Hi Melissa,
Thank you for your question. We received a similar question in the 'private' mode from another clinician, so I'll share some thoughts and also our advisors' answers here. Others may have other suggestions as well:
Before considering interventions, it's recommended that the potential for healability of the ulcer be assessed. See topic 'How to determine healability of a chronic wound'. Assuming this is a maintenance/non-healable fungating ulcer:
For necrotic tissue:
- Careful/gentle removal of loose non-viable tissue and debris could help with odor/infection control
For odor and exudate:
- By Cathy Milne, APRN: "There's evidence in the literature to use crushed Flagyl. I usually use 500mg for each breast on a daily basis - crush it into a fine powder and sprinkle it on to the wound after irrigating the area with either one quarter percent acetic acid or one quarter percent Dakin's solution. One study found that the crushed flagyl reduced odor better than the gel. I usually use a hydrofiber over this because it's very absorptive and does vertical wicking .Sometimes I will use exudry and ABD pads, though with the superabsorbant dressing available, that could also be an option over the hydrofiber....a lot depends on the patient's insurance coverage for dressings. To keep things in place I find a sports bra can be very helpful in these situations"
- By Elaine Song, MD: "Building upon Cathy's answer, in a large international survey (n=1444 clinicians) on interventions to control ulcer odor, more respondents considered off-label topical metronidazole "very effective" as compared to charcoal dressings (49.8% for flagyl vs. 48.4% of respondents that used these interventions). Charcoal dressings are also used to control odor as you pointed out and can be helpful if it's sealed and the wound is dry. Examples include CarboFLEX (ConvaTec), Actisorb Silver (Acelity). Reference:
https://woundreference.com/app/reference?id=2240"
For pain: - Provide analgesia before dressing changes, use non-adherent dressings and minimize frequency of dressing changes- The World Health Organization (WHO) Pain Ladder for cancer patients, with modifications for wound care may be used. Benefits and harms of each step should be considered. In summary:
>Step 1: A non-opioid analgesic (e.g., NSAID) with or without an analgesic adjuvant. Adjuvants include tricyclic antidepressants (e.g., nortriptyline starting at 10-30 mg at night), anticonvulsants (e.g., gabapentin), antihistamines, benzodiazepines, steroids, and phenothiazines.
> Step 2: If pain is not controlled: Continue the initial medication and add an opioid, such as codeine or tramadol, and an adjuvant
> Step 3: If pain is not controlled: Discontinue second step medications and initiate a more potent oral narcotic
PS: As a side note, colleagues frequently have similar questions/interests. For future Curbside Consults, if you deem appropriate, it'd be great if you could consider posting the question in the 'public' mode, so that Curbside Consult answers can be more easily found by premium members. Thanks!
![]()
![]()