COMMUNITY SERVICES DIVISION CLINICAL GUIDANCE DOCUMENT

FUNGATING WOUND CLINICAL GUIDANCE

Policy Number: 55 Scope of this Document: All relevant clinical staff

within Community Services Division

Recommending Committee: Skin Care Service Approving Committee: Clinical Policies & Procedures

Group Date Ratified: January 2018 Next Review Date (by): January 2020 Version Number: Version 6 Lead Executive Director: Executive Director of Nursing

and Operations Lead Author(s): Skin Care Service

COMMUNITY SERVICES DIVISION CLINICAL GUIDANCE

DOCUMENT

Version 6

Striving for perfect care and a just culture

55 – Fungated Wound Clinical Guidance. Version 6

COMMUNITY SERVICES DIVISION CLINICAL GUIDANCE DOCUMENT

FUNGATING WOUND CLINICAL GUIDANCE

Further information about this document:

Document name Fungating Wound Clinical Guidance (55)

Document summary To provide evidence based guidance to assist in the

management of fungating wounds and their common symptoms

Author(s)

Contact(s) for further information about this document

Skin Care Service

Published by

Copies of this document are available from the Author(s) and

via the trust’s website

Mersey Care NHS Foundation Trust V7 Building

Kings Business Park Prescot

Merseyside L34 1PJ

Trust’s Website www.merseycare.nhs.uk

To be read in conjunction with This document can be made available in a range of alternative formats including

various languages, large print and braille etc

Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

Version Control:

Version History: Version 5 Ratified by Clinical Standards Group 24 Jan-18

Version 6

Transferred to Mersey Care NHS Foundation Trust Template, with reference to Liverpool Community

Health NHS Trust replaced with Mersey Care name and branding

6 Jun-19

55 – Fungated Wound Clinical Guidance. Version 6

SUPPORTING STATEMENTS

this document should be read in conjunction with the following statements:

SAFEGUARDING IS EVERYBODY’S BUSINESS

All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

/ adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

• ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

EQUALITY AND HUMAN RIGHTS

Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

55 – Fungated Wound Clinical Guidance. Version 6

Purpose of the Guideline

This guideline has been developed to provide evidence-based guidance on the

management of fungating wounds. It aims to improve clinical practice and reduce

variations in standards of care within the primary care setting. Scope of the Guideline

This guideline is applicable to all registered health professionals employed by

Mersey Care NHS Trust (LCH) who are involved in the management of

patients with fungating wounds. Definitions

Definitions have been taken from The Free Dictionary Online (Medical) 2013 unless

otherwise indicated by a specific reference. Cutaneous: Relating to the skin.

Ischaemic necrosis: Local tissue death caused by inadequate blood supply.

Necrosis: Death of some or all the cells in an organ or tissue, resulting in irreversible damage.

Tissue: A group or layer of similarly specialized cells that together perform certain special functions.

Vasoconstriction: Narrowing of blood vessels.

Fungating Wounds

A malignant skin ulcer, also called ulcerating cancer or a fungating wound, develops:

• As a result of a primary skin tumour such as squamous cell carcinoma or

melanoma. • Through direct invasion of the structures of the skin by an underlying

tumour, or haematological malignancy such as cutaneous T-cell 55 – Fungated Wound Clinical Guidance. Version 6

lymphoma (mycosis fungoides).

55 – Fungated Wound Clinical Guidance. Version 6

• From metastatic spread of a distant tumour. Metastasis may occur along tissue planes, capillaries or lymph vessels. (Naylor, 2002)

Two different processes can be involved in the formation of malignant ulcers (Seaman, 2006; Langemo et al, 2007; McManus, 2007):

• An ulcerative process, in which a crater-like wound develops. • A proliferative process, in which a nodular 'fungus' or 'cauliflower' lesion

develops Most malignant skin ulcers develop from breast cancers or tumours in the head

and neck, due to the close proximity to blood vessels (Nazarko, 2006. Fujioka

and Yakabe, 2010). Sometimes a chronic wound may undergo malignant

transformation to produce a fungating wound, although this is rare. (Naylor,

2002)

These wounds often present with multiple unpleasant and difficult to manage

symptoms, commonly malodour, heavy exudate, bleeding and pain; others may

include pruritus (itching), excessive necrotic tissue, peri-wound maceration,

fistula or sinus formation, and wound infection. Unlike other chronic wounds, a

malignant wound is not likely to heal and is a constant reminder that the patient

has progressive cancer. Patients can also suffer from a number of psychological

and social difficulties such as impaired body image, depression, anger,

embarrassment and social isolation (Piggin & Jones 2007). The management of malignant wounds is therefore based on symptom control

with the aim of relieving suffering, maintaining function, and enabling patients to

engage in activities that are important to them. Given the complex nature of malignant fungating wounds and the emotive

sensitivity of the subject area, there are few research studies to support

evidence-based practice and guidance is often based on consensus of expert

opinion and case studies (Adderley & Smith 2008, Selby 2009) Duties and Responsibilities

55 – Fungated Wound Clinical Guidance. Version 6

As an employee of Mersey Care you will be expected to act all times in such a manner as to safeguard and promote the interests of patients and clients. To practice competently you must process the skills and abilities required for safe and effective practice. You must acknowledge the limits of your personal competence and only undertake practice and accept responsibilities for those activities for which you are suitably skilled and experienced (Nursing and Midwifery Council, 2015).

This policy links in with wound assessment training provided by Skin Care Service for all clinical practitioners who will deliver wound care management and treatment.

Monitoring Tool

Audit of this guideline will be undertaken as per Mersey Care forward audit plan

for individual localities and services, using the wound assessment audit tool. Development of the Guideline, Contributions and Peer Review

This guideline should be used in conjunction with the following M e r s e y

C a r e Clinical Guidelines and Policies: Wound Assessment 2016 (amended 2017)

Assessment & Management of Infected Wounds

2017 Wound Debridement 2016

Consent to Treatment 2016

Mental Capacity Act (2005) Policy 2017

Infection Prevention and Control Manual 2017 Accessed via:

http://opera.liverpoolch.nhs.uk/SIRS/Policies-and-

Procedures/Clinical%20Policies/forms/search.aspx The guideline was developed and peer reviewed by members of the Skin

Care Service and ratified by Mersey Care Clinical Policies Group. This guideline

has been peer reviewed by Mersey Care Palliative Care Team.

55 – Fungated Wound Clinical Guidance. Version 6

Equality Analysis This has been undertaken and the evidence has been retained by the

authors and the Equality and Diversity Lead of Mersey Care Dissemination and implementation

Once approved, this guideline will be added to the Clinical Policies database

and communicated via Mersey Care Weekly Bulletin. Training is also

available as part of Wound Assessment Training accessed via LCH Learning

and Development Bureau and delivered by the Skin Care Service. Evidence Base

The evidence to support this guideline is and is identified by letter:

A: Evidence obtained from systemic reviews and/or randomized control

trials. B: Evidence from multiple unacceptable studies or a single

acceptable study (Weak or inconsistent evidence)

C: Evidence which includes published and/or published studies and

expert opinion (Limited Scientific evidence). References

Alexander, S. (2009a) Malignant fungating wounds: epidemiology, aetiology and assessment. Journal of Wound Care. Vol 18, 7 p273 – 280. Accessed 09.01.2018

Alexander, S (2009b) Malignant fungating wounds: key symptoms and psychological issues. Journal of Wound Care. Vol 18, 8 p325 - 329. Accessed 09.01.2018

Alexander, S. (2009c) Malignant fungating wounds: managing malodour and exudate. Journal of Wound Care. Vol 18, 9 p 373 – 381. Accessed 09.01.2018

Alexander, S. (2009d) Malignant fungating wounds: managing pain, bleeding

55 – Fungated Wound Clinical Guidance. Version 6

and psychological issues. Journal of Wound Care. Vol 18, 10 p418 - 425. Boon. et al (2000) The community care of a patient with a fungating wound. British Journal of Nursing Vol 9 no 6. Tissue Viability Supplement S35 – S38.

British National Formulary (BNF) (2018). Available at: https://www.medicinescomplete.com/mc/bnf/current/PHP-drugs.htm Accessed 09.01.2018.

Cancer research UK (2017) Available at: http://www.cancerresearchuk.org/about- cancer/coping/physically/ulcerating-cancers. Accessed 12.01.2018.

Clark, J. (2002) Metronidazole gel in managing malodourous fungating wounds British Journal of Nursing 11:16, S54 -560

Draper, C. (2005) The management of malodour and exudate in fungating wounds British Journal of Nursing .Vol 14 (suppl) S 4-12

Fujioka, M. Yakabe, A. (2010) Palliative Surgery for Fungating skin cancers. Wounds 22 (10) 247-250

Grocott, P. (2007) Care of patients with fungating malignant wounds. Nursing Standard 21(24), 57-66.

Hollinworth, H. (2005) The management of patients pain in wound care. Nursing standard, 20,7, p65.

Laverty,D. (2003) Fungating Wounds: Informing practice through knowledge/theory British Journal of Nursing 12,15: 29 40.

Lloyd, H. (2008). Management of bleeding and malodour in fungating wounds. Journal of community nursing. 22, 8/9, p28-32.

McDonald, A. and Lesage, P. (2006) Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. Journal of Palliative Medicine 9(2), 285-295

Naylor W et al (2001) The Royal Marsden hospital Handbook of wound Management in Cancer Care. Blackwell Science, Oxford.

Naylor, W. (2002) Part 1: Symptom Control in the Management of Fungating Wounds. Available at: http://www.worldwidewounds.com/2002/march/Naylor/Symptom-Control- Fungating-Wounds. Accessed 09.01.2018

Naylor, W. (2005) “A guide to wound management in palliative care” Int Journal Palliative Nursing. 11.11, 572-9.

NICE (2016) Clinical Skills Summary (CKS) Available at:.

55 – Fungated Wound Clinical Guidance. Version 6

http://cks.nice.org.uk/palliative-care-malignant-skin-ulcer#!topicsummary 08/01/2018 Nazarko, L. (2006) Malignant Fungating Wounds. Nursing & Residential Care 8(9) 402-404.

Piggin, C. and Jones, V. (2007) Malignant fungating wounds: An analysis of the lived experience. International Journal of Palliative Nursing Vol 13 no8 p 384-391

Selby, T. (2009) Managing exudate in malignant fungating wounds and solving problems for patients. Nursing Times. Available at: https://www.nursingtimes.net/5001103.article?search=https%3a%2f%2fwww.nur singtimes.net%2fsearcharticles%3fqsearch%3d1%26keywords%3dManaging+ex udate+in+malignant+fungating+wounds+and+solving+problems+for+patients Accessed 10.01.18

Stephen-Haynes, J. (2008) An overview of caring for those with palliative wounds. British Journal of Community Nursing 13 (12), S24-S30

Twycross, R., Wilcock, A. & Howard, P. (Eds) (2014). Palliative care formulary (5th ed). Palliative drugs: Nottingham.

Wilson, V. (2005) Assessment and management of fungating wounds: a review. British Journal of Community Nursing; 10: (3), s28 -34).

Watret, L. (2011) Management of a fungating wound. Journal of community nursing: 25, (2), 31-36.

55 – Fungated Wound Clinical Guidance. Version 6

Assessment

Action Rationale Supporting evidence and level

A holistic assessment should be performed with a multidisciplinary approach incorporating:

• All aspects of the patients self care needs

• Psychological issues including: body image, sexuality, coping abilities, spiritual and cultural needs.

• Social and family/carer support .

Ensure Consent is obtained from the patient prior to any assessment/procedure. For more information refer to Mersey Care Consent to Treatment Policy 2016. In adults who lack mental capacity ensure Mental Capacity Assessment is completed and acting in best interests.(Available on SIRS) For more information refer to Mental Capacity Act 2005

It is important to assess the patient in relation to how they function normally and how their usual activities of living have been affected, so that a plan of interventions can be implemented to ensure a positive impact on the patient’s current and future lifestyle.

Patient (and carers where applicable) needs to be understand and agree to any planned interventions/assessments.

Patients and carers should be aware that healing is an unrealistic goal, it should be explained that the aim is to maintain or improve quality of life.

Clinicians need to be able to demonstrate documentation of consent in records. Where acting in Best Interest for people who lack capacity to consent, assessment of capacity needs to be documented.

Alexander (2009a) C

Emotional needs of practitioners should be supported within the (Nursing) team or via clinical supervision.

Nurses may find the stress and emotional impact of caring for patients with fungating wounds traumatic.

Laverty (2003) C

The nursing goals should aim to improve the patient’s quality of life. The management of the wound will dependent upon the patients symptoms.

Common symptoms include: • Pain • Malodour • Excessive exudate • Bleeding • Psychological issues.

Wilson (2005) C

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Assess the wound using Mersey Care wound assessment documentation.

To provide baseline information and will assist in monitoring improvement or deterioration of the wound and surrounding skin, any change in the type of tissue on the wound bed. Record whether wound is ulcerative or proliferative as this will determine dressing type. Allows for continuity of care.

Pudner (1998) C

Consider referral for specialist management if be required.

Vessel compression/obstruction, airway obstruction and the presence of a significant necrotic tissue which may be able to be debrided. Further palliative treatment may be appropriate.

CKS 2016 C

Wound Cleansing and Dressing

Action Rationale Supporting evidence and level

If wound cleansing is needed, Unless the wound is contaminated, Draper gently irrigate the wound and producing excessive exudate or (2005) C cleanse the skin around the ulcer. contains loose necrotic tissue that can CKS (2016) Ideally the cleansing fluid should be easily rinsed away, cleansing during be at body temperature. If this is dressing changes may not be not possible, warm the fluid to necessary. Consider the increased risk room temperature before use. of bleeding.

If a clean technique is being used,

CKS (2016) use tap water. Irrigation in the C shower may be suitable for some ulcers.

If a sterile technique is required

Hollinworth (for example if there is bone (2005) C involvement or patient is severely immunocompromised), use normal 0.9% saline.

Do not use gauze or cotton wool

These shed fibres and may increase

Naylor balls or clean the wound by the risk of infection. (2001) C swabbing.

Do not clean the wound by

Scrubbing causes pain and local tissue

CKS (2016) scrubbing. oedema. Irrigation is more protective of

fragile tissue.

55 – Fungated Wound Clinical Guidance. Version 6

Reported that use causes pain, tissue

Do not use topical antiseptics. damage and wound drying.

A wound dressing should be applied that meets the characteristics of the wound, with the following principles:

• The primary layer should

be low adherent, conformable and capable of venting excess moisture to the secondary layer

• The secondary dressing should be conformable, highly absorbent and be as aesthetically acceptable as possible

Local wound management is determined by the type, location, size and shape of the wound, together with presenting problem.

• To allow for non-traumatic

dressing application and removal.

• To maintain patients privacy and

dignity.

• To maintain patients comfort and emotional wellbeing.

Grocott (2007) C

Alexander (2009b) C

Watret (2011) C

Ensure peri-wound skin is Peri- wound skin is fragile and often Draper protected from potential effects of already compromised by the (2005) C trauma from adhesive dressings progression of the tumour. or maceration due to excessive exudate to maintain skin integrity.

Alexander If low / non adherent dressings (2009b) C are used then bandaging or hosiery may be used to retain dressings comfortably.

Consider the use of a skin barrier

Skin barrier films/creams are an alcohol

Watret

film/ cream or thin hydrocolloids. free product that dries rapidly to form a (2011) C thin, protective film whilst allowing absorption of exudate by dressings.

A thin hydrocolloid sheet can be cut to fit around the wound, sometimes referred to as ‘picture framing’. Hydrocolloid acts as a barrier to exudate and could provide an “anchor” for adhesive dressings. Can be left in place for several days while the main dressing is changed as necessary.

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Stoma therapy skin wafers have the advantage of repelling exudate rather than absorbing it.

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Management of Bleeding

Action

Rationale

Supporting Evidence & Level

Wounds at risk of bleeding Assess for any bleeding points within the wound or areas of tissue that are particularly friable and bleed easily. Review systemic medication e.g. aspirin, warfarin, Rivaroxaban, Apixaban Consider referral to oncologist for possible radiotherapy.

Ensure appropriate psychological support.

As the tumour extends it may lead to blood vessels being eroded by the cancer or due to the necrosis of the tissues increasing the risk of spontaneous bleeding or at dressing changes. The patient can become anaemic through prolonged blood loss and may be frightened of future uncontrollable haemorrhage (monitor patients haemoglobin levels).

Naylor (2002) C

Alexander (2009d) C

Trauma during dressing changes should be minimised. Soak dressings with saline to ease removal.

Use low / non adherent dressings that maintain the wound in a moist environment.

These tumours may be friable and bleed during dressing change. These actions may prevent trauma-induced bleeding.

UK Medicines Information (2001) C

Alexander (2009d) C

Active minor bleeding Apply gentle local pressure to bleeding point for 10 –15 minutes with a moist, non- adherent dressing (for example calcium alginate)

Local pressure may be effective in controlling minor local bleeding points, as long as it doesn’t cause any discomfort.

Alexander (2009d) C

CKS (2010) C

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Alternative options include: Tranexamic acid is used to promote blood Grocott Antifibrinolytics (Tranexamic clotting. It prevents clot breakdown in the (2000) C acid) (Use under specialist body. advice).

BNF (2013) Calcium alginate dressings Calcium alginates should be used with C (please - refer to wound caution as fibrous alginate dressings may formulary) irritate friable tissue. Naylor

(2002) C

Please Note - Topical

Extreme caution should be exercised if

Watret

adrenaline can be used with using topical adrenaline due to the (2011) C caution under medical potential for ischaemic necrosis due to supervision. Should the above local vasoconstriction. recommendations be insufficient to manage the minor bleed, please discuss use of adrenaline with a prescriber and/or Palliative Care Team

Sucralfate paste has in the past This treatment is effective and longer Emflorgo (1998) C

been the treatment of choice. lasting. However, due to issues with pharmacy obtaining it may not Promotes clotting in the wound. be an available treatment. To use: Crush two 1g tablets and mix with 5ml of a water soluble gel (eg KY Jelly) to

This practice is widely used and accepted as being clinically effective.

appropriate consistency. Sucralfate suspension 2g in 10ml BD for mouth and rectum. It may be used as often as

Twycross & Wilcock (2011) C

necessary to areas of bleeding. Always liaise with a member of the specialist team or the prescriber. Risk of major bleed

If the tumour is near a major blood vessel, make plans to deal with a major haemorrhage. Plans may include:

• Care setting • Information to care

To relieve anxiety and distress from haemorrhage as a result of a terminal event, strategic plan should be developed in conjunction with the patient/family/carers and multidisciplinary team following careful and individual patient assessment due to the sensitive nature of the potential event.

Alexander (2009d) C

UK Medicines Information (2001) C

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providers/ family • Contact

personnel/details • Emergency drugs

(sedation) • Equipment eg. dark

towels

Management of Exudate

Action

Rationale

Supporting Evidence & Level

Assess and document the volume and appearance of the exudate

Changes may indicate the presence of infection

CKS (2016) C

Occasionally, malignant wounds may have little or no exudate, so a dressing for low absorbency should be used eg.

• Low / non adherent • Vapour permeable

film

To maintain a moist wound bed McDonald & Lesage (2006) C

Ensure appropriate control of exudate with consideration to:

• Frequency of dressing change

• Appropriate dressing selection for highly exuding wounds eg.

• Absorbent • Alginate • Foam • Gelling Fibre

Control of exudate in malignant wounds is important to reduce malodour, prevent soiling of bedding / clothing and increase patients confidence and comfort.

Dressings should meet clinical characteristics of the wound and be conformable to adequately contain exudate, but with minimal bulk.

Grocott (2007) C

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If the wound has a small opening with a high exudate, a wound management bag or drainable stoma appliance might be appropriate.

To effectively manage exudate. Boon et al (2000) C

Consider referral to dietician for nutritional support, if exudate levels are high for a prolonged time.

Significant amounts of protein can be lost from a discharging wound.

CKS (2016) C

Management of Odour

Action

Rationale

Supporting Evidence & Level

Reduction and containment of malodour.

Malodour is commonly described as the symptom that causes the most distress to patients and their families. Malodour can cause nausea and reduce nutritional intake at a time when nutrition is needed.

Postulated theories for malodour in fungating wounds include:

• Devitalised tissue providing medium for growth of aerobic and anaerobic bacteria

• Exudate soaked dressings. • Wound extends into body cavity

and the resulting fistula increases exudate and malodour.

Symptom control and improving the patient’s quality of life may be the desired goals of treatment.

Alexander (2009c) C

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Debridement removes necrotic tissue and bacteria and is the primary treatment for malodorous fungating wounds. Debridement issues: Autolytic debridement may be appropriate but the clinical gains need to be assessed critically.

Practitioners should consider the potential negative effects of autolytic debridement increasing exudate while the necrotic tissue is undergoing liquifaction.

Naylor (2002) C

Surgical/sharp debridement is generally not an option for fungating wounds.

Larval therapy may be a consideration with specialist advice

Due to the potential for bleeding. Potential to increase the incidence of bleeding in friable malignant wounds. May only be suitable within a secondary care environment, due to high risk of bleeding.

Different approaches are adopted for the management of odour depending on the underlying cause of malodour, including:

Charcoal dressings.

Shown to contribute to odour control. Charcoal dressings act as filters to absorb malodour from wound, but the dressing must be inside a secure secondary dressing to achieve a seal to contain malodour. However activated charcoal is ineffective when wet and may be unsuitable in highly exuding wounds.

Draper (2005) C

Infection: Conditions in a necrotic wound are ideal for bacterial invasion and multiplication (commonly aerobic and anaerobic bacteria) necessitating systemic antibiotics.

Alexander (2009b) C

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Systemic / topical Limited evidence from small clinical trials CKS (2016) Metronidazole: has shown topical Metronidazole to be C

effective in the elimination or substantial reduction of malodour. It’s particularly effective against anaerobic bacteria and protozoa. However topical Metronidazole may be Joint ineffective when diluted with large Formulary amount of exudate or in the presence of committee thick necrotic tissue. (2011) C

Opinions differ as to the effectiveness of

Naylor

oral Metronidazole. Consideration should (2002) C be given to the possibility of adverse gastric side effects or reduced systemic effect if the blood supply to the wound is compromised.

Antimicrobial dressings: Should only be used on wounds indicating a need for antimicrobial treatment (infected wounds), although may have an adjunct effect in reducing malodour via reduction in bacterial load. Honey additionally may assist in debriding necrotic tissue.

CKS (2016) C

Naylor (2002) C

Other methods of odour control include the use of deodorising products as used in stoma care.

To minimise odour in the patient’s own environment. However interventions to prevent the production of malodour at its source are generally more successful than attempts to mask the malodour through the use of deodorisers, which may also cause nausea.

Alexander (2009b) C

CKS (2010) C

Ensure the correct disposal of soiled dressings.

To prevent the build-up of stale exudate. Naylor (2002) C

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Management of Pruritus (or itching)

Action

Rationale

Supporting Evidence & Level

Consider the use of a mild topical corticosteroid such as 1% hydrocortisone if the skin around the ulcer is red and scaly.

To provide relief of irritation and inflammation. Exclude other cause of the irritation such as local infection or irritation from dressings or treatments applied to the area.

CKS (2016)

Consider the use of: • Hydrogel sheet

dressings – these can be cooled in the fridge before use.

• Emollients • Menthol in

aqueous cream (unbroken skin only)

To provide symptomatic relief. Pruritis may be due to dry skin.

The recommendation not to prescribe antihistamines is based on expert opinion that itch does not generally respond to systemic antihistamines

Alexander (2009d) C

CKS (2015) C

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In conjunction with specialist palliative support consider: Transcutaneous Electrical Nerve Stimulation (TENS)

The use of anti- depressants under specialist supervision may help reduce Itching,

4 May be effective in relieving itching

associated with a malignant wound.

Please note this is not licensed for this use alone. Research is limited on this use. It must be used under medical supervision.

Grocott (2007) C

Stephen- Haynes (2008) C

CKS (2013) C

but can cause different side effects. (Try other Cancer treatments first). Research

UK (2013) C

4 The irritation referred to here is a creeping, intense itching sensation attributed

to the activity of the tumour, can be particularly prevalent in inflammatory breast disease and cutaneous infiltration – generally not responsive to antihistamines

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Management of Pain

Action

Rationale

Supporting Evidence & Level

Accurate assessment of pain is required. As with all aspects of care for the patient with fungating wounds an individualised plan of care should be devised as the causes of the pain may be multiple and include emotional factors.

In order to provide effective pain management.

Grocott (2007) C

Pain may be difficult to control, *These may also control itch. UK requiring regular drugs for neuropathic Medicines pain as well as opioids and NSAIDs*. Information

(2001) C Ensure administration of a Pain during dressing change breakthrough dose of analgesia at may be reduced through pre Naylor least 30 minutes prior to dressing medication with short acting (2005) C change where possible. opioids.

CKS (2016) C

Low / non-adherent dressings should be used. If pain cannot be controlled at dressing changes then it may be worth trying a product that requires less frequent changes.

Maintaining the wound in a moist environment will not only reduce dressing adherence but will also protect exposed nerve endings.

To help prevent pain during dressing changes.

Naylor (2002) C

Consider referral to specialist palliative services for non- pharmalogical / complimentary therapies such as:

• Relaxation • Massage • Aromatherapy • Visualisation • Hypnosis

May be helpful to reduce the patient’s anxiety or sensation of pain.

Alexander (2009d) C

Cancer research UK (2013) C

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