk of nausea and vomiting.10
Metronidazole has been evaluated for use as a topical agent
forreducing wound odor.16 It is a synthetic antimicrobial
drug,which works against anaerobic bacteria and protozoa;
however,it can take up to 2 to 3 days before odor is reduced.15
The
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Improving Quality of Care Based on CMS Guidelines 43
wound should be cleansed with normal saline and the
metron-idazole applied liberally and covered with a secondary
dress-ing. For heavily exudative wounds, consider the use of
crushedmetronidazole tablets sprinkled over the wound surface
andcovered with a petroleum-jelly-coated dressing. For drywounds,
the gel form of metronidazole is more appropriate.17
Metronidazole should not be used in conjunction with any
othertopical creams, gels, or ointments because its effectiveness
andantimicrobial activity could be potentially diluted.7 Although
ithas been shown to be effective in many odorous wounds, it
isineffective in wounds that are too moist or dry.15
Charcoal dressings also may be used to alleviate odor.
Becausethe molecules that are responsible for the malodor are
attractedto the carbon surface, the activated charcoal dressing
acts asa lter to absorb these molecules, preventing them from
beingreleased into the air.14 In order to be effective, a charcoal
dress-ing must be tted as a sealed unit directly on to the
wound.10
There are limitations for application on charcoal dressings in
fun-gating wounds because the dressing is effective only in
woundsthat produce minimal exudate.15 Silver dressings may
alsoreduce wound odor because of its antimicrobial effect againsta
wide range of organisms including methicillin-resistant
Staphy-lococcus aureus and vancomycin-resistant enterococcus,
thusinhibiting bacterial growth and preventing colonization;
however,they tend to be expensive especially when frequent
dressingchanges are needed.14
Alternative topical agents sometimes used to control odorinclude
sugar paste, medical honey, and yogurt.15 There are
several controlled trials and case studies supporting the
bene-ts of sugar paste and honey in wound care,16 but the
evidencefor yogurt is limited to anecdotal reports. Because sugar
pasteis not commercially available in the United States, a
speciccombination of caster sugar, icing sugar, polyethylene
glycol,and hydrogen peroxide is recommended in the literature.
Thispaste is prepared in both thick and thin consistencies in
thehospital pharmacy and stored in a screw-top plastic containerfor
up to 6 months. The table shows the formula for sugarpaste.18 Sugar
paste has the ability to absorb uid due to itshigh osmolality,
thereby starving bacteria of uid and inhibitingtheir growth. On
contact with the wound, sugar paste liquees,and prevents
dehydration of normal cells. It also enablessloughing of necrotic
cells and promotes granulation tissue for-mation.19 Some studies
have shown it to be effective againstStaphylococcus aureus,
Streptococcus faecalis, Escherichiacoli, and Candida albicans.18
Although it can be useful forpatients with fungating wounds, the
effect wears off over timeso it is necessary to apply a thick layer
to the surface of thewound and secure with a petroleum-jelly-coated
dressing twiceor more a day.15,19
Honey has been used as a dressing since ancient times, butdue to
the emergence of antibiotic-resistant strains of microor-ganisms,
there is an increased interest in its wound healingproperties.
Medical grade honey derived from the Leptosper-mum species found in
the manuka ower of Australia and NewZealand, inhibits bacterial
growth in several ways, including itsacidic pH, which prevents
biolm formation, the slow release ofhydrogen peroxide, which is
toxic to microbes, and highosmolality, which inhibits bacterial
growth.20 Honey also acts asa debriding agent with several
mechanisms of action. Itencourages autolytic debridement due to its
strong osmoticaction of pulling uid from the wound and washing the
base toremove debris and slough.21 The production of hydrogen
per-oxide contributes to debridement by activating proteases
tobreakdown unwanted tissue.20 Odor control is attributed
toinhibition of bacterial growth and removal of necrotic tissue
fromthe wound base.21 However, topical honey may be difcult toapply
and requires the use of an absorbant secondary dressing.Therefore,
it may not be an option for wounds that are toomoist. Advances in
technology have provided several forms ofhoney-impregnated
dressings, including alginates and hydro-colloids that may be more
effective in the management of fun-gating wounds. These dressings
received US Federal DrugAdministration approval in 2007 and are
manufactured throughMedihoney, Derma Sciences, Canada.20
Because blood vesselscan be disrupted by theinltration of tumor
cells,bleeding at the wound siteis common in patients withfungating
wounds
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44 Healthy Skin
other studies could be found to support its use. Maggots
arehighly effective in debriding necrotic tissue and removing
bac-teria through ingestion; however, there is a great potential
forbleeding and patient acceptance may be difcult.5
Psychosocial SupportFungating wounds are an ongoing reminder of
the underlyingdisease that frequently provoke a wide range of
negative emo-tions such as guilt, shame, confusion, frustration,
loss of power,and denial.25 Fungating wounds are often disguring
and mal-odorous, which can profoundly impair a patient's
self-image.26
Because the location, appearance, and odor of a wound maybe a
source of embarrassment and distress for both the patientand
family, all are at risk for social isolation, depression,
dimin-ished sexual expression, and difculty maintaining
relationshipswith family and friends.27 The WOC nurse should
evaluate theindividual's coping mechanisms and social support
networksto determine the impact of the wound on psychosocial
statusand social support networks.28 Patients and families
affectedby fungating wounds may require additional support and
coun-seling from psychologists, social workers, bereavement
coun-selors, as well as hospice and other professionals. Patients
andfamily members should play an active role in determining
woundcare, and treatments should be chosen to minimize thewound's
impact on the patient and family, provide adequatecontrol of
symptoms, and allow for the potential of intimacy. Thetreatment
plan should also provide comfort as well asindependence.29
ConclusionFungating wounds are a devastating complication of
malignan-cies. WOC nurses should take an active role in assessment
andmanagement of the fungating malignant wound, focusing
onmanagement of distressing symptoms such as pain,
excessiveexudate, odor, and bleeding. The WOC nurse is ideally
suited tomake recommendations for care, assure that appropriate
inter-ventions are being carried out, provide education to the
patientand caregivers, and offer solutions to existing and future
prob-lems. The WOC nurse should also act as an advocate forpatients
with fungating wounds by providing support andencouragement, and
helping assist the patient to maintain dignityand maximize comfort
during the end of life. WOC nursesshould generate and participate
in further research aboutfungating wounds, including the search for
the most effectivemethods for controlling odor and exudate.
Yogurt has also been used to control odor in fungating
wounds.Evidence is insufcient to conrm or refute its efcacy, but
clin-ical experience and anecdotal reports in the literature
suggestit is effective in some cases.9 Most manufactured yogurts
con-tain the active culture, lactobacillus, which produces lactic
acidlowering the pH in the wound bed and inhibiting growth of
odor-producing organisms.22 At least 1 newer yogurt preparation
alsocontains Bidobacterium culture; it is described as helping
reg-ulate the digestive tract, and its effect on malodorous
fungatingwounds is not known. Room temperature plain yogurt
shouldbe applied to the wound surface and covered with a
petro-leum-jelly-coated dressing.23 Treatment should be repeated
4times a day for 2 to 3 days until odor is resolved.
Aromatherapy is another option for odor management. Essen-tial
oils of lavender, lemon, citrus, or tea can be used on thebandage
or secondary dressing, but not directly on the woundbed itself.
Scented candles and burning oils, as well as kitty lit-ter and
coffee grounds placed throughout the patient's homemay help to mask
the odor.15 Frequent dressing changes andproper disposal of waste
products is also recommended sincesaturated dressings can harbor
odor.5
Debridement is useful in fungating wounds with large amountsof
necrotic tissue. Sharp wound debridement is contraindicatedbecause
of the risk for potential bleeding and malignant cellseeding.
Autolytic debridement is preferred because it avoidsthe risk for
bleeding and it can be promoted with any dressingregimen that
maintains a moist wound surface. Autolytic de-bridement may occur
naturally where devitalized tissue eventu-ally separates on its
own.14 Larval therapy has been suggestedfor use in fungating wounds
by Thomas and colleagues24 but no
Aromatherapy is another optionfor odor management.
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Improving Quality of Care Based on CMS Guidelines 45
Key Points As a WOC nurse, it is necessary to understand the
etiologyand presentation of fungating wounds so that they canbe
accurately assessed and managed.
Management of fungating wounds focuses on controllingpain,
cutaneous irritation, exudate, bleeding, odor, andpsychosocial
issues.
There is a need for further research by WOC nurses so
thatpatients can be managed more effectively.
Correspondence: Kelli J. Bergstrom, BSN, RN, ET, CWOCN,The James
Cancer Hospital and Solove Research Institute,300 W 10th St,
Starling Loving Hall Rm M200, Columbus,OH 43210
([email protected]).
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