Chapter 9: Malignant Wounds

INTRODUCTION

Most malignant dermal wounds are caused by over-exposure to ultraviolet light or by metastatic spread from a remote neoplasm to the skin; however, some malignancies can cause dermal lesions. In addition some chronic wounds and cutaneous scars, especially from burns, can transition into neoplastic lesions (termed Marjolin’s ulcer)¹ and require a totally different plan of care in order to achieve full wound closure. Some of the signs that a wound may be a neoplasm, either benign or malignant, are the following:

• Unusual appearance

• Easy bleeding

• Hypergranulation

• Rapid growth

• Failure to respond to standard care

• Repeated reoccurrence after apparent closure

• Unusual odor

• Pain

• Exudate

• Edema

Along with these physical symptoms come emotional stress, functional compromise, social concerns, and complications such as infection.² Any wound that is even suspicious of being malignant requires immediate confirmation or negation by tissue biopsy.

The objective of this chapter is to present the subtle characteristics of malignant wounds and the immediate medical care that is recommended to prevent further metastasis or wound complications. Palliative care for fungating or terminal illness wounds will also be discussed.

BASAL CELL CARCINOMA (BCC)

Pathophysiology

• Is the most common skin cancer, and the most frequently occurring cancer overall

• Arises from damaged undifferentiated basal cells

• Is the result of prolonged exposure to ultraviolet (sun or tanning bed) light which leads to the formation of thymine dimers, a form of DNA damage

• Occurs when the DNA damage is greater than what the cells can naturally repair³

• Involves the following risk factors:

  • Prolonged ultraviolet exposure in the sun or tanning beds

  • Fair skin, red or blond hair, or light-colored eyes

  • Radiation therapy for other skin conditions

  • Family history of skin cancer

  • Immunosuppression, including anti-rejection medication

  • Exposure to arsenic in water or industry

  • Certain inherited genetic disorders (e.g. Gorlin-Goltz syndrome, xeroderma pigmentosum)⁴

Clinical presentation

• Most commonly occurs on the head, face, neck, or extremities where skin is exposed to sun, but can occur anywhere on the body

• Can begin as a small pearly-white, scaly lesion that outgrows its blood supply, erodes, and eventually ulcerates. Can also form as a non-healing or expanding chronic rash.

• May bleed easily with any scraping or friction

• May have prominent telangiectatic surface vessels, rolled edges, or slightly raised dome shape

• Is painless and slow growing⁵

• May develop as a result of a non-healing traumatic wound¹

• Presents as three types:

  • Nodular—appears as shiny, pearly skin

  • Superficial—appears as a red patch, may be mistaken for eczema

  • Infiltrative—(also called morpheaform) appears as thickened skin or scar tissue; penetrates deeper and is harder to treat; is more aggressive⁶