Malignant Wound Care: Part 1

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 In Tip of the Month
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Any malignancy that has penetrated the structure of the skin, including mucous membranes, can be considered a malignant wound, including tumours that are found in the oral cavity, or vaginal, urethral, and rectal openings.  They are also commonly located on the head, neck, chest, back and groin.  They may be fungating, ulcerative or mixed in appearance (1).  Malignant wounds are most often considered non-healable due to underlying advancement of the disease process (1,2,3).

Proper management of such tumours using wound care principles is a foundational skill of palliative caregiving and can make a dramatic impact on the quality of life of those living with them.

Wound care requires a team approach (1).  Specialized wound care, enterostomal (ET) and palliative care consultant nurses can provide helpful recommendations.

Understanding the Pathophysiology

When treating a malignant wound, it is essential to understand the underlying processes taking place:

  • Tumours have their own blood supply and are highly susceptible to bleeding,
  • Tumour tissues are made up of poorly functioning cells and are therefore extremely fragile,
  • Tumour cells replicate more rapidly than normal cells and can quickly produce deadened tissue (i.e. slough, eschar) and drainage,
  • Tumour cells destroy and displace normal, healthy tissues (1).

Primary Considerations in Malignant Wound Care

“Treat the whole patient, not the hole in the patient” (Canadian Association of Wound Care, 2019).

A malignant wound can be an intensely distressing experience for a patient and their loved ones.  The appearance, odour and discomfort can be traumatic and isolating.  No matter what wound care treatment options are chosen, make wound care choices that support the patient’s quality of life.  Goals of malignant wound care might include reduction and/or management of pain, odour, drainage and appearance, as well as improved protection of the wound and functional ability of the patient (2,3).

Slow malignant wound growth & deterioration.

If indicated, chemotherapy, radiation therapy or surgical reduction targeted at slowing the disease process may reduce the speed of wound progression and improve symptoms (1,3).

Clinicians must work to protect the wound bed and tissues around the malignant wound.  Use barrier products on the surrounding skin and any skin affected by wound advancement or drainage.  Peri-tumour skin can become very fragile as the tumour erodes its boarders, and the acidity and moisture of tumour drainage may irritate, soften and damage the surrounding skin.  Manage disruption of the malignant wound and surrounding tissue by considering products that can manage the wound’s characteristics as well as reduce the frequency of dressing changes (2).

Malignant wounds are often covered with devitalized slough and/or eschar.  Debridement of a malignant wound is not recommended due to increased risk of significant hemorrhage and tissue damage.  Use gentle irrigation techniques (PSI of less than 8) with room temperature sterile water or normal saline.  Wound cleanser sprays with surfactants that support the body’s natural wound- cleaning process (autolysis) can be a useful option that protects both fragile and healthy tissue (2).

Choose non-adherent and non-abrasive products that will sit against the wound bed, such as silicone.  Avoid products that will dry out between dressing changes, resulting in tissue trauma (debridement) as the dressing is removed.  If a dressing becomes stuck on any part of the wound carefully & thoroughly soak the dressing in normal saline/sterile water until it can be gently removed (2).

Resources/References:

  1. Adderley, U., Holt, I. (2014).  Topical agents and dressings for fungating wounds.  Cochrane Database of Systemic Reviews, 5.  Accessed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464725/.
  2. Canadian Association of Wound Care. (2018). Chapter 2: Best Practice Recommendations for the Prevention and Management of Wounds in Foundations of Best Practice for Skin and Wound Management. Available at woundscanada.ca.
  3. Pallium Canada. (2018).  The Pallium Palliative Pocketbook: A peer-reviewed, referenced resource. 2nd Cdn Edition.  Ottawa, Canada: Pallium Canada.

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