Fungating Wounds

Fungating wounds are seen with advanced, incurable malignant tumors. They can arise from a primary cutaneous malignancy, a metastatic lesion or a malignant transformation of a chronic ulcer (Marjolin’s ulcer). Fungating wounds occur in approximately 10% of these patients, the majority of whom will die of their disease. Metastatic breast cancer, soft tissue sarcoma, melanoma, and head and neck cancers unresponsive to chemo or irradiation therapy are common examples of fungating wounds. Not unexpectedly, these patients suffer psychosocial distress producing a negative effect on their self-image and remaining quality of life. 

The fungating wound differs from the chronic, recalcitrant wound in many ways. Its pathology evolves from a direct, continuous proliferation and invasion of malignant cells into the supporting underlying tissues, blood and lymphatic vessels and periwound. The result is local tissue hypoxia with ongoing ischemic necrosis, a vicious cycle. Often these patients have undergone failed chemo or irradiation therapy, which compounds the matter.

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How I Do It

The treatment of fungating wounds is a palliative plan of care that shifts the focus from wound restoration to a patient support approach focusing on improving quality of life, management of wound pain and exudate if possible, odor control and avoiding wound complications. Surgical debulking is often not feasible, can result in extensive bleeding, and can be dangerous. 

A variety of treatment options exist. Moist wound care utilizing a medicated foam to support autolytic debridement is preferred. Careful, limited superficial wound debridement of nonadherent necrotic tissue should be attempted. Enzymatic debridement can be useful and is atraumatic. Protection of the periwound with a skin barrier or zinc oxide is needed to avoid maceration and denuding. Control of neuropathic pain avoiding narcotic medication if possible should be attempted. Premedicating prior to dressing changes is often beneficial. Avoiding dry, adhering dressings and limiting the frequency of dressing changes should be considered. Pruritus of the periwound, which can occur, can be addressed with a skin moisturizer and fexofenadine, the least sedative antihistamine. Hydration along with nutritional support utilizing protein, amino acids and vitamin supplements can be considered.

Dealing With Odor From Fungating Wounds

Fungating wound odor can be quite pronounced and offensive. It is the result of necrotic tissue breakdown combined with multiple bacterial strains, both anaerobic and obligatory anaerobic microbes. This produces a volatile, short chain fatty acid metabolite, isovaleric acid, which has an unpleasant odor.

To deal with this we have found Vashe wound cleanser, (Urgo Medical North America) to be quite beneficial. It is hypochlorous acid that acts to lowers the wound pH to 4–6, which is similar to intact skin. Vashe is noncytotoxic and acts as a debridement irrigator removing microorganisms from the wound. It is applied directly to the wound and periwound utilizing a 4 x 4 gauze sponge.
Ideally, Vashe can be used in conjunction with a wound Lolly (Debrisoft L&R USA Inc.) which is a soft, polyester fiber applicator constructed to attract and remove wound debris without causing significant mechanical trauma or bleeding. If either product is not available an alternative method is to utilize a soft toothbrush or a 4 x 4 gauze sponge to clean the wound with Johnson's baby shampoo, which contains surfactant, followed by a saline rinse.

Additionally, charcoal impregnated dressings which require an occlusive covering; topical, crushed Flagyl; or gentamicin powder are mentioned as treatment but seem to be less effective. Hemostasis, if required can be achieved with silver nitrate sticks and Surgicel (oxidized cellulose, Ethicon) cut into strips and applied directly to the bleeding site. A wound culture, topical or systemic antibiotics are not indicated and should not be used.

These treatment suggestions are offered for your consideration and use, and close clinical follow-up is required.

James V. Stillerman, MD, CWSP, FACCWS, is the Medical Director of Samaritan Medical Center for Advanced Wound Care in Watertown, NY. He is board certified in advanced wound care by the American Board of Wound Management and has 35 years of experience including vascular surgery. Dr. Stillerman is a board member for Hospice in Jefferson County, New York. Most recently, he received the SAWC Grand Rounds award for his poster presentation the treatment of enterocutaneuos fistulas. Dr. Stillerman has initiated a wound care lecture series for teaching the medial students and medical residents. He also provides lectures to many of the regional wound care centers. He is currently is developing a wound care treatment template to assist the emergency department, local nursing homes and hospital with wound care and prevention. He also consults via telemedicine as an adjunctive evaluation tool.
 
Dr. Stillerman recently joined the Editorial Board of Today’s Wound Clinic.

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