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PalliativeWound careICD-10 R23.x

Fungating skin wounds (palliative management)

Malignant cutaneous wound · ulcerated malignant wound · fungating tumour

Fungating wounds result from the cutaneous infiltration and growth of a primary or metastatic tumour breaching the skin. They cause significant physical and psychological morbidity — odour, exudate, bleeding, pain, infection, body-image disturbance, social isolation. UK NICE NG142 / NG31 palliative-care principles, Macmillan and EONS / EWMA guidance underpin a structured palliative wound-care framework. Skin-oncology relevance includes advanced cSCC, melanoma, breast, head & neck and gynaecological cancers.

CurrentLast reviewed 18 May 2026

Context

  • ~5-10% of patients with advanced cancer develop fungating cutaneous wounds.
  • Common tumours:
    • Breast cancer (40-60% of fungating wounds in UK).
    • Head & neck cancer.
    • Advanced cSCC, melanoma.
    • Gynaecological cancers.
    • Soft-tissue sarcoma, DFSP, angiosarcoma.
    • Cutaneous lymphoma (advanced MF, Sézary).
  • Often signals advanced / metastatic disease but not always end-of-life — some patients live years with fungating disease.

Common symptoms

  • Odour: anaerobic bacterial overgrowth (Bacteroides, Fusobacterium, Peptostreptococcus).
  • Exudate: heavy, often serosanguinous.
  • Bleeding: capillary, occasionally arterial — bleeding crisis is an emergency.
  • Pain: nociceptive, neuropathic, breakthrough.
  • Pruritus: local or distant (paraneoplastic).
  • Maceration / contact dermatitis of surrounding skin.
  • Secondary infection: cellulitis, sepsis.
  • Psychological: distress, body-image disturbance, isolation, depression.

Odour management

  • Local:
    • Metronidazole 0.8% gel / cream / crushed tablets topically.
    • Honey-impregnated dressings (Manuka — antimicrobial + debridement).
    • Activated charcoal dressings (Carboflex, Clinisorb).
    • Silver-impregnated dressings (Aquacel Ag, Acticoat).
    • Sodium hypochlorite irrigation (limited use).
  • Systemic:
    • Oral metronidazole 400 mg TDS for 7-10 days; can be cyclic.
  • Environmental: air filters / fans, scented candles / oils, frequent linen changes.

Exudate and bleeding

  • Exudate:
    • Highly absorbent dressings: foam (Allevyn, Mepilex), alginate (Kaltostat).
    • NPWT in selected cases (caveat: malignancy is relative contraindication; consider on case-by-case).
    • Skin barrier creams (zinc, dimeticone) for peri-wound protection.
    • Frequent dressing changes.
  • Bleeding (minor):
    • Topical tranexamic acid 5% (compresses, swabs).
    • Adrenaline 1:1000 soaks.
    • Sucralfate paste, alginate dressings.
    • Silver nitrate sticks for focal bleeding.
    • Cautery / radiotherapy for persistent bleeding.
  • Bleeding (major / arterial):
    • Dark towel for visual comfort.
    • Direct pressure.
    • Anticipatory plan including pre-prescribed midazolam / opioid for terminal haemorrhage.
    • Family education for end-of-life setting.

Pain and infection

  • Pain:
    • WHO analgesic ladder.
    • Topical lidocaine 5% prior to dressing changes.
    • Topical opioid (morphine 1:1000 in IntraSite Gel) for ulcer pain.
    • Neuropathic component: gabapentin, pregabalin, amitriptyline.
  • Infection:
    • Treat cellulitis / sepsis per NICE NG141.
    • Avoid prolonged antibiotic courses without clear indication.
  • Disease-directed therapy:
    • Palliative radiotherapy — particularly for bleeding cSCC / breast.
    • Cemiplimab / pembrolizumab for advanced cSCC / melanoma.
    • Electrochemotherapy.
    • Cryotherapy / laser ablation.

Psychosocial and multidisciplinary care

  • Acknowledge psychological burden — body image, intimate relationships, social isolation.
  • Body-image / counselling referral; Macmillan resources.
  • Carer support and education on wound care.
  • District / community nursing for home dressings.
  • Specialist palliative care / community palliative team early involvement.
  • Tissue viability nurse specialist.
  • Wound photography for objective monitoring.
  • Plan for end-of-life if refractory; document anticipatory care plan.

References

  1. Naylor W. Palliative management of fungating wounds. Br J Community Nurs. 2002;7(Suppl):S33-S38.
  2. European Wound Management Association (EWMA). Position document: management of malignant fungating wounds. London: MEP Ltd; 2008.
  3. Adderley UJ, Holt IG. Topical agents and dressings for fungating wounds. Cochrane Database Syst Rev. 2014;5:CD003948.
  4. NICE NG142. End of life care for adults: service delivery. London: NICE; 2019.
  5. Macmillan Cancer Support. Caring for a fungating wound. London: Macmillan; 2023.

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