Participants. Thirty-two patients (all women, mean age 60 years, range 30–96 years) were included in this study. All had breast cancer, mainly infiltrating ductal carcinoma; nine (28%) had neglected primary malignant wounds and 23 (72%) had cutaneous metastases. The mean duration of these wounds at the start of the evaluation was 13 months (range 1–64 months). Thirty-one (31, 96%) of the malignant lesions were located on the thorax; one was located in the axilla.
On the day of study initiation, 19 patients (60%) were undergoing systemic chemotherapy, three (9%) were on hormone treatment, and 10 (31%) were receiving palliative care. One of the patients in palliative care was undergoing local chemotherapy with miltefosine and two were receiving radiotherapy targeted on the wound.
Eighteen (56%) of the patients cooperated in all three successive evaluations, 10 (31%) completed two evaluations, and four (13%) were evaluated once. Among the patients who discontinued the study, three died, one was transferred to a palliative care unit, and four did not come to one of their appointments for psychological or social reasons. Four wounds achieved partial epithelialization.
Size. The mean initial length of the wounds was 12 cm (range 2–35 cm) and the mean width was 8 cm (range 2–26 cm). Wound surface area remained globally stable for the duration of the study, with a mean length of 12 cm and a mean width of 9 cm on day 42, although wounds tended to become excoriated (see Table 1).
Color. Twenty-four (24, 75%) of the wounds did not demonstrate any black necrotic tissue, 16 (50%) had ≥40% yellow and red tissue, and 30 (94%) had no pink. Budding malignant tissue (red) and fibrin or soft necrosis (yellow) dominated these wounds. The color classification remained stable for the duration of the study.
Periwound condition. In 58 (74%) of all the evaluations, the skin around the lesions was inflamed, which is usual for this type of wound because inflammation is related to the underlying tumor. This inflammation is not a sign of infection, even if it is sometimes difficult to differentiate the two phenomena. Contact eczema was observed in four (5%) of the cases and irritation in three (4%). In nine (12%) of the evaluations, the skin around the lesion was healthy.
Infection. No infectious episode (with fever or complications) was recorded during the evaluation period despite the vulnerability of the patients and the fact wounds were colonized by a relatively dense mixed flora. Fifty-four (54) different bacteria were found on the wounds: 37 aerobic and facultative anaerobic bacteria and 17 obligate anaerobes. The four wounds that showed signs of healing had no anaerobic germs and one to three aerobic or facultative anaerobic bacteria.
Local wound care procedures. Sixty-two wounds (79%) were cleansed with saline solution and 16 (21%) with water. Although cleansing with saline does not exclude prior cleansing with water, a shower with no dressing was advised before the local care was administered.
Dressings. A variety of primary dressings — ie, those in direct contact with the wound bed — were used. On average, alginate dressings were used in 31 (40%) of all dressing changes (day 1: 11 [34%]; day 21: 13 [50%]; day 42: seven [35%], including Kendall alginate® [Kendall, US, and Algosteril® Brothier, France]). Hydrofiber dressings (Aquacel®, ConvaTec, US) were the second most commonly used (day 1: 13 [41%]; day 21: seven [27%]; day 42: 10 [50%]), followed by hydrocellular dressings (Mepilex® nonadhesive dressings, Mölnlycke, Sweden) in nine (11%) dressing changes (day 1: four [12%]; day 21: four [15%]; day 42: one [5%]). Interface dressings (eg, Urgotul®, Urgo, France) were used in five cases (6% of the time), and a variety of other dressings in three cases (4% of the time).
In 12 (16%) of the cases, several layers of primary dressing were placed on the wound to facilitate exudate management. Secondary cover dressings included a combination of absorbent compresses (33 [42%]) (ie, Zetuvit®, Hartmann, Germany) and active charcoal dressings for odor control (ie, ActiSorb®, Systagenix, US). Occasionally, superabsorbent dressings were applied and removed quickly because of exudate leakage and discomfort. In 15 dressing changes (19%), a hydrocellular dressing (ie, Mepilex®, Mölnlycke, Sweden) was used over the primary dressing, and in 12 (15%) a combination of alginate, active charcoal, and absorbent compresses were applied. In nine cases (12%), a variety of compresses and in six (8%) only absorbent compresses were used. In a small percentage of cases (three, 4%), an alginate dressing and an absorbent compress were used together.
Antimicrobials. These products were prescribed for periods of 8 to 12 days at the first signs of clinically observed local infection (ie, increase in odor or discharge, unexplained change in the wound bed) or in cases of suspected biofilm. The antimicrobials or a cleansing solution (Prontosan®, BBraun, Germany) were combined with the treatment to achieve a regular, superficial debridement of the wound-bed, thereby optimizing the antibiofilm efficacy of the local care administered. Antimicrobials (impregnated dressings, cleansing solutions) were applied in 19% of the cases, including silver ion-impregnated alginate dressings (Release® non-adherent Ag, Systagenix, US) (8% of the time), silver ion-impregnated hydrocellular dressings (3%), silver nanocrystal dressings (Acticoat®, Smith & Nephew, UK) (1%), and other miscellaneous topical antibacterials (7% of the time).
Antimicrobial solutions (or cleansing solutions) were used in combination with dressings that did not contain antimicrobials; antimicrobial-impregnated dressings were applied as primary dressings.
Impact of local care and dressings on symptoms.
Exudate. The exudate was generally moderate and could be controlled using absorbent alginate, hydrofiber, or hydrocellular dressings or extra-absorbent compresses (see Figures 2 and 3). These products were sometimes applied in several thicknesses. Exudate increased significantly when the number of different bacteria was more than four (P = 0.007) and when at least one obligate anaerobe was present in the samples (P = 0.05) (see Table 2).
Odor. On day 1, no odor was recorded as intense (see Figure 4). However, in 17 out of 57 evaluations (30%) (those without a missing date), local care (ie, active charcoal dressings) did not completely control odor; even a moderately malodorous or minor smell could be difficult to treat (see Figure 5). On day 21, intense odors were treated with systemic antibiotics (metronidazole).
Knowing charcoal dressings are indicated to treat malodorous wounds, the authors assessed their efficacy in this indication to determine if inability to control odor was connected to any particular type of bacterial colonization (type of bacteria, quantity of germs). Microbiological results of the group of wounds for which odor was controlled by local care (charcoal dressings) were compared with the group that was only partly controlled by the same procedure (see Table 3). Odor was present in a significantly higher proportion of wounds with >105/g bacteria than in those with lower bacterial counts (P = 0.04) and in wounds with odor that contained one or more anaerobic bacteria (P = 0.05) (see Table 4). No significant differences in odor control were found for the presence of obligate anaerobes.
Bleeding (see Figure 6). Spontaneous bleeding is specific to fungating wounds because of the increase in angiogenesis related to the malignant process and, in some cases, blood vessels damaged by the underlying tumor. The local care rationales (alginates, hemostatic dressings, local adrenaline) generally controlled spontaneous bleeding when it occurred (see Figure 7). Bleeding at dressing changes was related to delicate, easily ruptured budding cells that form on this type of wound (see Figure 8). These bleeding episodes were globally controlled by applying a nonadherent, interface-type primary dressing or silicone-impregnated dressing (see Figure 9).
Pain. Most patients already were taking systemic analgesics for grade 1 pain (nonopioids), grade 2 pain (light opioids), or grade 3 pain (opioids) (see Figure 10). If pain was anticipated at dressing changes, the patient was apprised and offered either Entonox® (50% nitrous oxide and 50% oxygen; BOC Healthcare, UK; required five times among all evaluations), premedication (required five times), a topical anesthetic EMLA® (AstraZeneca, UK; three times), or Xylocaïne® (AstraZeneca, UK; five times). Other treatments such as local morphine or dressing the wound under general anesthetic also were offered in three cases (4%) (see Figures 11 and 12).
Unlike other symptoms, pain symptoms did not change much during the course of the study (see Figures 13 and 14).
Antimicrobials. Antimicrobials were combined as a single group because not many were prescribed. A reduction of the intensity of one of the three infection-related symptoms (odor, exudate, pain) was considered a positive effect of the dressing. However, in all of the evaluations, the comparison results were nonsignificant.