The skin is the largest organ of the body and is subject to a variety of problems in advanced disease of any kind. Among the more common skin problems of patients with advanced cancer are decubitus ulcers (bed sores), malignant ulcers (necrotic area caused directly by cancer), fistulas (abnormal opening between body parts or cavities, e.g., between rectum and vagina), fungating tumors (rapidly growing external tumors), itching or pruritus, infections, skin problems resulting from cancer treatment, and paraneoplastic syndromes. There is also a general deterioration of skin condition in patients with advanced cancer and other illnesses, including thinning, loss of elasticity, dehydration, deepening of sores and wrinkles, and pigmentation disorders. Skin problems, especially infections, are common in persons with AIDS.
Because a general deterioration of skin condition is very common, it is important to pay careful attention to (1) preventing problems and (2) identifying problems early in their development. See the discussion below on preventing skin breakdown.
Decubitus Ulcers (Pressure Ulcers or Sores, Bed Sores, Skin Breakdown)
Decubitus ulcers are caused by decreased circulation from pressure at a specific site, especially at or near bony prominences such as the sacrum ("tailbone"), hip, ankles, or sometimes ear. Multiple factors are involved in the development of decubitus ulcers, including:
Infection, fatigue, anemia, long-term steroid use, and edema increase the risk of skin breakdown. Decubitus ulcers can cause pain, infection, protein loss, multiplication of lesions, cellulitis, sepsis, osteomyelitis, and increased demands on the workload of caregivers. More than 20% of patients in hospice settings may develop pressure sores.
Like so many other problems of terminal illness, it is best to prevent decubitus ulcers. Preventive measures include frequent turning, correct positioning, good hygiene, and adequate hydration and nutrition. Readers will note that almost all these measures require good pain management. Frequent assessment of skin condition is important in identifying skin breakdown at an early stage. Unless development is stopped and reversed, decubitus ulcers generally progress as follows:
Preventing and Managing Decubitus Ulcers
|Prevention is the first priority. At the first hint of breakdown, treatment should be instituted as described below.|
Prevention includes the following:
Treatment of pressure ulcers
Malignant Ulcers, Fistulas, and Fungating Tumors
Malignant ulcers, fistulas, and fungating tumors usually are associated with advanced or rapidly advancing disease. They are most common in patients with breast cancer (>60%), sarcomas, recurrent gynecologic tumors and squamous cell tumors of the head and neck in the last six months of life. Associated problems include bleeding, odor (from secondary infection), drainage, pain, and appearance.
Managing Malignant Ulcers, Fistulas, and Fungating Tumors
Bleeding may progress from slight to profuse. Small amounts of bleeding can be managed by frequent cleaning and dressing changes (pressure bandages). Bleeding is managed medically by radiation, cryosurgery, or embolization. Patients with major, irreversible hemorrhage can be sedated and dark towels used to minimize the visual impact of bleeding.
Foul odor is due to anaerobic microorganisms. The infected area should be cleaned at least three times daily with hydrogen peroxide or povidone iodine. Systemic antibiotics are most effective in treating infection; and a topical antibiotic may be used as an adjunct, but not for primary treatment. Dressings may include charcoal packing or other compounds to absorb odor. Good air circulation is important and ionizers are helpful to some extent. Room "deodorizers" are helpful to some patients, but others find the smell of the deodorant worse than that of the wound. Oral medications that help reduce odor from wounds include metronidazole (Flagyl) and clindamycin, but neither is effective for long-term use.
Drainage from infection is treated as above. Drainage from fistulas (e.g., of gastric fluids or waste) to adjacent areas can result in infection, excoriation, and odor. Fistulas that open with one or two sites onto the skin can be managed similarly to an ostomy, both with respect to discharge (using an ostomy bag) and protection of surrounding skin (with stomahesive). Rectovaginal and rectoperineal fistulas require frequent cleaning and creative management, using tampons, sanitary pads, as well as more traditional dressings. All patients with fistulas should be referred to an interstomal specialist (a registered nurse who specializes in ostomy and related care). If the hospice or other involved program does not have an interstomal specialist on staff, they should (and are ethically bound to) arrange for a series of visits from a specialist from another agency.
Large malignant ulcers may be painful with or without infection. Pain is managed with analgesics and by treating the infection.
Biologic agents, e.g., blood-derived macrophages are probably the most effective treatment for ulcerating wounds. They are, however, expensive.
Problems of odor and appearance are psychologically and socially very difficult for most patients. Every effort should be made to control odor and keep air fresh. Visible tumors and wounds should be kept covered, especially when visitors are present. Some people wear a veil or swathe of cloth to cover large facial or neck tumors. Support and diversion are essential.
Itching is common in patients with primary polycythemia, Hodgkin's disease, lymphoma, leukemia, and pancreatic cancer, as well as other tumor types. Itching also develops as a result of systemic processes such as uremia and cholestasis especially when there is obstructive jaundice. Infections such as candida or eczema also cause itching. Itching is sometimes due to anxiety and beginning opioid use.
The cause is treated whenever possible. Comfort measures include:
Skin infections in patients with terminal cancer are most often bacterial, but also viral, fungal, or mixed. Infections are frequently complicated by or due to a combination of immuno-suppressive medications (e.g., steroids), neutropenia (decrease in the number of neutrophilic leukocytes and thus a tendency to develop infections), general debility, lymphedema, and other factors.
Managing Skin Infections
Some infections are prevented through effective hygiene, prevention of skin breakdown, early identification of skin changes, good wound care, and maintenance of other aspects of health status. Once present, skin infections are treated on the basis of the causative microorganism and symptoms such as pain or odor are managed as in any other circumstance.
One of the most common skin infections of patients with cancer is herpes zoster ("shingles") which is painful. Antiinflammatory and opioid drugs may be required. Since the pain is classed as neuropathic, anticonvulsants such as Tegretol or antidepressants such as Elavil are used to good effect. Early use of Elavil (and perhaps other such drugs targeting neuropathic pain) help decrease later pain, i.e., post-herpatic neuralgia.
Skin Reactions to Treatment
Both radiation and chemotherapy can cause skin problems. Because of advances in radiation therapy, radiation injuries are less common than in years past. Radiation can cause reddened, inflamed (sometimes with blisters), moist skin followed by superficial loss of tissue. Skin may also become dry and hair loss may occur. This problem usually resolves with only slight changes in pigmentation remaining. Late reactions to radiation may be irreversible and include thickening or atrophy of skin and malfunction of dermal glands.
Skin problems from chemotherapy in terminal illness include necrosis from intravenous drug extravasation (leaking into tissue at the injection site), hair loss, allergic or hypersensitive reactions, and changes in pigmentation. The primary use of chemotherapy in terminal illness is to palliate symptoms, and the amounts given and subsequent toxicity is not usually great.
Managing Skin Reactions to Treatment
People who receive radiation should avoid irritants such as harsh or heavily perfumed soaps, tight clothing, and trauma such as scrapes or bruises to the irradiated area. Skin should be cleansed gently with warm water and mild soap, and not a washcloth. Mild skin lotions should be used, but sparingly. Treatment of ulcers and infections is as discussed elsewhere. Once a reaction to radiation begins, there is nothing to reverse the process and it usually simply runs its course.
Paraneoplastic syndromes (or distant and indirect effects of cancer) of the skin include acanthosis nigricans, dermatomyositis, acquired ichthyosis, erythema gyratum repens, and others. Paraneoplastic syndromes of the skin may be painful, cause severe itching, result in necrotic areas, or cause other problems. Rash, thickening, increased pigmentation, and other skin and/or hair changes are typical. Treatment is generally limited to resolution of the tumor and/or palliation with corticosteroids.
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