The management of malodour

and exudate in fungating wounds

Charlotte Draper

care of both the patient and his/her wound. Much has been
Abstract written on comprehensive assessment plans by authors such as
The topic of malodour and exudate in fungating wounds is of particular Collier (1997a,b; 2003) and Naylor (2002a,c); however, it is
interest and relevance for community nurses who care for patients with beyond the scope of this review to discuss assessment in detail.
fungating wounds in the community setting. Community nurses can work
together with community oncology and palliative care services to manage Literature review
patients with fungating wounds at home, where once hospital admission A literature search of the databases Cinahl, Medline and the
would have been needed to provide the level of support and care these British Nursing Index was carried out using the keywords:
patients require. Fungating wounds present unique challenges and can be fungating, wound, malignant, cutaneous, malodour, cancer,
problematic as a result of the levels of exudate and malodour which they palliative and exudate. The search provided a wealth of
[Link] review sought to establish whether recent advances in wound references, and ‘snowballing’ from some of the references cited
care products and/or techniques, could be of value in the control of these on literature retrieved provided more [Link] websites
[Link] review established that there is little clinical research into for Worldwide Wounds, the European Wound Management
the care of fungating wounds, and that the development of new dressings Association and the NHS site, PRODIGY, were also used to
and techniques for controlling malodour and exudate is badly needed. provide information. The search was limited to 1992 as the
Key words:  Dressings  Infection Control  Wounds purpose of this review was to establish what is considered to be
current best practice in the management of malodour and

A
fungating wound is the result of infiltration of the exudate, based on the most recent evidence available.
skin and its supporting blood and lymph vessels by A review of the literature revealed that there is little clinical
cancerous cells (Grocott, 2000).This leads to loss of research on the management of fungating wounds on which to
vascularity which, in turn, leads to tissue hypoxia base or guide nurses’ practice (Haisfield-Wolfe and Rund, 1997;
and subsequent necrosis, resulting in a fungating wound. It can Kelly, 2002; Grocott, 2003). Most of the articles published on the
occur anywhere on the body and may be caused by metastatic care of fungating wounds are experiential accounts and case studies
spread from a distant tumour, or as a primary tumour, and may written by expert practitioners who offer advice and anecdotal
present either as a crater-like wound or as a proliferative evidence on how to manage symptoms based on practical
cauliflower-like ‘outgrowth’ from the skin, or as a combination experience. However, there is a lack of formal protocols based on
of both (Grocott, 1998; Young, 1997; Naylor, 2002a). A research and evidence on which to base the treatment of fungating
fungating wound rarely heals owing to its cancerous nature wounds. This indicates a need for dedicated clinical research
(Naylor, 2002a; Laverty, 2003). Adjuvant therapies, such as specific to this area so that a more systematic, evidence-based
hormone therapy, chemotherapy and radiotherapy, can be used approach to the management of the symptoms can be adopted.
to slow down its growth temporarily (Hallett, 1995), but it This review also established that the incidence of fungating
tends to extend over time and is characterized by the wounds is not recorded in population-based cancer registers
symptoms of malodour and heavy exudate. The management (Grocott, 2000) and, therefore, exact figures regarding the
of this type of complex wound is challenging both for nurses occurrence of these wounds are not known.
and for the wider multidisciplinary team involved (Haughton Fungating wounds occur most frequently in patients aged
and Young, 1995; Laverty, 2003; Chaplin, 2004). 60–70 years, and may develop in 5–10% of patients with
While there are other symptoms associated with this type of metastatic disease, usually during the last 6 months of life
wound, malodour and exudate are the two which frequently (Haisfield-Wolfe and Rund, 1997).The only available statistics
cause the most distress to patients (Naylor, 2002a; Hampton, relating to the incidence of these wounds are those from a
2004), and have therefore been chosen as the focus of this review. retrospective study carried out by Thomas (1992), using
It is also recognized that holistic patient assessment and thorough information and figures collected nationally from radiotherapy
wound assessment are prerequisites to any treatment. These are and oncology units over a 4-week period. This showed a
necessary to form a baseline against which to measure the maximum monthly total of 295 fungating wounds (2417
outcome of nursing interventions, and make decisions regarding annually).This study would need repeating to provide current
figures on the incidence of fungating wounds. However, these
Charlotte Draper is Community Staff Nurse, Poole Primary Care Trust,
figures alone indicate that fungating wounds require
Hadleigh Lodge Practice, Corfe Mullen, Dorset
considerable resources to manage them, both in terms of
Accepted for publication: May 2005
nursing time and other NHS resources.

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 Malodour and management prescribing or presumptive prescribing is not desirable because of
Malodour in fungating wounds is caused by the breakdown of the dangers of antibiotic resistance developing. It is therefore
proteins in the necrotic tissue by anaerobic bacteria of the recommended that oral metronidazole should only be used if there
Bacteroides spp. and Clostridium spp. These include Bacteroides are host signs of reaction to infection, such as an increase in
fragilis, Prevotella spp., Fusobacterium nucleatum, Clostridium malodour and exudate and/or pain,and cellulitis around the wound
perfringens and anaerobic cocci (Moody, 1998; Thomas et al, (Collier, 2000). In this case the wound should be swabbed and the
1998). This results in the production of the chemical main causative organisms isolated. A course of metronidazole,
compounds, putrescine, cadaverine and volatile short-chain possibly in conjunction with another antibiotic, can then be
fatty acids, all of which emit extremely pungent, foul-smelling prescribed (Collier, 1997a; Benbow, 1999).The side-effects of oral
odours (Thomas et al, 1998). Aerobic bacteria are also present metronidazole can also be a contraindication for its [Link] side-
in fungating wounds and have characteristic odours of their effects include nausea and intolerance to alcohol, which may cause
own, although these tend to be much less pungent. Aerobes vomiting (Fairbairn, 1994; Grocott, 2000). Peripheral neuropathy
commonly isolated include Proteus spp., Klebsiella spp. and has also been reported with prolonged use (Fairbairn, 1994).
Pseudomonas spp. (Thomas et al, 1998). A further argument against the use of oral metronidazole is
The results of a study by Bowler et al (1999) on the action of that, owing to the lack of blood supply to the necrotic tissue,
bacteria in chronic wounds suggest that anaerobic bacteria are there is doubt as to whether therapeutic levels of the drug are
capable of producing a much stronger odour by working in achieved at the wound site (Thomas et al, 1998; Grocott, 1999;
synergy with aerobic bacteria, and that interrupting this synergistic Naylor, 2002a). If used, the recommended dose is 400 mg t.d.s.
relationship could hold the key to eliminating malodour. Bowler (PRODIGY Guidance, 2004) or 1 g rectally b.d. (Fairbairn,
et al’s study involved 43 patients with leg ulcers; no fungating 1994). In some cases, following an initial course, a long-term
wounds were included. However, both these types of wound are maintenance dose may be required for continued control of
similar in that they are polymicrobial, containing a wide spectrum malodour. In this case 200 mg b.d. is recommended, and it is
of aerobes and [Link] relationship between the bacteria is advised that, at this dose, side-effects are minimal and the
an area that requires further research, as a clearer understanding of therapeutic effect is maintained (PRODIGY Guidance, 2004).
the way in which the types of bacteria work together could have
a significant impact on the way malodour is treated. Topical metronidazole
Malodour is sensed by the olfactory receptors situated Topical metronidazole gel 0.8% applied directly to the wound
behind the top of the nose and processed in the olfactory bulbs surface once or twice daily following cleansing, as
in the brain, and in the limbic and hypothalamic neural systems recommended by PRODIGY Guidance (2004), is found in
responsible for motivational and emotional behaviour (Van practice to be effective in the elimination or substantial
Toller, 1994). Strong and unpleasant odours can lead to reduction of malodour (Clark, 2002; Davies, 2003; Holloway,
involuntary gagging, triggering the vomit reflex, and will 2004). Studies show it is usually effective within 2–3 days
diminish the patient’s sense of taste and appetite (Van Toller, (Moody, 1998; Bale et al, 2004). Metronidazole is a synthetic
1994), affecting nutritional status (Hack, 2003). The effects of drug, which works by preventing bacterial replication through
uncontrolled odour can also have a devastating impact on a binding to their DNA, thus reducing the bacterial burden in
patient’s life, leading to psychological stress, social isolation and the wound (Hampson, 1996). Topical metronidazole is
withdrawal (Price, 1996; Lawton, 1998; Benbow, 1999). For traditionally thought of as effective against anaerobes; however,
these reasons it is vital to control or eliminate malodour. Thomas et al (1998) state that, at the concentration used
Malodour is difficult to assess objectively as there is no topically, it may also be effective against aerobes. Its use is
‘standard’ unit that can be used to measure and record it (Davies, recommended by expert practitioners such as Haughton and
2003). Therefore, the presence and severity of malodour is a Young (1995), Clark (2002) and Moody (1998).
subjective issue that can depend on many variables, such as the Grocott (1999) argues that in large, heavily exuding wounds,
patient’s ability to perceive odour, which can decline with age, topical application of gel may be ineffective as it becomes
and the nurses’ and carers’ perceptions of that odour (Holloway diluted by the exudate and absorbed into dressings, while the
et al, 2002). For recording and documenting purposes, authors thickness of the necrotic tissue and the size of the wound may
suggest different ‘tools’ for the assessment of malodour. In limit its efficacy. Grocott (1999) also queries how the dose of
practice, the subjective opinions of patients and carers are the topically applied gel is calculated, and argues that more research
best indicators to guide nursing intervention and actions (Clark, is needed to support its use. No large-scale randomized
2002). Management of malodour consists of three main controlled studies exist to prove its effectiveness, although
elements (Grocott, 2000): systemic metronidazole; topical historically there have been many small studies that date back
metronidazole and/or antimicrobials; and charcoal dressings. beyond the scope of this review. More recently, studies by
Additionally, thorough wound cleansing and debridement of Bower et al (1992), Finlay et al (1996) and Bale et al (2004),
necrotic tissue in which the anaerobic bacteria flourish will help have all established that metronidazole gel is safe, effective and
to reduce the bacterial burden and improve the action of less toxic than oral metronidazole. Recommendations from the
antibacterials, or even obviate their need (Grocott, 2000). study by Bower et al (1992) for the control of malodour were
daily wound cleansing and dressing for 7 days, followed by a
Systemic metronidazole 5-day course of metronidazole gel applied once daily at a dose
Oral metronidazole may be administered to help combat malodour. of 1 g/cm2. Bower et al (1992) found an improvement in
However, Grocott (2000) and Hampson (1996) state that over malodour in all participants by day 11.

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 Finlay et al (1996) studied the use of topical metronidazole gel fitting to the wound as a sealed unit so that odour cannot escape
on 47 patients, and found a decrease in malodour in 95% of (Grocott, 1999). This can present problems in wounds that are
patients by day 14. However, Finlay et al (1996) estimated that the large, irregularly shaped or situated in awkward places as a seal can
cost of topical metronidazole was 10 times that of its systemic use. be hard to achieve, and available dressing sizes are limited
Bale et al (2004) studied the use of metronidazole gel on 41 (Grocott, 1998). Caution is needed if dressings have to be cut to
patients and concluded that it was effective in eliminating fit a wound as some may release fibres, which should not be
malodour in all patients in 3 days. Both Finlay et al (1996) and allowed to come into contact with the wound surface (Benbow,
Bale et al (2004) recorded a significant reduction in pain, exudate 1999). Heavily exuding wounds will need to be redressed at
and cellulitis with the use of topical metronidazole. All of these frequent intervals to avoid saturation of the charcoal dressing.
studies were too small to be statistically significant, and were not Some charcoal dressings also contain silver, which may enhance
exclusively centred on fungating wounds. Further, Bower et al odour control by their antibacterial action (Thomas et al, 1998;
(1992) discontinued the use of the control group during the trial Benbow, 1999) but, as previously discussed in this text, silver is
because of ethical reasons and, for the same reasons, Finlay et al expensive and, if dressings are being changed frequently, the extra
(1996) stated that it was not felt appropriate to use a control expense may not be justifiable unless there are proven benefits.
group; therefore, the methodology of both these could be No studies could be found comparing the effectiveness of
questioned (Hampson, 1996). However, the findings of these activated charcoal dressings with added silver, against plain
studies, along with anecdotal accounts of its effectiveness, are the charcoal, to provide evidence that either is more or less effective.
best current available evidence to support its use. As it is so Activated charcoal dressings are manufactured in different forms,
expensive, more robust evidence in support of its use is needed but no studies could be found that compare the differing types,
to secure its use in the future. in vivo, on fungating wounds. An in vitro study by Thomas et al
(1998), testing the ability of different charcoal dressings to
Topical antimicrobials prevent the passage of volatile compounds, found that the ability
Other topical antimicrobials that may be used are honey and sugar of a dressing to contain odour was determined by two factors:
paste. Sugar is thought to absorb fluid, thereby starving the bacteria physical absorbency and the activity of the charcoal itself. The
of moisture and inhibiting their ability to grow and multiply multicomponent dressing, CarboFLEX (ConvaTec), was found
(Haughton and Young, 1995;Thomas et al, 1998; Benbow, 1999). to be most efficient. Holloway et al (2002) evaluated this same
Additionally, honey releases hydrogen peroxide at low dressing in vivo on 46 malodorous wounds, and concluded that
concentration which, while having antimicrobial action, is thought it was effective in controlling odour in 91% of patients.
to be harmless to healthy tissue (Booth, 2004). In practice, both can Hampton (2003) evaluated another charcoal dressing,
be messy to apply and should not be used in patients with diabetes Clinisorb (CliniMed), in a small pilot study, and it was found to
(Benbow, 1999). Booth (2004) maintains there is little evidence to compare well with dressings previously used on the 20 patients
support their use and that more research is needed. Silver before the trial. A total of 100% of patients found odour control
sulphadiazine cream is also effective against nearly all pathogens improved or was the same as the previous [Link] studies
(Benbow, 1999; Hack, 2003), and its use may be considered, are too small to be statistically significant and do not provide
although there are currently no studies available regarding its use strong evidence to support any particular dressing. In practice, the
on fungating wounds. Live yoghurt has been suggested as an nurse will have to be guided by what is found to best suit each
alternative therapy,but its use is controversial as live Lactobacillus spp. patient and wound. In the community situation, choice may well
may infect the wound (Haughton and Young, 1995). be determined by dressings available on the local formulary.
All topically applied substances are at risk of being diluted by
exudate and their efficacy decreased; therefore, careful Debridement
consideration should be given to their [Link] are a plethora of Surgical debridement is not generally an option because of the
silver dressings which may be used to treat fungating wounds. bleeding potential of fungating wounds (Dowsett, 2002; Naylor,
Silver acts as an antimicrobial, inhibiting bacterial growth 2002b; Goode, 2004), and because it could ‘seed’ the malignant
(Lansdown, 2002). However, these dressings are expensive and cells (Hampton, 2004). Young (1997) and McMurray (2003)
therefore the perceived benefits of using them need to be carefully advocate the promotion of gentle autolytic debridement by the
considered. No studies relating to their use on fungating wounds use of hydrocolloids and hydrogels. Caution must be taken to
could be found. Cost, and the limitations placed by local dressing ensure that the increase of exudate, which occurs with the use
formularies, may well determine whether they can be used. of these products (Vuolo, 2004), does not become too heavy to
be contained and managed by dressings.
Charcoal dressings Davies (2003) documents the successful use of a hydrocolloid
Activated charcoal dressings applied to fungating wounds can and hydrogel used together to debride a fungating wound in
significantly help to control malodour (Haughton and Young, the community setting. An increase in exudate was coped with
1995;Thomas et al, 1998; Benbow, 1999), and may be applied as by more frequent dressing changes. Dowsett (2002) maintains
primary or secondary dressings, according to the product used. that a wound may autodebride to some extent and that
Activated charcoal works by filtering the malodorous chemical devitalized tissue eventually dies off and may separate
compounds, preventing their release into the air, and by spontaneously. Polysaccharide beads or paste, foam dressings and
adsorbing bacteria (Thomas et al, 1998; Benbow, 1999; Naylor, alginates can also aid debridement by maintaining correct
2002a).The effectiveness of activated charcoal is only maintained moisture balance at the wound surface (Benbow, 1999;
if it remains dry (Thomas et al, 1998). Dressings also require PRODIGY Guidance, 2004). Thomas et al (1998) state that

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 larval therapy is highly effective in debriding necrotic tissue, but should be used for the protection of periwound skin
many patients could be repelled by the thought of ‘maggots’. (Cameron, 2004; Vuolo, 2004). These protect the skin from
No studies on their use on fungating wounds could be found. damage by exudate and adhesives, do not block the absorption
of exudate by dressings (Anderson, 2002;Vuolo, 2004), and can
Cleansing also help adhesive dressings to form a good seal. The use of
The use of warm physiological saline 0.9% is recommended adhesive products should be avoided if the skin around the
for the removal of stale exudate and loose debris from the wound is very oedematous and vulnerable as skin stripping
wound surface (Naylor, 2002a;Watret and Armitage, 2002), and may occur when they are removed. Close-fitting garments and
is an important first step in the control of malodour (Collier, tubular stockinettes can be used to retain dressings (Grocott,
1997a; Chaplin, 2004; Holloway, 2004). Carville (1995) 2000; Vuolo, 2004). Thin hydrocolloid sheets and semi-
documents the use of chlorhexidine 0.05% and acetic acid permeable films may also be applied to protect periwound skin
0.25% for the cleansing of a fungating wound. However, the (Naylor et al, 2001;Vuolo, 2004).
use of topical antiseptic solutions is generally contraindicated Current options for managing exudate include the use of a
owing to their toxicity to healthy tissue and possible local variety of dressings that are recommended in the literature.
reactions (Goldberg and McGinn-Byer, 2000; Naylor, 2002a; Dressings used to manage exudate need to be chosen carefully;
Holloway, 2004), and because their antiseptic properties are they should have minimum bulk, while preventing leakage, and
rapidly inactivated by body fluids (Naylor, 2002a). In some be cosmetically acceptable (Naylor et al, 2001).
cases their use may be considered after individual assessment, if For lightly exuding wounds, the use of hydrogels,
it is thought that the advantages of use outweigh the hydrocolloids and absorbent vapour-permeable adhesive
disadvantages (Watret and Armitage, 2002). dressings, which contain exudate while maintaining a moist
Wound cleansing should be gentle as inappropriate cleansing wound environment, are recommended (Collier, 2000; Naylor
with cold fluids, or using too much pressure, may cause pain, et al, 2001). Moist wound conditions are essential for patient
trauma and bleeding (Naylor, 2002a; McMurray, 2003). comfort, and to minimize the risk of pain trauma and bleeding
Fairbairn (1994) advocates that, if appropriate, soiled dressings at dressing change (Collier, 2000; Naylor, 2002a). For moderate
can be removed before showering; the warm water cleanses the to heavily exuding wounds, alginates, alginate-plus dressings,
wound, and taking a shower enables the patient to feel ‘clean’, hydrofibre, hydrogel sheets, hydropolymer foam, and foam
which can have a positive psychological [Link] importance dressings, which absorb and contain exudate and allow
of thorough wound toilet and/or cleansing cannot be evaporation of moisture, and dressings which facilitate vertical
overemphasized. Bale et al (2004), in their study on the effects ‘wicking’ of fluid, are promoted as suitable products (Young,
of metronidazole gel on malodorous wounds, found that 76% 1997; Pudner, 1998; Naylor et al, 2001). For wounds with a
of patients in the placebo arm of the trial, who were not sinus or fistula, stoma bags or Wound Manager (ConvaTec)
treated with the gel, experienced elimination of malodour. systems are advocated (Carville, 1995; Haisfield-Wolfe and
This was attributed to the fact that, while taking part in the Rund, 1997; Pudner, 1998; Naylor et al, 2001).
trial, their wounds were cleansed, and dressings were changed There is little evidence to support the use of any individual
at regular and frequent intervals. Bower et al (1992) recorded brand of dressing. Case studies, such as those by Naylor (2001)
the same effect in a similar trial. These findings indicate that and Burns and Stephens (2003) into a hydropolymer dressing
stale exudate and saturated dressings that require changing and a glycerine hydrogel sheet dressing respectively, provide
contribute significantly to the cause of malodour. Cleansing some anecdotal evidence of the effectiveness of these dressings.
and redressing need to be carried out according to the The most extensive research into dressings and their
demands of the wound and severity of symptoms, possibly effectiveness, and the most informative on which to base
several times in a 24-hour period. In the community setting dressing choice, has been by Grocott (1998, 2000). Grocott
this can put heavy demands on staff resources. (1998) studied 17 patients using foam dressings, evaluating their
effectiveness using the TELERTM system of measuring
Exudate management outcomes and evaluating effectiveness of dressings against
Excess exudate is a key problem in fungating wounds, particularly desired goals ([Link] study concluded that
those that are large or in the advanced stage. High levels of in 16 out of 17 patients, dressings were inadequate to cope with
exudate are produced as a result of the abnormal capillary exudate as a result of poor dressing fit, and leading to leakage of
permeability within the wound, caused by the disorganized malodour and exudate. From this study, Grocott (1998)
tumour vasculature (Naylor, 2002a), and by secretion of vascular identified certain factors crucial to successful exudate control:
permeability factor by tumour cells (Haisfield-Wolfe and Rund, quality of the product used; composition and consistency of
1997). Autolysis of necrotic tissue by bacterial proteases also exudate; dressing fit and conformability to wound shape and
increases exudate levels (Collier, 1997a). size; and the ability of the dressing to absorb and vent moisture
Exudate levels may be reduced by the use of topical steroids, –– a high moisture vapour transfer rate (HMVTR).
which reduce inflammation (Haisfield-Wolfe and Rund, Following this, as part of an extensive research project, Grocott
1997). Prolonged contact of exudate with the periwound skin (2000) evaluated eight different dressing systems (some
will cause maceration, excoriation and loss of the skin’s components of these systems were developed in partnership with
integrity, leading to breakdown and enlargement of the wound a drug company, i.e. those with a HMVTR not available on tariff).
(Collier, 2000; Cameron, 2004;Vuolo, 2004).The use of liquid The two systems which performed best, and whose components
barrier films, e.g. Cavilon (3M) or SuperSkin (CliniMed), are available, comprised:

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