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Referral and warning signs
When to refer
Need for palliative radiotherapy/chemotherapy assessment. Uncontrolled bleeding. Severe pain unresponsive to standard measures. Complex wound management requiring specialist nurse/doctor input.
Red flags
- Major haemorrhage from the wound.
- Signs of rapidly spreading infection or sepsis.
- Severe, uncontrolled pain.
- Rapid enlargement of the wound.
Signs and symptoms
- Ulcerated lesion, often with irregular edges.
- Friable tissue, prone to bleeding.
- Malodour.
- Variable amounts of exudate.
- Pain.
- Associated cellulitis or infection.
- Visible tumour tissue.
Risk factors
- Advanced cancer (breast, head and neck, melanoma, sarcoma, etc.).
- Tumour progression through the skin.
Diagnosis
Clinical assessment
Diagnosis based on clinical appearance in a patient with known malignancy. Assess wound characteristics (size, depth, tissue type, exudate, odour, bleeding). Assess for surrounding cellulitis. Assess pain.
Investigations
- Usually none required for diagnosis of the wound itself.
- Wound swab for culture and sensitivity if secondary bacterial infection suspected.
- Biopsy may be considered if diagnosis uncertain, but often avoided due to bleeding risk.
Diagnostic criteria
Clinical appearance of wound in the context of underlying malignancy.
Management
Non-pharmacological management
- Treat underlying cause (cancer) if appropriate (radiotherapy, chemotherapy - specialist decision).
- Gentle Wound Cleansing: Use normal saline (0.9% NaCl) or cooled boiled water with salt (1 tsp/pint).
- Dressings: Choose non-adherent dressings to minimize trauma and bleeding. Aim for exudate management and odour control (e.g., charcoal dressings if available, foams). Change daily or as needed.
- Protect Surrounding Skin: Use barrier creams (e.g., petroleum jelly, zinc oxide).
- Manage Bleeding: Apply direct pressure. Consider haemostatic dressings (e.g., alginates) or agents like adrenaline solution (topical, dilute) if available and appropriate.
- Manage Exudate: Use absorbent dressings.
- Patient positioning to minimize pressure on wound.
Pharmacological treatment
- Pain Management: Use WHO analgesic ladder (see PAL001). Consider topical analgesics if appropriate.
- Odour Control: Topical Metronidazole powder or gel applied daily directly to wound.
- Infection Control: Treat surrounding cellulitis with appropriate systemic antibiotics (see UCG 22.1.3).
- Reduce Tumour Bulk (Specialist): Palliative radiotherapy or chemotherapy may help shrink the tumour and reduce wound symptoms.
Monitoring
Monitor wound appearance (size, exudate, odour, bleeding). Assess pain control. Monitor for signs of infection. Monitor dressing tolerance and effectiveness.
Complications
- Severe pain.
- Bleeding (can be significant).
- Secondary infection / Cellulitis / Sepsis.
- Malodour leading to social isolation.
- High exudate levels leading to skin maceration and dressing difficulties.
- Psychological distress (body image, odour).
Prevention
- Not preventable once tumour infiltrates skin, but early cancer treatment may prevent occurrence.
- Good skin care may delay breakdown in some cases.
Patient education
- Explanation of the wound as part of the cancer.
- Wound care instructions (cleansing, dressing).
- Signs of infection to report.
- Pain management strategies.
- Strategies for odour and exudate management.
- Importance of protecting surrounding skin.
- Psychosocial support resources.
Uganda-specific notes
Fungating wounds are common presentations of advanced cancers (esp. breast). Management focuses on symptom control: hygiene, simple dressings, pain relief, and topical metronidazole for odour. Access to advanced dressings and palliative radiotherapy is limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 13, Section 13.2.4