Assessment

and
Management
of Fungating
Wounds
By Kelli J. Bergstrom,
BSN, RN, ET, CWOCN

38 Healthy Skin

Treatment

Fungating
wounds present
unique challenges,
including prevention or
management of bleeding
and control of exudate
and odor.

Abstract

Etiology and Presentation

A fungating wound is a malignant lesion that inltrates the skin

and its supporting blood and lymph vessels. They tend to
develop in the last few months of a patient's life, and often
impair psychosocial well-being. Fungating wounds present
unique challenges for WOC nursing management, including
prevention or management of bleeding and control of exudate
and odor. Our knowledge of the epidemiology, etiology,
assessment, and management of these lesions is limited. This
article provides an overview of the epidemiology of fungating
wounds, their assessment and options for management,
focusing on local wound management, control of associated
symptoms, and psychosocial support for patient and family.

A fungating wound, also known as a malignant lesion, is

dened as the inltration and proliferation of malignant cells in
to the skin and its supporting blood and lymph vessels.6 It may
evolve from the site of the primary cancerous lesion or from a
secondary lesion.7 Fungating malignant wounds may be locally
advanced, metastatic, or recurrent.8 Metastatic spread tends to
occur along pathways of minimal resistance, such as tissue
planes, blood or lymph vessels of the skin, or through implantation of tumor cells through a surgical incision.9 They frequently
occur in patients between the ages of 60 and 70 years and
often develop during the last 6 months of life.10 Diagnosis is
based on histological assessment and cultures from the
surface of the wound to confirm the presence of anaerobic
organisms that ourish on the necrotic tissue. If these organisms are not accurately identied, inappropriate treatments can
lead to the production of by-products that can interact with
wound drainage resulting in periwound maceration.7

Introduction
A cancer diagnosis can be devastating for any patient, especially when complicated by a fungating wound. A fungating
wound can be present for years, but they usually develop in the
last few months of a patient's life. Although fungating wounds
pose a challenge for patients and caregivers, Clark1 reports that
only 90 research articles have been published on the topic in
the past 30 years. Approximately 5% of patients with cancer
and 10% of those with metastatic disease will develop a
fungating wound.2,3 Although they can arise from any type of
underlying malignant tumor, the majority of metastatic cutaneous lesions arise from primary tumor sites involving the
breast, lungs, skin, and gastrointestinal tract.4 Fungating
wounds require additional research focusing on their etiology
and presentation, physical and social impact, and management,
especially as patients approach end of life,5 and WOC nurses
should both initiate and participate in interdisciplinary studies
addressing these challenging wounds.

Fungating wounds have a tendency to expand rapidly, and they

show a propensity to become locally invasive, or form shallow
craters.7 Initially, they present as multiple nontender nodules that
are skin-toned, pink, violet-blue, or black-brown in color, but
they go on to develop in to papillary lesions (resembling a cauliower stalk) that may be complicated by an ulcer, sinus tract,
or stula.8 The most common location for a fungating malignant
tumor is the breast; these lesions represent 62% of fungating
wounds. Head and neck lesions account for 24%, the groin,
genitals and back account for approximately 3%, and all other
regions account for 8% of all fungating wounds.10 As these
lesions expand, they tend to disrupt the local blood supply,
resulting in necrosis of the malignant tumor and underlying

Improving Quality of Care Based on CMS Guidelines 39

Treatment

Assessment is an ongoing process due to

the progressive nature of the wound, and
the evolving condition of the patient.10

tissue. Anaerobic organisms readily grow and proliferate in this

warm, moist, and oxygen-poor environment. It is the proliferation of these anaerobic organisms that create their characteristic
exudate and malodor. Tumor inltration of the local lymphatic
vessels can also affect interstitial tissue drainage resulting in
lymphedema of the affected region.7

The management goals of a fungating tumor vary, depending on

the stage of the underlying cancer, the patient's prognosis, and
the individual's own goals and wishes. In some cases, the goal
is to arrest tumor growth. In these cases, a multidisciplinary
approach is required that may include radiotherapy, chemotherapy, surgery, hormone manipulation, neutron therapy, and low
intensity laser therapy.10 In other situations fungating tumors
occur at the end of life, and treatment is completed in a palliative care setting that focuses on comfort and maintenance of
the best possible quality of life for the patient and family.11 In
either case, it is important to remember that the symptoms produced by a fungating wound are often as distressing as the
wound itself. Therefore, management focuses on alleviation of
bothersome symptoms including pain, cutaneous irritation,
exudate, bleeding, odor, and psychosocial support, regardless
of whether treatment is delivered in a palliative or aggressive
care context.

Pain
Assessment
Assessment is an ongoing process due to the progressive
nature of the wound, and the evolving condition of the
patient.10 It is necessary for the WOC nurse to take a holistic
approach in assessing the interrelationship between patient and
the wound.7 In addition to assessing local wound factors, the
WOC nurse should consider the cause and stage of the underlying cancer, previous and current treatment, the patients
understanding of the diagnosis, nutritional status, impact of the
malignancy and wound on the patient's and caregivers psychosocial status and quality of life. Assessment should also
evaluate availability of resources and social support networks.9
Local wound assessment includes evaluation of its location,
dimensions, depth, percentage of devitalized tissue, degree of
tissue adherence of the wound surface, volume and characteristics of exudate, odor, history of bleeding, quality and intensity
of pain, signs of stula or sinus formation, and condition of the
periwound skin.9 Assessment data are then used to develop a
management plan, taking care to ensure that the planned
interventions are consistent with the patient's goals and priorities and do not adversely interact with other components of the
management plan.7

Pain is a subjective symptom impacted by the underlying condition, the wound itself, and dressing changes.10 Assessment
includes location, nature, duration, onset, frequency, intensity,
impact on activities of daily living, aggravating and alleviating
factors, current analgesia use, and effects of treatment. Standardized pain scales are used to assess intensity. Evaluation
should also differentiate nociceptive pain (caused by stimulation of nerve endings when provoked by inammatory mediators) from neuropathic pain (caused by nerve damage and
dysfunction) because treatment differs depending on the type of
pain. Analgesics, including opioids and nonopioid agents, are
used for nociceptive pain, while adjuvant agents, such as
amitriptyline and carbamazepine, are more effective for neuropathic pain. Analgesics and adjuvant agents may be prescribed
separately or concurrently to achieve a combined effect.
According to recent case studies, topical opioids applied to the
wound surface can provide immediate local analgesia and work
indirectly to diminish the inammatory process.10,12 When managing pain associated with dressing changes, several interventions may be implemented, such as a booster dose of
analgesia prior to dressing changes, use of nonadherent soft
silicone dressings, gentle care techniques, and reduced
frequency of dressing changes.

Continued on page 42

40 Healthy Skin

Periwound Skin Irritation

Patients 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 damage
to the patient's peripheral nerve supply, which is responsible for
transmitting pruritic sensations. Typical inammatory mediators
are not involved; therefore, intense itching is normally not
responsive to traditional antihistamines. Alternative options for
treatment include cancer specic hormone therapy, chemotherapy, tricyclic antidepressants, or Transcutaneous Electrical
Nerve Stimulation.13

Exudate
Fungating wounds may produce large amounts of exudate
resulting in discomfort and embarrassment for the patient.
Exudate also may lead to periwound maceration, increasing the
risk of infection.10 Several types of dressings may be used to
manage high-volume exudate, and WOC nurses are a valuable
resource when selecting an appropriate dressing. The optimal
dressing should be nonadherent to the tumor to reduce pain
and trauma associated with dressing changes. It should effectively absorb exudate and toxins while maintaining a moist surface that supports autolytic debridement of necrotic tissue. If
the wound is friable and bleeds easily, a dressing with hemostatic properties is benecial. Control of odor and restoration of
body symmetry and cosmetic acceptability with the use of less
bulky dressings are also important principles to consider for the
patient's self-image.7 The categories of dressings normally recommended include activated charcoal dressings for odor control, alginates for bleeding wounds, foam/hydropolymer
dressings for exuding wounds, hydrocolloid sheets for lightly
exuding wounds or protection of surrounding skin, hydrober
dressings for heavily exuding wounds, and semipermeable lm
membranes for protection of intact skin. If the volume of wound
exudate is too high even for highly absorbent dressings and
requires more than 2 to 3 dressing changes per day, a wound
manager pouch may be necessary to collect drainage and protect
surrounding skin.9 Ointment based skin protectants or liquid
polymer acrylate barrier lms should be considered for patients
with exudate that compromises intact skin.10
Not only is the selection of the most effective dressing a challenge; determining the best way to secure the dressing is often
difcult. Some dressings are self-adhesive, but most require a
separate product. Depending on the location and size of the
wound, traditional adhesives, such as a tape, may not be
appropriate. In addition, the patient may be more vulnerable to

42 Healthy Skin

skin tears and breakdown due to the underlying malignancy and

its impact on nutritional status. In some cases, standard adhesive products may potentiate problems and a cling dressing
wrap or a tubular net bandage may be used to secure dressings
without resorting to an adhesive secondary cover.

Bleeding
Because blood vessels can be disrupted by the inltration of
tumor cells, bleeding at the wound site is common in patients
with fungating wounds.10 There are several treatment options
to control spontaneous bleeding, including oral antibrinolytics,
such as tranexamic acid, and radiotherapy.8 In situations where
the bleeding is associated with dressing changes, interventions
to prevent bleeding include gentle technique for application and
removal of dressings, maintaining a moist wound and dressing
interface, gentle cleansing techniques, and use of nonbrous,
nonadherent dressing materials. Certain dressings, such as calcium alginates, have hemostatic properties that exchange
sodium ions for calcium ions, promoting the clotting cascade
within the wound bed.5 It is important for the WOC nurse to
monitor the patient's hemoglobin levels because if the patient
becomes anemic, a blood transfusion or iron tablets may be
required.10

Odor
The presence and severity of odor is subjective and inuenced
by 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 of
a fungating wound. 15 As noted previously, wound odor is
associated with necrotic tissue that supports the growth of
anaerobic bacteria, and the presence of volatile fatty acids in
the wound. Stagnant exudate, infection, and stula formation
are also contributing factors.1
Treatment for odor encompasses multiple aspects of wound
care. Systemic antibiotics may be appropriate if there is evidence of clinical infection. However, excessive use of antimicrobial agents should be avoided because it can lead to
overgrowth of resistant organisms such as methicillin-resistant
Staphylococcus 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 for
reducing 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

Because blood vessels

can be disrupted by the
inltration of tumor cells,
bleeding at the wound site
is common in patients with
fungating wounds

wound should be cleansed with normal saline and the metronidazole applied liberally and covered with a secondary dressing. For heavily exudative wounds, consider the use of crushed
metronidazole tablets sprinkled over the wound surface and
covered with a petroleum-jelly-coated dressing. For dry
wounds, the gel form of metronidazole is more appropriate.17
Metronidazole should not be used in conjunction with any other
topical creams, gels, or ointments because its effectiveness and
antimicrobial activity could be potentially diluted.7 Although it
has been shown to be effective in many odorous wounds, it is
ineffective in wounds that are too moist or dry.15
Charcoal dressings also may be used to alleviate odor. Because
the molecules that are responsible for the malodor are attracted
to the carbon surface, the activated charcoal dressing acts as
a lter to absorb these molecules, preventing them from being
released into the air.14 In order to be effective, a charcoal dressing must be tted as a sealed unit directly on to the wound.10
There are limitations for application on charcoal dressings in fungating wounds because the dressing is effective only in wounds
that produce minimal exudate.15 Silver dressings may also
reduce wound odor because of its antimicrobial effect against
a wide range of organisms including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus, thus
inhibiting bacterial growth and preventing colonization; however,
they tend to be expensive especially when frequent dressing
changes are needed.14
Alternative topical agents sometimes used to control odor
include sugar paste, medical honey, and yogurt.15 There are

several controlled trials and case studies supporting the benets of sugar paste and honey in wound care,16 but the evidence
for yogurt is limited to anecdotal reports. Because sugar paste
is not commercially available in the United States, a specic
combination of caster sugar, icing sugar, polyethylene glycol,
and hydrogen peroxide is recommended in the literature. This
paste is prepared in both thick and thin consistencies in the
hospital pharmacy and stored in a screw-top plastic container
for up to 6 months. The table shows the formula for sugar
paste.18 Sugar paste has the ability to absorb uid due to its
high osmolality, thereby starving bacteria of uid and inhibiting
their growth. On contact with the wound, sugar paste liquees,
and prevents dehydration of normal cells. It also enables
sloughing of necrotic cells and promotes granulation tissue formation.19 Some studies have shown it to be effective against
Staphylococcus aureus, Streptococcus faecalis, Escherichia
coli, and Candida albicans.18 Although it can be useful for
patients with fungating wounds, the effect wears off over time
so it is necessary to apply a thick layer to the surface of the
wound and secure with a petroleum-jelly-coated dressing twice
or more a day.15,19
Honey has been used as a dressing since ancient times, but
due to the emergence of antibiotic-resistant strains of microorganisms, there is an increased interest in its wound healing
properties. Medical grade honey derived from the Leptospermum species found in the manuka ower of Australia and New
Zealand, inhibits bacterial growth in several ways, including its
acidic pH, which prevents biolm formation, the slow release of
hydrogen peroxide, which is toxic to microbes, and high
osmolality, which inhibits bacterial growth.20 Honey also acts as
a debriding agent with several mechanisms of action. It
encourages autolytic debridement due to its strong osmotic
action of pulling uid from the wound and washing the base to
remove debris and slough.21 The production of hydrogen peroxide contributes to debridement by activating proteases to
breakdown unwanted tissue.20 Odor control is attributed to
inhibition of bacterial growth and removal of necrotic tissue from
the wound base.21 However, topical honey may be difcult to
apply and requires the use of an absorbant secondary dressing.
Therefore, it may not be an option for wounds that are too
moist. Advances in technology have provided several forms of
honey-impregnated dressings, including alginates and hydrocolloids that may be more effective in the management of fungating wounds. These dressings received US Federal Drug
Administration approval in 2007 and are manufactured through
Medihoney, Derma Sciences, Canada.20

Improving Quality of Care Based on CMS Guidelines 43

Aromatherapy is another option

for odor management.
other studies could be found to support its use. Maggots are
highly effective in debriding necrotic tissue and removing bacteria through ingestion; however, there is a great potential for
bleeding and patient acceptance may be difcult.5

Psychosocial Support

Yogurt has also been used to control odor in fungating wounds.

Evidence is insufcient to conrm or refute its efcacy, but clinical experience and anecdotal reports in the literature suggest
it is effective in some cases.9 Most manufactured yogurts contain the active culture, lactobacillus, which produces lactic acid
lowering the pH in the wound bed and inhibiting growth of odorproducing organisms.22 At least 1 newer yogurt preparation also
contains Bidobacterium culture; it is described as helping regulate the digestive tract, and its effect on malodorous fungating
wounds is not known. Room temperature plain yogurt should
be applied to the wound surface and covered with a petroleum-jelly-coated dressing.23 Treatment should be repeated 4
times a day for 2 to 3 days until odor is resolved.
Aromatherapy is another option for odor management. Essential oils of lavender, lemon, citrus, or tea can be used on the
bandage or secondary dressing, but not directly on the wound
bed itself. Scented candles and burning oils, as well as kitty litter and coffee grounds placed throughout the patient's home
may help to mask the odor.15 Frequent dressing changes and
proper disposal of waste products is also recommended since
saturated dressings can harbor odor.5
Debridement is useful in fungating wounds with large amounts
of necrotic tissue. Sharp wound debridement is contraindicated
because of the risk for potential bleeding and malignant cell
seeding. Autolytic debridement is preferred because it avoids
the risk for bleeding and it can be promoted with any dressing
regimen that maintains a moist wound surface. Autolytic debridement may occur naturally where devitalized tissue eventually separates on its own.14 Larval therapy has been suggested
for use in fungating wounds by Thomas and colleagues24 but no

44 Healthy Skin

Fungating wounds are an ongoing reminder of the underlying

disease that frequently provoke a wide range of negative emotions such as guilt, shame, confusion, frustration, loss of power,
and denial.25 Fungating wounds are often disguring and malodorous, which can profoundly impair a patient's self-image.26
Because the location, appearance, and odor of a wound may
be a source of embarrassment and distress for both the patient
and family, all are at risk for social isolation, depression, diminished sexual expression, and difculty maintaining relationships
with family and friends.27 The WOC nurse should evaluate the
individual's coping mechanisms and social support networks
to determine the impact of the wound on psychosocial status
and social support networks.28 Patients and families affected
by fungating wounds may require additional support and counseling from psychologists, social workers, bereavement counselors, as well as hospice and other professionals. Patients and
family members should play an active role in determining wound
care, and treatments should be chosen to minimize the
wound's impact on the patient and family, provide adequate
control of symptoms, and allow for the potential of intimacy. The
treatment plan should also provide comfort as well as
independence.29

Conclusion
Fungating wounds are a devastating complication of malignancies. WOC nurses should take an active role in assessment and
management of the fungating malignant wound, focusing on
management of distressing symptoms such as pain, excessive
exudate, odor, and bleeding. The WOC nurse is ideally suited to
make recommendations for care, assure that appropriate interventions are being carried out, provide education to the patient
and caregivers, and offer solutions to existing and future problems. The WOC nurse should also act as an advocate for
patients with fungating wounds by providing support and
encouragement, and helping assist the patient to maintain dignity
and maximize comfort during the end of life. WOC nurses
should generate and participate in further research about
fungating wounds, including the search for the most effective
methods for controlling odor and exudate.

Key Points
As a WOC nurse, it is necessary to understand the etiology
and presentation of fungating wounds so that they can
be accurately assessed and managed.
Management of fungating wounds focuses on controlling
pain, cutaneous irritation, exudate, bleeding, odor, and
psychosocial issues.
There is a need for further research by WOC nurses so that
patients 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 (kelli.bergstrom@osumc.edu).

20. Pieper B. Honey-based dressings and wound care: an option for care in the United
States. J Wound, Ostomy, Continence Nurs. 2009; 36(1):6068.
21. Blair SE, Coccetin NN, Harry EJ, Carter DA. The unusual antibacterial activity of
medical-grade leptospermum honey: antibacterial spectrum, resistance and
transcriptome analysis. Eur J Clin Microbiol Infect Dis. 2009; 28(10):11991208.
22. Gribbons CA, Aliapoulios MA. Treatment for advanced breast carcinoma. Am J Nurs.
1972; 72(4):678682.
23. Welch LB. Simple new remedy for the odor of open lesions. RN. 1981; 44(2):4243.
24. Jones M, Andrews A, Thomas S. A case history describing the use of sterile larvae
(maggots) in a malignant wound. World Wide Wounds [serial online]. February 14,
1998; Available from: CINAHL Plus with Full Text.
25. Lund-Nielsen B, Muller K, Adamsen L. Malignant wounds in women with breast cancer:
feminine and sexual perspectives. J Clin Nurs. 2005; 14:5664.
26. Lo SF, Hu WY, Hayter M, Chang SC, Hsu MY, Wu LY. Experiences of living with a
malignant fungating wound: a qualitative study. J Clin Nurs. 2008; 17(20):26992708.
27. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant wounds
in patients with advanced illness. J Palliat Med. 2006; 9(2):285295.
28. Laverty D. Fungating wounds: informing practice through knowledge/theory. Br J Nurs.
2003; 12(15):S29S40.
29. Kirsner R. Malignant wounds. Wound healing perspectives: a clinical pathway to
success. 2007;4(1):18.
Printed with permission from the Journal of Wound, Ostomy & Continence Nursing.
January/February 2011; 38(1):3137.

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Improving Quality of Care Based on CMS Guidelines 45