Comfort and Closure: A New Perspective on the Treatment of Fungating Breast Wounds and Use of a Hypochlorous Acid–Preserved Wound Cleanser

Wound care management of fungating breast wounds is challenging. This article presents 3 cases in the hospital-based outpatient wound care setting that demonstrate how a hypochlorous acid–preserved wound cleanser (HAPWOC) (Vashe; Urgo Medical North America) was used, synergistically with other wound care modalities, to achieve a significant reduction in wound drainage, size, odor, and in one case full wound closure. The HAPWOC has a pH of 3.5 to 5.5, which is conducive to wound healing.^1-3 Evidence-based research on HAPWOC shows that its use is also conducive to cell survival⁴ and is effective in microbe, biofilm,^5-10 and necrotic matter removal.¹¹ It is also effective in odor control.¹² Hypochlorous acid–preserved cleansers have been recommended by several researchers^13-16 given the deep level of associated high-quality evidence.^4-19

A case series of 3 patients with malignant, highly exudative breast wounds with foul odor and heavy necrotic tissue is described. Odor and drainage were the chief complaints. Therapy goals were to control drainage and reduce odor. These goals were achieved using HAPWOC as a wound cleanser and as a primary dressing. HAPWOC was used as a dressing by moistening 4 × 4 gauze (Kerlix; Cardinal Health) and placing it directly in contact with the wound bed.

Case 1. A 59-year-old woman noted a breast mass in April 2020. An ultrasound and fine-needle biopsy were completed in early September 2020; within 48 hours of the biopsy, the patient noted an ulcer forming over the right breast. Biopsy results confirmed high-grade stage IIIc ductal carcinoma (ER+). On November 4, 2020, the patient self-referred to the wound care center with a mass that extended through the skin, creating a fungating breast wound measuring 6.5 cm × 9.5 cm × 2.3 cm.

The lesion and copious wound drainage with malodorous smell suggested infection. The patient was using metronidazole cream and over-the-counter ABD pads that were changed up to 8 times per day to control drainage and reduce odor. The patient was prescribed once-daily dressing changes using HAPWOC-soaked gauze and an ABD pad. Weekly sharp debridement was performed to reduce bacterial overload and associated odor and drainage. The patient also was treated with oral amoxicillin-clavulanic acid for increased pain and positive wound culture. Topical custom compounded biofilm-eliminating gel with clindamycin 1%, levofloxacin 1%, and vancomycin 2.5% was started at week 3, and the patient underwent 4 cycles of chemotherapy. The wound healed, and the patient was discharged 8 weeks after the initial wound care visit (Figure 1).

Case 2. A 64-year-old woman presented to the emergency department in December 2020 with extreme weakness. She reported a 4- to 6-month history of a bleeding left breast/chest wall mass. Biopsy results of the mass demonstrated infiltrating ductal carcinoma. The patient was admitted and treated with empirical antibiotics. The patient’s wound was treated with metronidazole 500 mg tablets; 5 tablets were crushed and sprinkled in the wound periodically for 4 weeks to manage wound odor as needed. Vashe-moistened gauze was used as a primary dressing. Vancomycin 2.5%, levofloxacin 1%, formulated in a biofilm-affecting wound gel was initiated 3.5 weeks after initial wound treatment. Improvement in the left chest wound showed a 99% reduction over 15 weeks (Figure 2).

Case 3. An 89-year-old woman presented to the emergency department in November 2020 with shortness of breath. Evaluation revealed an ulcerative right chest wall mass and dermal nodules. Computed tomography scan showed multiple pulmonary nodules consistent with metastatic disease to the lungs. Results of a biopsy of the breast remnant demonstrated high-grade infiltrating ductal carcinoma. With cancer treatment and excellent wound care (including the protocol described above), the chest wall wound healed almost completely. Systemic metastatic disease, including pleural effusion and pulmonary metastatic lesions, improved. Wound treatments included metronidazole 500 mg tablets, crushed (2) and sprinkled in the wound over 2 weeks, for additional odor control. The biofilm-focused gel without antibiotics was introduced into the wound after 3.5 weeks of wound treatment. Over 12 weeks, the wound volume decreased by 89% (Figure 3).

DISCUSSION

Regardless of treatment goals, fungating malignant breast wounds require a multidisciplinary approach. The patient’s primary care provider should be managing underlying comorbidities that may impair healing. In addition, the patient may be seeing an oncologist, radiation oncologist, or surgeon who provide treatments such as chemotherapy, radiotherapy, hormone manipulation, and surgery.

Autolytic and mechanical debridement usually are not recommended due to the high vascularity of these wounds; however, sharp debridement is still an option if completed carefully. Local wound management should be aimed at controlling symptoms and establishing goals of treatment: healing versus palliative care.

Fungating wounds are malodorous because exudate that is rich in proteinaceous matter provides an ideal environment for bacterial proliferation. In addition, when the wound is chronic, it is likely that microbes exist in a biofilm-associated state where they are resistant to topical or systemic antibiotics. It has been shown that HAPWOC can mechanically remove microbes and biofilm material,^4-10 and that it does so with very little cellular toxicity,⁴ which can negatively affect wound healing. Fungating ulcers and chronic wounds likely have many elements in common, such as the presence of necrotic material and microbial matter.^20-23

This case series shows that palliation is not the only possible endpoint for these wounds. Certainly, a multifaceted approach was used, including antibiotics and a biofilm-affecting gel formulated with personalized antibiotics. Nevertheless, the role of the wound cleanser was critical because it came into contact with the wound frequently, sometimes several times a day. The author believes that the ability of the cleanser to provide a cell-friendly, noncytotoxic environment is crucial and therefore one must avoid the use of harsh cleansers with cytotoxic agents.⁴ When combined with other evidence-based and/or empirical treatments, HAPWOC can lead to healing or near-healing outcomes over time and thus improve quality of life for this vulnerable population. In particular, the odor management property of HAPWOC,¹² which is perhaps related to its ability to mechanically remove microbes, biofilm matter, and necrotic debris, is a valuable addition to the healing effects, impacting patient quality of life positively.

The author found that HAPWOC, which has a pH that is conducive to wound healing, works synergistically with other evidence-based or empirical treatments to manage and close, or nearly close, these challenging wounds. It is known that the control of the wound pH, at a slightly acidic range, is ideal for healing.^1-3 The HAPWOC is formulated at this pH, and this may have contributed to the unexpected and positive healing profiles seen.

CONCLUSION

Based on this experience, for the author, healing is now the goal of managing fungating breast wounds. HAPWOC wound cleanser should be considered in the care of these wounds both as a cleanser and incorporated into the primary dressing. The HAPWOC should be used to moisten 4 × 4 gauze and be changed daily after wound odor and drainage have decreased significantly.

Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.

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