Palliative care - malignant skin ulcer
Exam Tips
- In OSCEs, begin by clarifying patient priorities and quality-of-life goals; this is central to palliative wound care.
- Describe lesion morphology explicitly (ulcerative crater vs proliferative/fungating mass) and link it to dressing strategy.
- State that wound swabs are not routine; take them only when clinical infection is present and after cleansing.
- Mention key 'do not do' points: avoid scrubbing, avoid cotton wool/gauze fibre shedding, avoid routine topical antiseptics, and avoid routine sharp/mechanical debridement in friable malignant tissue.
- For pain at dressing change, prioritise non-adherent dressings and careful saline-assisted removal; topical diamorphine/morphine hydrogel (0.1% w/w) is a specialist option.
- Always include safety-net escalation: uncontrolled bleeding, airway compromise, vessel compression/obstruction, or uncontrolled symptoms require urgent specialist input.
Definition
A malignant skin ulcer is a cancer-related wound caused by primary skin malignancy or cutaneous metastasis, typically presenting as either an ulcerative crater or a proliferative/fungating mass. In palliative care, it is usually a non-healing lesion where the realistic aim is symptom control (pain, odour, exudate, bleeding, distress) and preservation of quality of life rather than cure.
Pathophysiology
Tumour infiltration of skin and subcutaneous tissue disrupts normal architecture, causes fragile neovascular tissue, and can outgrow its blood supply, producing necrosis. Necrotic tissue plus impaired local perfusion promotes mixed aerobic/anaerobic colonisation, leading to malodour and increased exudate. Nerve involvement, inflammation, repeated dressing trauma, and vessel erosion/compression drive pain and bleeding. Clinically, lesions evolve along two patterns: ulcerative tissue loss (crater) and proliferative fungation (nodular/exophytic mass) (see Figure: ulcerative versus proliferative malignant wound morphology).
Risk Factors
- Advanced breast cancer (commonest source of fungating malignant wounds)
- Head and neck malignancy with local skin invasion
- Primary skin cancers (basal cell carcinoma, squamous cell carcinoma, melanoma)
- Vulval malignancy with local tissue breakdown
- Less common skin malignancies (for example cutaneous T-cell lymphoma, Kaposi sarcoma)
- Immunocompromise and poor local tissue perfusion (increase infection/necrosis burden)
Clinical Features
Symptoms
- Persistent wound pain, often worse at dressing change
- Malodour causing nausea, poor appetite, and social withdrawal
- Heavy or persistent exudate requiring frequent dressing changes
- Intermittent bleeding or blood-stained dressings
- Pruritus around or within the lesion
- Psychological distress (anxiety, low mood, reduced self-image, intimacy concerns)
Signs
- Ulcerative crater or proliferative/fungating nodular lesion
- Friable tissue that bleeds on contact
- Necrotic/sloughy tissue within wound bed
- Periwound maceration or excoriation from exudate
- Local signs of infection (erythema, warmth, increasing pain, purulent discharge)
- Bulky dressings and reduced mobility/function
Investigations
Management
Lifestyle Modifications
- Set shared goals early: explain that complete healing is often unrealistic and prioritise comfort, dignity, and function
- Involve tissue viability/district nursing/palliative care specialists from the outset
- Use gentle no-touch irrigation; avoid scrubbing and avoid routine unnecessary cleansing
- Protect periwound skin (barrier film/cream) and choose non-adherent dressings sized to avoid tension
- Address psychosocial impact directly (odour embarrassment, isolation, intimacy concerns); involve family/carers with consent
- Escalate urgently for red flags: brisk bleeding, airway compromise, major vessel involvement, or uncontrolled pain
Pharmacological Treatment
Opioid analgesia (systemic)
- Morphine sulfate immediate-release oral 2.5-5 mg every 4 hours as needed in opioid-naive adults (titrate to effect)
- Morphine sulfate modified-release oral every 12 hours for background pain after titration
- Oxycodone oral 1-2 mg every 4-6 hours as needed if morphine not tolerated (dose-adjust)
Start low and titrate; prescribe breakthrough doses; co-prescribe laxative and antiemetic where appropriate. Use caution and dose reduction in renal impairment (especially morphine due to active metabolites). Monitor sedation and respiratory depression.
Topical opioid for painful ulcerating wounds (specialist use)
- Diamorphine 0.1% w/w in hydrogel (1 mg diamorphine per 1 g hydrogel) applied to wound bed at dressing change
- Morphine 0.1% w/w in hydrogel as alternative specialist formulation
Requires specialist palliative/tissue-viability guidance and local protocol. Avoid indiscriminate use on large areas because systemic absorption can occur; monitor for opioid toxicity.
Malodour control (topical/local antimicrobial)
- Metronidazole 0.75% gel, apply thin layer once or twice daily to malodorous wound areas
- Metronidazole 400 mg orally every 8 hours for 5-7 days if deep anaerobic infection is clinically suspected
Topical metronidazole is commonly used for anaerobe-related odour. Oral therapy should be targeted and time-limited. Avoid alcohol with systemic metronidazole; review interactions (for example with warfarin, increased INR risk).
Antibiotics for overt cellulitis/systemic infection (not routine colonisation)
- Flucloxacillin 500 mg to 1 g orally four times daily for 5-7 days (longer if severe)
- Clarithromycin 500 mg orally twice daily if penicillin allergy (non-severe infection)
- Doxycycline 200 mg on day 1 then 100 mg once daily (alternative where appropriate)
Do not treat malodour/colonisation alone with repeated systemic antibiotics. Follow local antimicrobial policy and microbiology advice in complex wounds.
Haemostatic/bleeding support
- Tranexamic acid 500 mg to 1 g orally three times daily for troublesome recurrent oozing (specialist advice)
- Adrenaline (epinephrine) 1:1000 topical application on gauze for short-term focal bleeding control in supervised settings
Use caution with thromboembolic risk for tranexamic acid. Topical adrenaline may cause local ischaemia and systemic cardiovascular effects; reserve for supervised acute control.
Pruritus and inflammation adjuncts
- Cetirizine 10 mg orally once daily for itch
- Topical corticosteroid to inflamed periwound skin (for example hydrocortisone 1% once or twice daily for short courses)
Avoid prolonged potent steroid use on fragile/thin skin due to atrophy risk. Reassess if itch persists, as progression or infection may be the driver.
Surgical / Interventional
- Specialist (usually conservative) debridement planning; avoid routine sharp/mechanical debridement in friable malignant tissue
- Referral for surgical/tissue-viability debridement when necrotic burden is severe and benefits outweigh bleeding risk
- Palliative haemostatic procedures or interventional radiology if recurrent significant bleeding
- Oncology-directed local control where appropriate: palliative radiotherapy, selected surgery/debulking, systemic therapy (chemotherapy/hormonal therapy) after specialist review
Complications
- Chronic pain and procedure-related pain at dressing changes
- Local or systemic infection, including anaerobic infection in necrotic tissue
- Bleeding from friable tumour tissue or vessel erosion
- High-volume exudate with periwound maceration and skin breakdown
- Severe malodour leading to nausea, poor intake, weight loss, and fatigue
- Pruritus and sleep disturbance
- Major psychosocial morbidity (depression, anxiety, social isolation, impaired intimacy)
Prognosis
Prognosis is determined mainly by the underlying cancer stage and response to oncological treatment. Complete wound healing is uncommon in advanced disease; good outcomes are measured by reduced pain, odour, exudate, and bleeding, plus improved dignity, function, and psychosocial wellbeing through multidisciplinary palliative care.
Sources & References
✅NICE Guidelines(1)
- Palliative care - malignant skin ulcer[overview]