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clinical review

malodour in
palliative care
wounds in
primary care
Georgina Gethin, PhD, RGN, HE Dip Wound Care, FFNMRCSI
Research Co-Ordinator/Lecturer,
Centre for Nursing and Midwifery Research, RCSI

alodorous wounds are very distressing for

patients and carers. Odour may be a sign of
infection in some wounds but it is also one of
the most distressing symptoms of malignant
fungating wounds. It can cause social isolation,
depression, nausea, anorexia and in some cases is so distressing
as to cause a gagging or vomiting reflex. This paper will explore
the causes of malodour with particular reference to palliative
care wounds. It will also highlight its effect on individuals and
present some strategies to manage or control it.
The World Health Organisation estimates that 10.9 million new
cases of cancer are diagnosed annually (WHO, 2009). In Ireland,
the national cancer forum reports almost 20,000 new cases
each year (NCF, 2006). Cancer is a major cause of morbidity
and worldwide accounted for 7.4 million deaths in 2004 (WHO,
2009). This is expected to increase to 12 million by 2030 (WHO,
Cancer is a generic term for a large group of diseases that
can affect any part of the body (WHO, 2009). One defining
feature of cancer is the rapid creation of abnormal cells that
grow beyond their usual boundaries, and which can then
invade adjoining parts of the body and spread to other organs.
This process is referred to as metastases, which are the major
cause of death from cancer (WHO, 2009). While there are no
precise figures for fungating wounds it is estimated that of
those persons with metastatic disease, approximately 5-10%

experience skin involvement which usually occurs during

the last 6-12 months of life (Lo et al, 2006). Of those with skin
involvement and specifically, malignant fungating wounds
(MFW), approximately 62% originate from breast cancer,
followed by head and neck 24%, genitals and back 3% and
other sites 8% (Naylor, 2002).
Fungating refers to a malignant process of both ulcerating
and proliferative growth. Lesions that have a predominantly
proliferative growth pattern may develop into a nodular
fungus or cauliflower shaped lesion, whereas a lesion that is
ulcerating will produce a wound with a crater-like appearance
(Grocott, 1995). Some lesions present with a mixed appearance
of both proliferating and ulcerating areas.
Quality of life
Palliative care focuses on relieving suffering and achieving the
best possible quality of life for patients and their care providers.
Optimal palliative care services integrate the expertise of a
team of providers from different disciplines to address the
complex needs of seriously ill patients and their families.
According to Grocott (2010) palliative wound care is essentially
concerned with improving quality of life and one of the key
goals is to prevent wounds inhibiting patients and families
day-to-day functioning.
Unfortunately, persons with malignant fungating lesions
often present late seeking help (Boon et al, 2000). It is
speculated that this may be due to embarrassment about
appearance such as exudate leakage or due to a fear of being

clinical review
Malodour which is cited
as being one of the most
distressing features
of such wounds has
also been the cause of
involuntary gagging
and vomiting.
diagnosed with cancer (Probst, 2010). Such wounds have
enormous psychological impact on the quality of life of the
individual causing embarrassment, social isolation, withdrawal
from daily activities, poor self esteem, and all at a time when
support is much needed (Lund-Nielsen et al, 2005; Lo et al,
2008; Probst et al, 2009). Malodour which is cited as being one
of the most distressing features of such wounds has also been
the cause of involuntary gagging and vomiting (Draper, 2005).
A study by Lo et al (2008) reported that in the absence of
specialist knowledge about the management of fungating
wounds, some patients report engaging in a variety of
strategies to manage the wound, including; restricting water
intake, using toilet paper to cover the wound, brushing using a
baby toothbrush and herbal remedies
Causes of odour
Wound malodour is caused by bacterial infection in devitalized
tissue within the wound. More specifically it is due to a cocktail
of volatile agents that includes short chain organic acids,
produced by anaerobic bacteria (Moss et al, 1974), together
with a mixture of amines and diamines such as cadaverine and
putrescine that are produced by the metabolic processes of
other proteolytic bacteria (Thomas et al, 1998).
Organisms frequently isolated from malodorous wounds
include anaerobes such as bacteroides and Clostridium
species and aerobic bacteria including Proteus, Klebsiella and
Pseudomonas spp. (Thomas et al, 1998). More recently, a study
to determine the chemical identity of the cancer derivedwound odour among women with breast cancer identified
dimethyl trisulfide (DMTS), as the source of odour (Shirasu et al,
2009). DMTS is a compound that is known to be emitted from
some vegetables and micro-organisms and is also produced by
aerobes such as Pseudomonas aeruginosa (Shirasu et al, 2009).
Dead and devitalized tissue also causes wound malodour
and provides an ideal environment for bacterial proliferation
which in turn contributes to odour. Together with exudate
production, all serve to increase odour. Furthermore, fungating
lesions are thought to interfere with tissue oxygenation,
lymphatic drainage and haemostasis and reduced tissue
perfusion, due to abnormalities in the vascularisation of solid
tumors, lead to local cell anoxia and sometimes cell death and
tissue necrosis (Hirst, 1992: Cited in Adderley and Smith, 2010).
Managing odour
Wound malodour is not an isolated phenomenon and thus,
treatment strategies should attempt to address the cause

of the odour and management of it. There is a paucity of

clinical research studies which have evaluated strategies for
the management of wound malodour. This may be due in
part to the difficulties surrounding quantifying something
which cannot be seen or touched or measured. One study
demonstrated that of all wound assessment parameters the
inter-rater reliability of wound odour was very poor (Gethin
and Cowman, 2007). Strategies to manage malodour can be
divided into two categories: wound management agents and
environmenal agents.
Wound management agents
Metronidazole (Flagyl) is an antibiotic agent used topically
or systemically for reduction of malodour and is particularly
effective for anaerobic bacteria and protozoa. While used
extensively there are variations in the concentrations used and
the methods of application. Metronidazole tablets have been
crushed and mixed with sterile water to create either a 0.5%
solution (5mg/cc) or 1% solution (Seaman, 2006). This is then
used as a wound irrigant or alternatively gauze is soaked in the
solution and applied to the wounds. There is much anecdotal
evidence to support this practice although little scientific
evidence exists. It is also used as a gel at a concentration of
0.75% (Kalinski et al 2005). Research has shown a statistically
significant (p<0.05) decrease in wound odour after 24 hours,
as determined by both patient and investigator (Kalinski et al
2005). This statistical difference was maintained through days
7 and 14. Importantly, this method of application has not been
associated with any pain or discomfort for the patient.
In a study of eleven patients with fungating wounds Bowler
et al (1992) evaluated the efficacy of metronidazole gel on
wound odour. Patients received either 0.8% gel or placebo
applied daily for six days. Odour was measured using a ten
point visual analogue scale In the placebo group (n=5),
the average odour assessment remained above six. In the
treatment group the mean odour scores showed a statistically
significant reduction over the six days (p> 0.01).
Honey has been reported to effectively reduce and even
eradicate odour as a result of the preferential metabolism by
bacteria of honeys glucose, which produces lactic acid, instead
of amino acids that produce
malodorous ammonia, amines
and sulfur compounds
(White and Molan, 2005).
Honey and in particular
Manuka honey has been
reported to eliminate
wound odour in fungating
and non-fungating
lesions (Gethin and
Cowman, 2009;
Simon et al, 2009;
Moore, 2010;
Segovia, 2010).
As honey
also has

clinical review
antimicrobial and debriding properties it is particularly
useful, as it assists in eliminating those elements which cause
the odour initially, namely, slough and bacteria (Gethin and
Cowman, 2009). As an antibacterial agent it has demonstrated
efficacy against a wide range of wound colonising pathogens
(Cooper and Molan, 1999; Gethin and Cowman, 2008). It has
anti-inflammatory properties which can assist in reducing
exudate production (Molan, 2002).
A systematic review of the use of honey in cancer care
concluded that honey may be used for radiation-induced
mucositis, radiotherapy-induced skin reactions, hand and foot
skin reactions in chemotherapy patients and for oral cavity
and external surgical wounds (Bardy et al, 2008). The authors
suggest that there is further scope for the use of honey within
the cancer setting and particularly in the care of head and neck
cancer patients.
Many formulations of honey exist but for the malignant
fungating wound it can be applied either directly as a gel or
in alginate dressings impregnated with honey. Frequency of
application should be based on levels of exudate and efficacy
of treatment. In order to maximize its potential, honey should
be in close contact with the wound surface for at least 12 hours,
although if levels of exudate are small it can be left in place
for up to seven days (Gethin and Cowman, 2009). It is worth
nothing that not all honeys are suitable for use in open wounds
and clinicians should restrict their use to licensed medical
grade honey.
A systematic review reported that activated charcoal dressings
applied to fungating wounds significantly controlled odour
if the dressings fit as a sealed unit and if the wound was
maintained dry (Draper, 2005). If not sealed the odour can
escape. This is a problem in management of fungating wounds
in which the peri-wound skin is often very sensitive and is not
amenable to the use of adhesives. Activated charcoal dressings
absorb toxins, as well as pro-inflammatory endogenous and
exogenous proteases (Wound Care Handbook, 2010). The
use of a charcoal cloth for management of odour has been
incorporated into pads containing surgical gauze and a layer
of a water repellent fabric. When these pads were used in the
treatment of fungating breast cancer, gangrene and immediate
post operative colostomies, the associated odours were said
to be totally suppressed (Thomas et al, 1998). According
to Thomas et al (1998) charcoal dressings which combine a
physical absorbent with a charcoal component performs best.
One study of the management of malignant
lesions reported a reduction in malodour
by both patients and investigators when
wounds were cleansed and either charcoal
applied directly to the wound surface or as
a secondary dressing when hydrogel was
used to deslough the wound bed (LundNielsen et al, 2005). The use of charcoal
dressing in combination with a
foam dressing with an adhesive
border made the patients in that
study feel protected against
malodour and encouraged
them to resume social activities
(Lund-Nielsen et al, 2005). Given
the variations in composition
of dressings containing charcoal
the manufacturers instructions
should be consulted prior to use
for optimal performance.

Honey and in particular

Manuka honey has
been reported to
eliminate wound odour
in fungating and nonfungating lesions.
Aromatherapy agents
An interesting report by Mercier and Knevitt (2005) shares their
experience of using aromatherapy in patients with fungating
lesions. The choice of essential oil is decided by the patient in
consultation with the staff member. If odour is only present
during dressing changes the oil may be vaporized in the
room before and during the procedure. When the odour is
detectable outside of dressing changes a few drops are applied
to the outer dressing. Some oils are then used in the cleaning
of the wound such as tea tree oil. Oils are also blended into a
cream and applied directly to the wound. It is recommended
that such practices should be discussed with a pharmacist who
is assess the safety of particular oils for use in patient care.
The use of green tea bags has also been explored (Yian,
2005). The author of this paper reports on the application
of green tea bags as a secondary dressing. The bags help to
absorb exudate and the antioxidants in the green tea act as a
deodorizer. Further research is required to explore this option
further but it may offer an interesting option for some patients.
Environmental agents
Wound odours have traditionally been masked by burning
incense and in more recent times, by the use of aerosols or
air fresheners. While there is a abundance of retail products
aimed at eliminating odour these are often perfumed and are
poorly tolerated by persons with cancer.
Much anecdotal evidence exists for various environmental
strategies including burning of oils which can create a pleasant
aroma, in particular dried sage may be helpful. Other oils such
as eucalyptus or clove oil can be beneficial. However, caution
should be exercised in over-use as the strong odour may in
itself be distressing.
Placing charcoal or cat litter in an open tray under a bed can
assist in absorbing odours. Additionally an open dish of coffee
beans or shaving cream in a room is said to be very effective.
General environmental control strategies such as removal of
soiled linen or open bins can also make an atmosphere more
pleasant and enhance the patients surroundings.
Odour caused by wounds can be distressing for both the
patient and the caregiver and may be a reminder of their
underlying disease process. Odour can cause the patient to
feel embarrassed or ashamed, and may lead them to become
isolated and withdraw from their daily activities. Effective
management should be based on reduction in slough,
control of bacteria and can include a number of topical or
environmental agents including charcoal, iodine, honey or

clinical review
Unfortunately, persons
with malignant
fungating lesions often
present late seeking
help...this may be due to
embarrassment about
appearance ...or fear of
being diagnosed with
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