Chronic cutaneous wounds often are complex, recalcitrant to healing, and may not follow a predictable trajectory of repair despite standard interventions. The exact mechanisms that contribute to poor wound healing remain elusive but likely involve an interplay of systemic and local factors. To establish realistic objectives, wounds are classified as healable, maintenance, and nonhealable based on prognostic estimation of the likelihood to achieve healing. (See Table 17-1 for definitions.)
| Wound Prognosis | Can the Cause Be Treated? | Effect of Coexisting Medical Condition/Drugs on Prognosis | Goals/Objectives |
|---|---|---|---|
| Healable | Yes, can be corrected or compensated with treatment Examples: pressure redistribution; correction of incontinence; friction/shear and poor nutrition for pressure ulcers; compression for venous leg ulcers | Coexisting medical conditions and drugs do not prevent healing. | Promote wound healing. Example: Venous ulcers 30% smaller by week 4, to heal by week 12 |
| Maintenance | No, cannot be treated because of poor treatment adherence or lack of appropriate resources Examples: lack of financial resources to acquire appropriate footwear for foot ulcers | Coexisting medical conditions and drugs may stall healing, such as hyperglycemia. | Prevent further skin deterioration or breakdown, trauma, and wound infection. Promote patient adherence. Advocate for patients to acquire appropriate resources. Optimize pain and manage other symptom. |
| Nonhealable: Palliative or malignant | No, the cause is not treatable. Examples: widespread metastasis including the skin, advanced stages of cutaneous malignant conditions, chronic osteomyelitis |
| Prevent further skin deterioration or breakdown, trauma, and wound infection. Promote comfort. Optimize pain and manage other symptoms. |
Palliative Wounds
As a result of the deterioration of the body and multiple system failures that are intrinsic to the dying process, patients at the end of life are vulnerable to skin breakdown that may not always be preventative. Underlying physiologic changes lower tissue perfusion, which compromises cutaneous oxygen tension, delivery of vital nutrients, and removal of metabolic wastes. In fact, observable signs of skin changes and related ulceration have been documented in more than 50% of individuals in the 2 to 6 weeks before death.
Wounds and associated skin changes that develop in palliative patients are generally considered nonhealable in light of poor health condition and the demands of treatment, which may outweigh the potential benefits. These patients often suffer from conditions that are incurable and life limiting, including malignancy, advanced diseases associated with major organ failure (renal, hepatic, pulmonary, or cardiac), and, in some cases, profound dementia. Management of these cutaneous palliative wounds are challenging to patients and their health care providers. Although wound healing may not be realistic, it is imperative to maintain patients’ dignity and quality of life by addressing psychosocial concerns (e.g., fear of dying or pain), empowering patients’ independence, promoting the highest achievable quality of life, enhancing the ability to perform activities of daily living, and optimizing pain management.
Malignant Wounds
A malignant wound can result from tumor necrosis, fungating tumor cells, an ulcerating cancerous wound, or a malignant cutaneous wound. Infiltration of malignant cells in these wounds is secondary to local invasion of a primary cutaneous lesion or metastatic spread. Clinicians should raise the index of suspicion of malignancy in the following scenarios:
- 1
Wounds that are manifestation of primary skin cancer and certain types of malignancies. These include basal cell carcinoma, squamous cell carcinoma, melanoma, Kaposi sarcoma, cutaneous lymphomas, and cutaneous infiltrates associated with leukemia.
- 2
Wounds in patients with history of cancer to rule out cutaneous metastasis. Malignant wounds have been estimated to affect 5% to 19% of patients with metastatic disease. Another study reported that 5% of cancer patients develop malignant wounds. The chest and breasts, head and neck, and abdomen are the most common sites where metastatic malignant wounds develop.
- 3
Wounds that do not heal over a long time. These types of wounds may undergo malignant transformation. A Marjolin ulcer or a squamous cell carcinoma may develop in an area of chronic inflammation. These changes have been documented from a chronic osteomyelitis sinus, persistent trauma, and burn scar.
- 4
Chronic wounds in patients with chronic immunosuppression. Patients at risk include those receiving azathioprine, methotrexate, and cyclosporin therapy and those with other immunodeficiency disorders, including human immunodeficiency virus infection.
- 5
Wounds secondary to treatment of malignancies. This includes patients such as those undergoing late radiation therapy change with the development of a secondary malignancy.
Extension of a tumor to the surface of the skin may initially present as localized, raised induration and evolve to a fungating or ulcerative skin lesion ( Figure 17-1 ). Fungating lesions are fast growing and resemble a cauliflower or fungus, extending beyond the skin surface. On the other hand, ulcerative lesions are characterized by deep craters with raised margins. As the tumor continues to grow, disrupting blood supply and outstripping local tissue perfusion, hypoxia is inevitable. This creates areas of necrosis. The presence of necrotic tissue establishes an ideal milieu for secondary bacterial proliferation. Vertical extension of the tumor, however, may reach the deeper structure, leading to sinus or fistula formation. Obstruction of normal vascular and lymphatic flow has been linked to copious exudate production and edema.
Management of Malignant and Other Wounds
Hopes
A systematized and comprehensive approach is required to manage the complexity of malignant and palliative wounds and optimize patient outcomes. The plan of care begins with treating the wound cause, when possible, and addressing patient concerns before local wound care. Based on previous study results, local wound care must be modified to address several key concerns: h emorrhage, o dor, p ain, e xudate, and s uperficial infection (HOPES). Wound management for malignant wounds is outlined in Figure 17-2 and described in the rest of the chapter.
Treatment Approach
Prevention
Although the care of palliative and advanced malignant wounds is centered on symptom management, other supportive strategies to prevent exacerbation of existing wounds and emergence of new ulcers are equally important.
To prevent pressure ulcers, at-risk individuals benefit from therapeutic support surfaces and regular repositioning. (Frequency is determined by the patient’s condition. Some clinicians recommend repositioning at least every 4 hours.) Although best practice recommendations are targeted at pressure redistribution and shear elimination, the plan of care must be customized to promote comfort and meet the needs of patients, including their circle of care. Suboptimal nutrition is common due to various combinations of cancer-related factors, including impaired absorption; increased metabolic demand; and decreased oral intake as a result of poor appetite, swallowing difficulties, nausea, vomiting, taste alteration, and mucositis. Nutritional supplementation with enriched protein and other micronutrients (zinc, vitamins A, E, and C) should be considered. Meticulous skin care after each incontinent episode, together with the use of a mild cleanser and skin protectant, may reduce irritation to skin.
Antitumor Therapies
Depending on disease trajectory, therapies including radiotherapy, surgery, laser therapy, chemotherapy, and hormonal blocking agents may be considered to reduce the tumor size and alleviate associated symptoms. Topical application of anticancer agents such as miltefosine and imiquimod may delay tumor progression.
Patient-Centered Concerns with Malignant Wounds
It is unequivocal that malignant wounds constitute a significant source of emotional distress to patients and their families. In a survey of patients living with malignant wounds, pain, aesthetic distress, and mass effect were the three most commonly expressed symptoms. In several qualitative studies, recurring themes revolve around powerlessness, anxiety, embarrassment, and the bleak feeling of isolation due to wound related stigma; however, they also involve willpower to maintain a positive outlook. To address patient-centered concerns, clinicians must engage, empathize, educate, and enlist their patients in the overall plan of care. Individualized education and appropriate information should be provided to help patients understand the parameters of care.
Local Wound Care Issues (Hopes)
H: Hemorrhage or Bleeding
The granulation tissue within a malignant wound bleeds easily due to local stimulation of vascular endothelial growth factor (VEG-F), resulting in excess formation of abundant but fragile blood vessels. Reduced fibroblast activity and ongoing thrombosis of larger vessels in infected and malignant wounds may compromise the strength of collagen matrix formation, rendering the granulation less resilient to trauma. Even minor trauma from the removal of wound dressings that adhere to wound surface can provoke bleeding. Other health conditions (e.g., abnormal platelet function, vitamin K deficiency) may also put patients with cancer and other terminal diseases at risk of bleeding. Frank hemorrhage can occur as the tumor erodes into a major blood vessel.
A variety of hemostatic agents can be applied topically to control hemorrhage ( Table 17-2 ). In severe cases, suturing a proximal vessel, intravascular embolization, laser treatment, cryotherapy, radiotherapy, or electrical cauterization may be necessary.
| Categories | Example | Comments |
|---|---|---|
| Natural hemostats | Calcium alginates Collagen Oxidized cellulose | Used to control minor bleeding Available as a dressing material Can absorb moderate to large amount of wound exudate Bioabsorbable |
| Coagulation agents | Gelatin sponge Thrombin | Expensive Increases risk of embolization |
| Sclerosing agents | Silver nitrate Tricholacetic acid | May cause stinging/burning Leaves coagulum that can stimulate inflammation |
| Fibrinolytic antagonists | Tranexamic acid | Oral agent; can produce gastrointestinal side effects (nausea/vomiting) |
| Astringents | Aluminum sucralfate | May leave residue on wound |
O: Odor
Unpleasant odor and putrid discharge are associated with increased bacterial burden, particularly involving anaerobic and certain gram-negative (e.g., Pseudomonas ) organisms. Bacterial metabolic byproducts produce this odor. To eradicate wound odor, metronidazole, as an anti-inflammatory and anti-infective agent against anaerobes, has been demonstrated to be efficacious. Topical metronidazole is readily available as a gel and cream. Alternatively, gauze can be soaked with intravenous metronidazole solution to use as a compress or tablets can be ground into powder and sprinkled onto the wound surface. Some patients derive the greatest benefit from oral metronidazole administration.
Activated charcoal dressing has been used to control odor with some success. To ensure optimal performance of charcoal dressing, edges should be sealed and the contact layer should be kept dry. If topical treatment is not successful or practical, putting odor-absorbing agents such as cat litter or baking soda (not charcoal; it only works as a filter) beneath the bed may reduce odor.
P: Pain
Pain is consistently reported by patients as one of the worst aspects of living with chronic wounds, which profoundly affect their quality of life. Wound-related pain is frequently experienced during dressing changes. Dressing materials adhere to the fragile wound surface due to the glue like nature of dehydrated or crusted exudate; each time the dressing is removed, potential local trauma may evoke pain. Granulation tissue and capillary loops that grow into the product matrix, especially gauze, can also render dressing removal traumatic. According to a review of dressings and topical agents for secondary intention healing of postsurgical wounds, patients experienced significantly more pain with gauze than with other types of occlusive dressings. Nonetheless, gauze continues to be a commonly used dressing materials, indicating a need to bridge research to practice. Careful selection of dressings with atraumatic and nonadherent interfaces, such as silicone, has been documented to limit skin damage and trauma with dressing removal and minimize pain at dressing changes.
Avoidable pain may also result from damage to the periwound skin. Repeated application and removal of adhesive tapes and dressings pull the skin surface from the epithelial cells, which can precipitate skin damage by stripping away the stratum corneum. In severe cases, contact irritant and allergic dermatitis results in local erythema, edema, and blistering on the wound margins. Enzyme-rich exudate may spill onto the periwound skin, causing maceration and tissue erosion with a subsequent increased risk of trauma and pain. To minimize trauma induced by adhesives, a number of sealants, barriers, and protectants are useful on the periwound skin ( Table 17-3 ).
| Types | Description | Application | Comments |
|---|---|---|---|
| Silicone | Polymers that include silicone together with carbon, hydrogen, and oxygen | Apply to periwound skin. | Allergy is rare. Certain types of silicone products are tacky, facilitating dressing adherence to the skin without any adhesive. |
| Zinc oxide/ petrolatum | Inorganic compounds that are insoluble in water | Apply a generous quantity to skin. | May interfere with the activity of ionic silver. |
| Acrylates | Film-forming liquid skin preparation to form a protective interface on skin attachment sites | Spray or wipe on skin sparingly. | Allergy is uncommon. |
| Facilitates visualization of periwound skin. | |||
| Hydrocolloid | Hydrocolloid wafer consists of backing with carboxymethylcellulose as filler, water-absorptive components such as gelatin and pectin (commercial gelatin desserts), and adhesive | Window frame the wound margin to prevent recurrent stripping of skin. | Allergies have been reported from some colophony-related adhesives (Pentylin H) associated with some hydrocolloid dressings. |
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