Malignant Wounds: How to Identify and Treat Them

Some wound care clinicians have experience caring for patients with malignant wounds.

But you may not be familiar with them at all. We recently spoke with a malignant wounds expert to learn more about them.

That expert is Joni Brinker, MSN/MHA, RN, WCC, an Ohio-based consultant and clinical nurse educator with Optum Hospice Pharmacy Services of Eden Prairie, Minn.

She is a returning speaker for our 2020 virtual Wild on Wounds (WOW) national conference in September. She offered the following explanation.

What are malignant wounds?

“Malignant wounds are external manifestations of malignant cancer cells and cancer,” Brinker said. “In short, these wounds are a display of seeing the cancer externally.”

It’s helpful to be aware that the nomenclature of malignant wounds can vary depending on the practice environment, according to Brinker.

“In addition to the term ‘malignant wounds,’ you’ll also hear the terms ‘fungating wounds’ or ‘metastatic cutaneous lesions,’” she said.

How malignant wounds present

Brinker highlighted the following major presentations of malignant wounds:

Nodules appear first

If a malignant wound is developing, it typically appears first as a nodule under the skin. These nodules can be tender or non-tender, and they can vary in color from flesh to pink to beige. Sometimes, they are brown, blue or purple.

Orange peel skin

If the patient has inflammatory breast cancer, it can present as an orange-peel appearance to the skin in the breast.

Edema and necrosis

Once the cancer begins to grow, there is less perfusion to the skin, and the lymphatic vessels become involved. You may begin to see mild edema or necrosis.

Additional manifestations when cancer grows

This could include a cauliflower appearance to the skin or a crater or crater appearance in the skin, according to Brinker.

She said as the cancer metastasizes, clinicians should expect it to also affect deeper structures of the body, such as a fistula in the wound bed or pathological fractures in the extremities.

“Malignant wounds can occur with any type of cancer. However, they are most often seen with cancers of the head and neck, breast, groin (penile, ovarian, vulvar and rectal), and sometimes skin cancers,” she said.

Approximately 5% to 10% of cancer patients will develop malignant wounds, according to Brinker.

“The sad reality is many patients who develop malignant wounds are too embarrassed to tell their physicians about it,” she said.

Five ways malignant wounds occur

Brinker said clinicians should be aware that wherever a cancer is located in the body, this is the location where the wounds likely will present. Two examples are breast cancer that can result in wounds to the breast and chest, and bone or skin cancer that results in an extremity fracture.

Malignant wounds can develop from several conditions, including:

Primary skin cancer

Squamous and basal cell carcinomas, malignant melanoma.

Primary tumor

Breast or soft tissue sarcoma where the tumor erodes through the skin.

Tumor with metastasis

When cells invade the blood or lymphatic system, such as when lung cancer with metastasis to the lymphatic system present in the skin.

Seeding of cancer

This can spread to other areas from surgical procedures. In an appendectomy, for example, if the appendix was malignant, surgical removal can seed other areas of the body on rare occasions.

Chronic wounds

Lower-extremity ulcers of wounds can become malignant.

Common dressings and treatments

When considering treatment options, the more products you are familiar with, the better off you’ll be in providing optimum care for your patients, according to Brinker.

“It helps to be flexible in order to find the right solution and best products to use for the wounds you’re treating,” she said.

Brinker said there are options and care recommendations, such as:

•  Using a contact layer first to help prevent other dressings from sticking to the wound. This also can help reduce wound pain and bleeding of malignant wounds.
• Absorptive dressings can be used for wounds that have copious amounts of exudate. For a high-output fistula, consider foam dressings, calcium alginate and hydrofiber.
• With fistulas, consider using a fistula pouch or wound pouch. Some clinicians use colostomy supplies and adapt them to create a wound pouch.

Clinicians also should know that if a wound is dry, moisture should be added, if needed.

If a wound is wet, use an absorptive dressing.

When no additional moisture is needed on a dry wound, pad and protect it with gauze or a dry foam dressing.

Topical antimicrobials are generally used first if a wound infection develops.

Non-traditional dressings

One aspect of providing care to patients with malignant wounds that can alarm a new clinician is the use of non-traditional products for care, according to Brinker.

This includes using:

• Incontinence products as a dressing to cover a large area of the body
• Clothing to fasten a dressing
• Clean peri-wash bottles to clean wounds in peri areas

Malodorous wounds

Malodor is a common issue for patients with malignant wounds. These can be very embarrassing, and unpleasant odors can sometimes permeate an entire residence, according to Brinker.

She recommends various environmental strategies to counteract malodors by introducing familiar, more pleasant scents in the patient’s room, such as cat litter or coffee grounds in the patient’s room or positioning dryer sheets near air vents.

Brinker said the main causes of malodorous wounds are:

• Slough in the wound
• Poor exudate management
• Dressing that has been on too long
• Wound infection

Final points to consider

Clinicians who are new to malignant wounds need to know that unless a patient is undergoing curative care with chemotherapy or radiation, their wound or wounds will get worse as the cancer progresses.

“It’s important for clinicians to remember you can still provide patients optimum wound care, reduce pain, minimize malodors and help make them more comfortable,” Brinker said.

Treating patients with malignant wounds also requires psychosocial treatment, too.

“These patients can become depressed, embarrassed about their wounds and odors, feel despair and isolate themselves,” Brinker said. “It’s essential we talk with them to address their feelings and facilitate help from clergy, a therapist or social worker if they desire.”

Learn more about malignant wounds from Joni Brinker during our virtual Wild On Wounds conference.