Topical agents and dressings for fungating wounds

BACKGROUND: Fungating wounds arise from primary, secondary or recurrent malignant disease and are associated with advanced cancer. A small proportion of patients may achieve healing following surgical excision, but treatment is usually palliative. Fungating wound management usually aims to slow disease progression and optimise quality of life by alleviating physical symptoms, such as copious exudate, malodour, pain and the risk of haemorrhage, through selection of appropriate dressings and topical agents. OBJECTIVES: To review the evidence of the effects of dressings and topical agents on quality of life, and symptoms that impact on quality of life, in people with fungating malignant wounds. SEARCH METHODS: For this second update we searched the Wounds Group Specialised Register (searched 28 October 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library 2010 Issue 4, Ovid MEDLINE (2005 to October Week 3 2010), Ovid MEDLINE (In-Process & Other Non-Indexed Citations, October 27, 2010), Ovid EMBASE (2008 to 2010 Week 42) and EBSCO CINAHL (1982 to 22 October 2010). There was no restriction on language. SELECTION CRITERIA: Eligible studies comprised randomised controlled trials (RCTs) or, in their absence, controlled clinical trials (CCTs) with a concurrent control group. DATA COLLECTION AND ANALYSIS: Data extraction and risk of bias assessment was undertaken by one review author and checked for accuracy by a second. MAIN RESULTS: Two trials involving 63 people were included. One RCT in women with superficial breast lesions compared 6% miltefosine solution with placebo and found that miltefosine delayed tumour progression. The study reported that the time to treatment failure was significantly longer in the miltefosine group (median 56 days) than in the placebo group (median 21 days) (P value 0.007, log-rank test). A second trial compared topical metronidazole with placebo and found that metronidazole reduced malodour, although there was no statistically significant difference between the two groups. Both these trials, however, had methodological limitations and the latter was underpowered. AUTHORS' CONCLUSIONS: There is weak evidence from one small trial that 6% miltefosine solution applied topically to people with superficial fungating breast lesions (smaller than 1cm) who have received either previous radiotherapy, surgery, hormonal therapy or chemotherapy for their breast cancer, may slow disease progression. There is insufficient evidence in this review to give a clear direction for practice with regard to improving quality of life or managing wound symptoms associated with fungating wounds. More research is needed.