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Palliative care Skin and nail

Palliative care - malignant skin ulcer

Last revised in October 2026

A malignant ulcer is a proliferative or cavitating primary or secondary cancer in the skin.It may appear as a crater-like wound, a nodular 'fungus'

Palliative care - malignant skin ulcer: Summary

  • A malignant skin ulcer describes a skin lesion caused by cancer where the tumour cells have infiltrated the skin, blood and lymph vessels, and potentially surrounding structures such as muscle, typically causing a hard-to-heal or non-healing wound.
    • These lesions can be due to an ulcerative process in which a cavitating, crater-like 'fungating' wound develops, a proliferative process in which a raised nodular lesion develops, or both.
    • A malignant skin ulcer may also be referred to as a fungating wound, ulcerating tumour, ulcerating cancer, malignant wound, or neoplastic skin lesion or wound.
  • Malignant skin ulcers typically develop due to:
    • A primary skin cancer such as basal cell carcinoma, squamous cell carcinoma, malignant melanoma, cutaneous T-cell lymphoma, or Kaposi's sarcoma.
    • A metastatic skin lesion secondary to different malignancies, such as breast cancer, head and neck cancer, or cancer affecting the groin and genital area.
    • Erosion of the skin by an underlying malignancy.
  • Possible complications include pain, infection, bleeding, exudate, itch, malodour, psychosocial issues, and distress.
  • Assessment of a malignant skin ulcer involves:
    • Asking about symptoms of the ulcer and any complications, nutritional status and oral intake, comorbidities affecting wound healing, medications affecting risk of bleeding and infection, allergies to wound dressings and other products, previous treatments, impact on quality of life, coping strategies, and social support.
    • Examination of the ulcer including location, size, depth, wound edge and peri-wound skin, signs of complications, nutritional status, weight, and functional status.
    • Considering investigations such as wound swab for culture and sensitivity and bloods for full blood count and clotting screen if there is wound bleeding.
  • General management of a person with a malignant skin ulcer in primary care includes:
    • Ensuring a healthcare professional with expertise in wound management is involved in the person's care for wound dressings, cleansing, and decisions about debridement.
    • Assessing treatment goals, expectations, and advising about sources of information and support.
    • Offering emotional and psychosocial support.
    • Optimizing nutritional status.
    • Arranging referral to a tissue viability team, dermatologist, oncologist, and/or palliative care specialist if symptoms persist, depending on clinical judgement.
  • Management of complications of a malignant skin ulcer includes:
    • Pain — identifying and treating the underlying cause where possible, using appropriate analgesia, and ensuring the use of breakthrough analgesia before dressing changes if needed.
    • Infection — taking a wound swab if there is suspected systemic infection, and prescribing an appropriate antibiotic if indicated.
    • Bleeding — reviewing and stopping any causative medications, applying direct pressure, and seeking specialist advice or arranging emergency hospital admission if clinically appropriate.
    • Exudate — protecting the peri-wound skin, using barrier products, and seeking specialist advice if needed.
    • Malodour — treating any underlying cause, using environmental strategies, and prescribing topical or oral metronidazole if an appropriate dressing does not control symptoms.
    • Itch — keeping nails short, avoiding overheating and sweating, treating any underlying cause, managing suspected contact dermatitis, and offering drug treatment if indicated.

Have I got the right topic?

From age 16 years onwards.

This CKS topic covers the assessment and management of malignant skin ulcers (also known as fungating wounds, ulcerating tumours or cancers, malignant wounds, or neoplastic skin lesions).

This CKS topic does not cover the management of any underlying cancer which may have been treated with radiotherapy, chemotherapy, hormonal treatment, or surgery. This CKS topic also does not cover the management of Marjolin's ulcer, pressure areas, or cancer-related fistulae.

There are separate CKS topics on Adult malnutrition, Cellulitis - acute, Corticosteroids - topical (skin), nose, and eyes, Dermatitis - contact, Palliative care - breathlessness, Palliative care - constipation, Palliative care - cough, Palliative care - general issues, Palliative care - nausea and vomiting, Palliative care - oral, Palliative cancer care - pain, Palliative care - secretions, and Pressure ulcers.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

October 2026 — reviewed. A literature search was conducted in October 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has undergone minor restructuring to improve clarity and navigation. The recommendations have been updated in line with current evidence in the literature. Various web links to patient and carer information have been added to the topic.

Previous changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

July 2023 — minor update. The manufacturers' Summary of Product Characteristics (SPC) for metronidazole has been updated to note that QT prolongation has been reported (unknown frequency), particularly when metronidazole was administered with drugs with the potential for prolonging the QT interval.

March 2021 — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

October 2018 — minor update. Adverse effects of metronidazole updated in the Prescribing information section.

July 2015 to October 2016 — reviewed. Literature searches were conducted in September 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. There have been structural changes to the topic and changes to the recommendations have been updated in line with National Institute for Health and Care Excellence (NICE) guidance Care of dying adults in the last days of life (NICE, 2015).

July 2015 — topic title changed to reflect broader topic coverage than specifically cancer care.

May 2015 — reviewed and updated. A literature search was conducted in January 2015 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic structure has been altered to reflect a symptom-based approach and changes to antibiotic prescribing advice have been made.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

April 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. 

June 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic. 

April to July 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

September 2008 — minor correction to the Changes section. 

October to December 2005 — reviewed. Validated in March 2006 and issued in May 2006.

October 2005 — minor technical update. Issued in November 2005.

September 2002 — written. Validated in October 2002 and issued in December 2002.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 October 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 October 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 October 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 October 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 October 2026.

New policies

No new national policies or guidelines since 1 October 2026.

New safety alerts

No new safety alerts since 1 October 2026.

Changes in product availability

No new product availability since 1 October 2026.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make an accurate diagnosis of a malignant skin ulcer.
  • Assess and manage a malignant skin ulcer and any complications in the palliative care setting.
  • Advise about sources of information and support for the person and carers/family members.
  • Arrange referral a district nurse, palliative care nurse, or tissue viability nurse for advice on dressings and wound care, if needed.
  • Arrange referral to an oncology, palliative care, or dermatology specialist, if clinically appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

End of life care for adults

  • Adults who are likely to be approaching the end of their life are identified using a systematic approach.
  • Adults approaching the end of their life have opportunities to discuss advance care planning.
  • Adults approaching the end of their life receive care that is coordinated between health and social care practitioners within and across different services and organisations.
  • Adults approaching the end of their life and their carers have access to support 24 hours a day, 7 days a week.
  • Carers providing end of life care to people at home are supported to access local services that can provide assistance.

[NICE, 2021]

Decision-making and mental capacity

  • People aged 16 and over who may lack capacity to make decisions are supported with decision-making in a way that reflects their individual circumstances and meets their particular needs.
  • People aged 16 and over at risk of losing capacity to make decisions, and those with fluctuating capacity, are given the opportunity to discuss advance care planning at each health and social care review.
  • People aged 16 and over who are assessed as lacking capacity to make a particular decision at the time that decision needs to be made, have a clear record of the reasons why they lack capacity and the practicable steps taken to support them.
  • People aged 16 and over who lack capacity to make a particular decision at the time that decision needs to be made have their wishes, feelings, values and beliefs accounted for in best interests decisions.

[NICE, 2020]

Background information

What is it?

  • A malignant skin ulcer describes a skin lesion caused by cancer where the tumour cells have infiltrated the skin, blood and lymph vessels, and potentially surrounding structures such as muscle, typically causing a hard-to-heal or non-healing wound [Grocott, 2015; Starace, 2022; Ousey, 2024].
    • These lesions can be due to an ulcerative process in which a cavitating, crater-like 'fungating' wound develops, a proliferative process in which a raised nodular lesion develops, or both [Twycross, 2021; Starace, 2022; Ousey, 2024].
    • Clinically, malignant skin ulcers may present as masses, plaques, papules, ulcers, skin nodules, discolouration, or hard-to-heal wounds [Fang, 2024]. The diagnosis may be confirmed following skin biopsy and histopathological analysis [Grocott, 2015; Starace, 2022; Fang, 2024].
  • A malignant skin ulcer may also be referred to as a fungating wound, ulcerating tumour, ulcerating cancer, malignant wound, or neoplastic skin lesion or wound in the literature [Starace, 2022; Ousey, 2024].

What are the causes?

Malignant skin ulcers typically develop in malignant lesions close to, or on, the surface of the skin, due to [Young, 2017] [Starace, 2022] [Fang, 2024] [Ousey, 2024]:

  • A primary skin cancer such as basal cell carcinoma, squamous cell carcinoma, malignant melanoma, cutaneous T-cell lymphoma, or Kaposi's sarcoma.
  • A metastatic skin lesion secondary to different malignancies, such as breast cancer, head and neck cancer, or cancer affecting the groin and genital area, most commonly.
  • Erosion of the skin by an underlying malignancy.

How common is it?

Malignant skin ulcers are relatively rare. The exact prevalence is thought to be underreported in the literature due to feelings of shame, fear, and embarrassment among patients [Ousey, 2024].

  • An epidemiological cross-sectional descriptive study in an oncology hospital setting analyzed wound data from participant interviews, physical examination, and medical record review (n = 341 adults) and found [Firmino, 2020]:
    • The overall prevalence of malignant skin ulcers in hospitalized patients was 3.8%.
    • Fourteen malignant skin ulcers were identified in 13 patients.
    • 75% of affected patients were men, with a mean age of 60.5 years.
    • 43% of the lesions were located in the head and neck region.
  • Expert opinion in a review article states that malignant skin ulcers affect 5–10% of people with cancer, and notes they usually appear in the last 6–12 months of a person's life, but may be present for years [Starace, 2022].

What are the complications?

Possible complications of malignant skin ulcers vary depending on the underlying cause and anatomical location, and may include [Ousey, 2024] [Gethin, 2025]: 

  • Pain
    • Wound pain results from the rapid growth of malignant skin ulcers, which may compress adjacent soft tissues and nerves. Pain levels may depend on ulcer location, size, the depth of tissue invasion and damage (causing nociceptive pain), degree of nerve involvement (causing neuropathic pain), local skin inflammation and ischaemia, and the need and frequency of dressing changes or other treatments [Regnard, 2010; Young, 2017; Ousey, 2024; Gethin, 2025].
    • The European Wound Management Association (EWMA) joint publication states that more than 50% of people with fungating malignant skin ulcers affecting the breast report severe, persistent wound-associated pain [Gethin, 2025].
  • Infection
    • If the blood supply to the malignant skin ulcer is compromised, skin and underlying tissue necrosis may occur. In addition, moisture-associated skin damage, high exudate levels, and peri-wound maceration may complicate lesions, for example in groin/genital wounds. Both of these factors may increase the risk for secondary bacterial infection and intertrigo [Ousey, 2024]. See the CKS topics on Candida - skin and Cellulitis - acute for more information.
  • Bleeding
    • Wound bleeding can be due to angiogenesis within the ulcer causing capillary friability and low-volume constant bleeding, direct blood vessel invasion by a tumour, wound trauma, and/or infection [Ousey, 2024; Gethin, 2025].
    • The presence of minor bleeding significantly increases the risk of more severe bleeding. Major haemorrhage (rare) may result from tumour erosion into a blood vessel or treatment-related thrombocytopenia, aplastic anaemia, or impaired liver function [Ousey, 2024; Gethin, 2025]. See the CKS topics on Platelets - abnormal counts and cancer and Jaundice in adults for more information.
  • Exudate
    • Excess exudate may result from tumour necrosis, infection, or leakage from an enterocutaneous fistula formed due to a rapidly proliferating tumour, for example. High exudate levels can lead to potential leakage through dressings, and soiling of clothing and bedding [Ousey, 2024]. It can result in delayed wound healing and increase the risk of other wound complications such as peri-wound maceration, excoriation, skin stripping, wound enlargement, and infection [Gethin, 2025].
  • Malodour
    • Malodour may result from poor tissue perfusion due to infection, high levels of exudate, and/or wound slough or necrotic tissue, allowing anaerobic and aerobic bacteria to produce volatile agents together with foul-smelling compounds such as cadaverine and putrescine produced by the metabolic processes of other bacteria [Grocott, 2015; Ousey, 2024; Gethin, 2025].
    • Odours can spread to clothing, bedding, furniture and living areas, affecting the person's quality of life and causing stress, embarrassment, isolation, depression, fatigue, and carer distress. In addition, malodour can cause nausea, reduced appetite, weight loss, malnutrition, and reduced wound healing [Fang, 2024; Ousey, 2024; Gethin, 2025]. See the CKS topic on Adult malnutrition for more information.
  • Itch
    • This may be caused by the wound healing process, irritant contact dermatitis due to excess exudate or wound maceration, allergic contact dermatitis due to allergens in topical products and dressings, or other systemic causes, and is likely to be mediated by inflammatory processes and nerve damage [Ousey, 2024; Gethin, 2025]. See the CKS topics on Dermatitis - contact and Itch - widespread for more information.
    • Itch is more likely to affect large ulcers and areas with necrotic tissue, granulation tissue, and/or oedema [Gethin, 2025].
  • Psychosocial
    • Psychosocial distress, frustration, and embarrassment may result from issues of altered self-image, stigma (particularly if the wound affects the breast, genital, or groin areas), malodour, and restricted mobility (for example due to bulky or unsightly dressings) [Ousey, 2024; Gethin, 2025].
    • In addition, knowledge that malignant skin ulcers may indicate progressive cancer and the non-healing nature of many lesions may lead to depression, anxiety, low self-esteem, social isolation, and impact on work, social life, and sexual relationships [Regnard, 2010; Young, 2017; Ousey, 2024; Gethin, 2025]. See the CKS topics on Depression and Generalized anxiety disorder for more information.

Diagnosis

How should I assess a person with a malignant skin ulcer?

If a person presents with a malignant skin ulcer in the palliative setting:

  • Ask about:
    • Any symptoms such as pain intensity, location, duration, characteristics, and triggers; clinical features of infection (increased pain, exudate, fever, systemically unwell); level and type of bleeding; type and amount of exudate (indicated by the frequency of dressing changes and/or leakage); intensity of any malodour; and any exacerbating or relieving factors.
    • The person's oral intake, nutritional, and functional status.
    • Any comorbidities which may affect wound healing, including diabetes mellitus, heart failure, venous insufficiency, clotting disorders, malnutrition, or lymphoedema.
    • Any medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelets, anticoagulants, corticosteroids, or other immunosuppressives, which may increase the risk of bleeding or infection complications.
    • Any allergies, including to wound dressings or other wound care products.
    • Previous treatments including radiotherapy or surgery which may increase the risk of bleeding complications.
    • The person's treatment wishes and goals.
    • The person's concerns about the ulcer, and its impact on their daily functioning and quality of life, including eating and drinking, swallowing, communication (head and neck wounds), continence and sexual function (groin/genital wounds).
    • The person's emotional wellbeing, any mood changes which may indicate pain or distress, coping strategies, home environment, social situation and support.
  • Examine the person.
    • Perform a general examination to check temperature, weight, body mass index (BMI) and signs of weight loss, hydration and nutritional status, and any evidence of oedema or lymphoedema.
    • Assess the malignant skin ulcer and any satellite lesions, including anatomical location, size, depth, and nature, wound edge, and condition of the surrounding skin, as these factors may affect dressing choice, the method of securing the dressing, and the frequency of dressing changes.
    • Assess the amount of necrotic tissue within the ulcer, as this affects the need for cleansing or debridement by a healthcare professional with appropriate expertise.
    • Assess for signs of complications including pain, infection, bleeding, exudate, malodour, and itch.
      • Assess the volume and appearance of any exudate, as changes to seropurulent (cloudy, creamy, yellow), purulent (opaque, yellow, brown, or green), or haemopurulent (reddish, milky, opaque) exudate, which is often thick or sticky and/or associated with malodour, may indicate underlying infection.
      • Assess for signs of infection, such as fever or malaise; increased purulent exudate or abscess formation, new or increasing pain, increasing malodour; increased wound breakdown, hypergranulation, erythema, warmth, swelling. Note: signs of wound necrosis, exudate, and malodour may not necessarily indicate active infection.
  • Arrange additional investigations in primary care, depending on clinical judgement.
    • Arrange a wound swab for culture and sensitivity if there are signs of systemic infection.
      • Cleanse the area using sterile water or 0.9% saline, then run the tip of the swab across the wound in a 'zig-zag' manner and at the same time rotate the swab handle.
    • Consider checking the person's full blood count and clotting screen if there is wound bleeding. See the CKS topic on Platelets - abnormal counts and cancer for more information.

Basis for recommendation

These recommendations are based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], expert opinion in palliative care textbooks [Regnard, 2010; Twycross, 2021], and expert opinion in review articles on malignant skin ulcers [Starace, 2022; Fang, 2024].

Clinical features on history-taking
  • The EWMA joint publication notes that the severity of different symptoms may vary depending on the underlying cause(s), the stage of wound development, and patient-related factors. It notes that assessment of pain in the palliative setting is subjective and can be complex [Gethin, 2025].
  • The information that an increase or change in the amount of exudate, pain, or malodour may indicate underlying wound infection is based on the UK consensus document [Ousey, 2024].
  • The EWMA joint publication notes that patient perception and clinician ratings and perception of malodour can differ significantly [Gethin, 2025].
  • Asking about the person's concerns and management goals can help to guide treatment choices and symptom management [Ousey, 2024].
Clinical features on examination
  • The recommendation to perform a general assessment is based on the UK consensus document, which highlights that a person's nutritional status can impact on wound healing [Ousey, 2024]. This approach is supported by the EWMA joint publication [Gethin, 2025].
  • The recommendation to assess the anatomical location and characteristics of a malignant skin ulcer is important, as this may impact on dressing choice and management, particularly in difficult-to-access areas. In addition, dressing fitting of protruding and nodular wounds can be more challenging, which potentially affects the ability to absorb fluid in high exudate wounds. Measuring wound size is important to monitor any progression and help choose the correct dressing size [Ousey, 2024].
  • Expert opinion in a palliative care textbook notes that the type and volume of wound exudate determines the type of dressing used [Twycross, 2021].
  • The information about the different types of wound exudate which may indicate infection is based on the UK consensus document. It notes, however, that signs of wound necrosis, exudate, and malodour may not necessarily indicate active infection [Ousey, 2024]. This is supported by the EWMA joint publication [Gethin, 2025] and expert opinion in a review article [Fang, 2024].
Arranging investigations in primary care
  • The recommendation to arrange a wound swab for culture and sensitivity if there are signs of systemic infection is based on the UK consensus document [Ousey, 2024] and expert opinion in review articles [Starace, 2022; Fang, 2024].
  • The recommendation to consider checking blood tests if there is wound bleeding is extrapolated from the EWMA joint publication [Gethin, 2025] and expert opinion in a review article [Fang, 2024]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Management

Scenario: Management

From age 16 years onwards.

How should I manage a malignant skin ulcer in the palliative setting?

Ensure a healthcare professional with expertise in wound management is involved in the person's care, such as a district nurse, palliative care nurse, or tissue viability nurse.

  • Explore the person's needs and concerns, and advise about sources of information and support, depending on the person's and carer/family wishes:
    • Advise that complete wound healing may not be possible in advanced or metastatic disease, and the aim of treatment is usually to reduce wound size, manage symptoms, and optimize quality of life.
    • The MacMillan cancer support (website www.macmillan.org.uk) patient information Ulcerating cancer wounds may be helpful.
  • Offer management of any symptoms and complications, including wound cleansing, debridement, and appropriate dressings, depending on the person's presentation and wishes.
  • Offer psychosocial and emotional support as needed.
  • Optimize the person's nutritional status as much as possible. See the CKS topic on Adult malnutrition for more information.
  • Assess for and manage any other physical, social, cultural, religious, and spiritual needs of the person, carers, and/or family members. See the CKS topic on Palliative care - general issues for more information.
  • Arrange referral to a tissue viability team, oncologist, and/or palliative care specialist, depending on clinical judgement, if:
    • There is diagnostic uncertainty.
    • Additional disease-modifying cancer treatment may be possible, such as radiotherapy, chemotherapy, or hormone therapy to encourage tumour shrinkage, and/or debulking surgery.
    • Symptoms are uncontrolled with optimal management in primary care.
    • There is suspected systemic infection and specialist wound debridement may be needed.
    • There are complications which need specialist management (such as large vessel compression or obstruction, airway obstruction, or the presence of significant necrotic tissue or exposed underlying structures such as tendon or bone).

Wound cleansing and debridement

Ensure a healthcare professional with expertise in wound management is involved in the person's care, such as a district nurse, palliative care nurse, or tissue viability nurse [Twycross, 2021; Ousey, 2024]. They are likely to be involved in decision-making regarding the following:

  • Assessing whether ulcer cleansing is required.
    • Cleansing is useful for removing visible debris, excess slough, exudate, bacteria, or any remaining dressing materials or treatments.
    • Cleansing is advised prior to obtaining a microbiological swab (but do not take swabs unless there is clinical evidence of infection).
    • Routine washing of wounds is not necessary or desirable and may cause pain.
  • Selecting the cleansing fluid.
    • If a clean technique is being used, use tepid tap or shower water.
    • If a sterile technique is required (for example, where there is bony involvement or in a severely immunocompromised person), use 0.9% sodium chloride solution.
    • Ideally, the cleansing fluid should be at body temperature, or if this is not possible, the fluid should be warmed to room temperature before use.
  • Gently irrigating the ulcer and surrounding skin using non-woven sterile swabs. 
    • Use a no-touch technique.  
    • Do not clean wounds by scrubbing, which causes pain and local tissue oedema. Irrigation is more protective of fragile tissue.
    • Do not use cotton wool or gauze swabs as these shed fibres and increase the risk of infection.
  • Reviewing whether wound debridement (removal of necrotic, devitalized, sloughy, or infected tissue) is needed.
    • Removal of non-viable debris may help wound healing and reduce infection.
    • It is important to select a method of debridement that is acceptable to the person and safe, depending on wound vascularity and the proposed method of debridement.
    • Autolytic debridement may be promoted by the use of specialist dressings, for example if there is suspected infection, but should be avoided if there is wound bleeding. See the section on Dressing choice and management for more information.
    • Sharp debridement (using a sterile blade, scalpel, or scissors) is not recommended as it may cause bleeding in friable tissue. If sharp debridement is felt necessary, consider referral to the local tissue viability team, if not already under their care.
    • Mechanical debridement (removing necrotic tissue with gauze) is not recommended as it may indiscriminately remove granulation and epithelial tissue.

 [Twycross, 2021; Ousey, 2024; Gethin, 2025]

Dressing choice and management

Ensure a healthcare professional with expertise in wound management is involved in the person's care, such as a district nurse, palliative care nurse, or tissue viability nurse [Twycross, 2021; Ousey, 2024]. They are likely to be involved in decision-making regarding the following:

  • The choice of dressing will depend on:
    • The type, site, and size of the ulcer.
      • An appropriate size and type of dressing should be selected to avoid stretching or applying dressings under tension.
    • The presence of complications.
      • If there is pain at dressing changes, non-adherent dressings should be used if possible, and dressings should be removed carefully (by soaking adherent dressings with normal saline or using dressing adhesive removal products before removal to minimize trauma). Use of additional barrier products to protect the skin may help. Topically applied opioids or other topical preparations may be recommended on specialist advice. A secondary dressing may also be applied to improve comfort.
      • If there is evidence of infection, dressings with antimicrobial or antiseptic properties (for example silver, iodine, or medical-grade honey-impregnated dressings) may be considered. Some dressings can assist with autolytic debridement (for example hydrogels, hydrocolloids, foams, and alginates).
      • If bleeding is present, non-adherent dressings should be used, and dressings with haemostatic properties can be considered (for example, alginate or gelatine). Dressings should be removed carefully (soak adherent dressings with normal saline before removal) to minimize trauma and bleeding risk.
      • If exudate is present, non-adherent dressings should be used to reduce the risk of trauma and bleeding on dressing removal. Alginate dressings may encourage autolytic debridement and granulation tissue formation. Antimicrobial dressings may be useful if excess exudate is secondary to infection. An outer superabsorbent dressing helps to absorb and retain fluid, and promotes a moist wound environment for healing if there is heavy exudate. If frequent dressing changes are needed, adhesive tape or dressings should be avoided.
      • If malodour is present, activated charcoal or cinnamon-based dressings may help absorb the smell. Charcoal dressings may deactivate if wet, so they may not be effective if there is excess exudate. In addition, charcoal dressings should be applied as a sealed unit to prevent volatile chemicals from escaping into the air. Dressings with antimicrobial or antiseptic properties, silver-impregnated dressings, or hydrogel dressings and alginate paste may be helpful.
  • Dressings should be changed as often as needed to manage pain, infection, bleeding, exudate, and odour, but changes should be minimized where possible. If appropriate, the person or carers/family members can be supported to change dressings.
  • The area around the ulcer should be prepared carefully to ensure a good seal between the dressing and the wound, to reduce the risk of exudate pooling and leakage.
    • If there is a risk of skin maceration and excoriation due to prolonged exposure to moisture and skin friability, protect the surrounding skin with a barrier cream or film. See the section on Exudate for more information.
    • Alternative ways of securing dressings (such as netting or briefs) may be considered if the surrounding skin is damaged.
  • Aim for a good cosmetic effect when applying dressings, for example:
    • Use dressings to fill any defect (for example, a cavity in an ulcer).
    • Ensure dressings protect clothing.
    • Use a less bulky dressing material if the person is going out (this may mean using a less absorbent dressing).

[Twycross, 2021; Ousey, 2024; Gethin, 2025]

Basis for recommendation

These recommendations are largely based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], expert opinion in palliative care textbooks [Regnard, 2010; Grocott, 2015; Twycross, 2021], and expert opinion in review articles on malignant skin ulcers [Young, 2017; Starace, 2022; Fang, 2024].

Advising on sources of information and support
  • The recommendation to provide patient education and information is based on the EWMA joint publication, which highlights this may promote patient engagement and adherence to treatment protocols. It states '...it is important to establish a management plan and desired outcomes that are aligned with patient and treatment goals and that is respectful of patient values' [Gethin, 2025].
  • The UK consensus document notes that malignant skin ulcers will only potentially heal if the underlying cancer causing them responds to treatment. Many wounds will not heal due to the person's stage of disease, functional status and associated comorbidities, and the nature of the wound itself [Ousey, 2024]. This is supported by the EWMA joint publication [Gethin, 2025], expert opinion in a palliative care textbook [Regnard, 2010], and expert opinion in a review article [Fang, 2024].
Managing symptoms and complications
  • This recommendation is based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a palliative care textbook [Twycross, 2021].
Offering psychosocial and emotional support
  • The recommendation to offer psychosocial support is based on the fact that high levels of stress and anxiety may lower the person's pain threshold and tolerance, so offering support may help to reduce other symptoms such as pain [Ousey, 2024]. Similarly, expert opinion in a review article notes that providing psychosocial support may help to promote wound healing and reduce pain [Fang, 2024]. This approach is supported by expert opinion in another review article [Young, 2017]. It is also pragmatic, based on what CKS considers to be good clinical practice.
Optimizing nutritional status
  • This recommendation is based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a review article [Fang, 2024].
Assessing the holistic needs of the person, carers, and/or family members
  • This recommendation is based on the UK consensus document [Ousey, 2024] and the EWMA joint publication [Gethin, 2025]. It is also pragmatic, based on what CKS considers to be good clinical practice.
Arranging specialist referral
  • The recommendation if there is diagnostic uncertainty is based on the UK consensus document [Ousey, 2024].
  • The recommendation if additional cancer treatment may be possible is based on expert opinion in palliative care textbooks [Regnard, 2010; Grocott, 2015; Twycross, 2021], and expert opinion in a review article, which notes that treatment of the underlying disease offers the best chance of effective wound management [Fang, 2024].
  • The recommendation if symptoms remain uncontrolled is based on the UK consensus document [Ousey, 2024]. It is also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation if specialist wound debridement may be needed is based on the UK consensus document [Ousey, 2024].
  • The recommendation if there are complications which may need specialist management is extrapolated from the UK consensus document [Ousey, 2024].

How should I manage a painful malignant skin ulcer?

If a person presents with a painful malignant skin ulcer in the palliative care setting:

  • Prescribe appropriate analgesia if needed, depending on the nature, severity, and frequency of pain. See the CKS topics on Analgesia - mild-to-moderate pain, Neuropathic pain - drug treatment, and Palliative cancer care - pain for more information.
  • Identify and manage the underlying cause of pain where possible, for example infection, surrounding skin inflammation or excoriation, and/or during dressing changes.
  • If there is pain during dressing changes or with other wound treatments:
    • Ensure a healthcare professional with expertise in wound management is involved in the person's care, such as a district nurse, palliative care nurse, or tissue viability nurse, who can select an appropriate dressing, manage any exudate, and limit the frequency of wound cleansing and dressing changes, if possible.
    • Advise on distraction techniques which may reduce the perception of pain during wound care procedures.
    • Offer appropriate analgesia such as a breakthrough dose of short-acting opioid at least 30 minutes before a dressing change where possible. Prescribe the lowest effective dose and increase the dose slowly and, if needed, to provide symptom relief. See the CKS topic on Palliative cancer care - pain for more information.
  • Consider seeking specialist advice or arranging referral to the palliative care team or specialist pain team, if symptoms do not respond to primary care management.

Basis for recommendation

These recommendations are based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], an epidemiological study of malignant skin ulcers [Firmino, 2020], expert opinion in palliative care textbooks  [Regnard, 2010; Grocott, 2015; Twycross, 2021], and expert opinion in review articles on malignant skin ulcers [Young, 2017; Fang, 2024].

Prescribing appropriate analgesia if needed
  • This recommendation is extrapolated from the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a review article [Young, 2017]. 
Identifying and managing the underlying cause
  • This recommendation is based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in palliative care textbooks [Regnard, 2010; Twycross, 2021].
    • Pain management is a key treatment priority for many people with a malignant skin ulcer [Ousey, 2024].
    • An epidemiological cross-sectional descriptive study in an oncology hospital setting found that malignant skin ulcers were characterized as painful in 83.3% of the study population, with significant pain present during dressing changes in 93% of the sample [Firmino, 2020].
Managing pain during dressing changes
  • The recommendation about ensuring an appropriate healthcare professional provides wound management is based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in palliative care textbooks [Regnard, 2010; Twycross, 2021].
  • The recommendation about using distraction techniques is based on the EWMA joint publication, which states that using technology including virtual reality may help to 'distract patients from the physical sensations of wound care procedures, effectively reducing pain perception, anxiety, and stress' [Gethin, 2025].
  • The UK consensus document recommends prescribing analgesia prior to dressing changes if needed and appropriate [Ousey, 2024]. Similarly, the EWMA joint publication recommends considering use of analgesia before wound-related procedures if needed, allowing time for its administration and effect [Gethin, 2025]. This approach is also supported by expert opinion in palliative care textbooks [Grocott, 2015; Twycross, 2021].
Seeking specialist advice or referral
  • This recommendation is extrapolated from the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], expert opinion in a palliative care textbook [Twycross, 2021], and expert opinion in a review article [Fang, 2024].
    • The EWMA joint publication notes that various topical agents such as Emla cream, topical local anaesthetics, or topical opioids may be considered for refractory wound pain. It highlights that topical agents may be preferred as they are easy to apply and may have fewer systemic adverse effects and drug interactions compared with systemic treatments.
    • The UK consensus document also notes that there may be a role for palliative radiotherapy for refractory wound pain in some cases [Ousey, 2024]. 
    • Expert opinion in a palliative care textbook notes that topical morphine may be helpful but is not always feasible due to the extent of wound ulceration in some cases [Twycross, 2021].

How should I manage an infected malignant skin ulcer?

If a person presents with an infected malignant skin ulcer in the palliative care setting:

  • Seek advice from a healthcare professional with expertise in wound management, to ensure the area is cleansed to clear visible debris, excess slough, exudate, and topical product residue, and to assess whether ulcer debridement is needed.
    • Ensure an appropriate dressing is used with an optimum frequency of dressing change.
    • Autolytic debridement may be promoted by the use of specialist dressings. Specialist referral for surgical debridement may be needed.
  • If there is suspected superficial infection, consider the use of topical metronidazole gel 0.75% applied for 5–7 days.
  • If there is suspected systemic infection:
    • Arrange for a wound swab to be taken for culture and sensitivity. See the section on Assessment for more information. Use clinical judgement when interpreting a swab result, as the presence of bacteria may represent colonization and does not always indicate that a wound is infected.
    • Consider prescribing an oral antibiotic such as metronidazole 400 mg three times a day for 7–14 days, depending on clinical judgement. See the section on Metronidazole in Prescribing information for more information.
    • Review the choice of antibiotic and consider switching once the swab result and antibiotic sensitivities are available, if there is evidence of cellulitis, there is no response to oral metronidazole, or if the person is systemically unwell. See the CKS topic on Cellulitis - acute for more information on antibiotic choices.
  • If an antibiotic is indicated for malodour, see the section on Managing malodour for more information.

Basis for recommendation

These recommendations are largely based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], expert opinion in palliative care textbooks [Grocott, 2015; Twycross, 2021], and expert opinion in a review article on malignant skin ulcers [Fang, 2024]. 

Ensuring appropriate wound management
  • These recommendations are based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a palliative care textbook [Twycross, 2021].
    • The EWMA joint publication notes that 'proper skin cleansing is essential for maintaining skin integrity and preventing irritation or infection' [Gethin, 2025].
Managing suspected superficial infection
  • This recommendation is extrapolated from the UK consensus document [Ousey, 2024] and expert opinion in a palliative care textbook [Twycross, 2021].
    • The UK consensus document recommends use of topical or oral metronidazole for management of malodourous or infected malignant skin ulcers. It states that topical metronidazole can be considered when oral treatment is impractical or causes unacceptable adverse effects, the malignant skin ulcer is relatively small and easily accessible for topical application, and/or the lesion is poorly vascularised and very sloughy.
    • This approach is supported by expert opinion in a palliative care textbook, which recommends use of topical metronidazole gel if there is evidence of superficial infection [Twycross, 2021].
Managing suspected systemic infection
  • The recommendation to take a wound swab for culture and sensitivity is based on the UK consensus document [Ousey, 2024].
  • The recommendation to prescribe an oral antibiotic such as metronidazole is based on expert opinion in a palliative care textbook [Twycross, 2021]. It is also pragmatic, based on what CKS considers to be good clinical practice.
  • The recommendation to review antibiotic choice and consider switching is extrapolated from the UK consensus document [Ousey, 2024], together with expert opinion in palliative care textbooks [Grocott, 2015; Twycross, 2021] and in a review article [Fang, 2024]. 

How should I manage a bleeding malignant skin ulcer?

If a person presents with a bleeding malignant skin ulcer in the palliative care setting:

  • Ensure a healthcare professional with expertise in wound management is involved in the person's care, such as a district nurse, palliative care nurse, or tissue viability nurse.
  • Minimize or reduce the risk of bleeding wherever possible.  
    • Ensure an appropriate dressing choice is used.
    • Review and consider stopping any potentially contributing drugs, such as antiplatelets or anticoagulants, depending on the person's comorbidities, stage of illness, and estimated prognosis.
  • If there is acute bleeding from a definite point in the ulcer, manage depending on the severity of bleeding.
    • For mild bleeding, apply direct pressure to the bleeding point for 10–15 minutes with a moist, non-adherent dressing, taking care to avoid causing unnecessary pain.
    • For heavy bleeding, apply direct pressure to the wound and seek urgent medical advice from the person's oncologist or palliative care team if bleeding does not stop after 30 minutes, depending on clinical judgement.
      • Consider arranging emergency hospital admission, depending on the stage of disease, estimated prognosis, and the person's wishes and advanced care plan. See the CKS topic on Palliative care - general issues for more information.
      • Specialist dressings using topical tranexamic acid, topical sulcrafate paste, topical adrenaline, or silver nitrate sticks and/or oral tranexamic acid may be used in the community on the advice of a specialist.
  • If there is severe bleeding in the terminal phase of illness:
    • Use dark-coloured towels to apply pressure to the bleeding point and to absorb blood, to mask blood loss and minimize distress to the person and carers/family members.
    • Put the person in the recovery position if clinically appropriate.
    • Consider prescribing and administering anticipatory medication for sedation to provide symptom relief. See the CKS topics on Palliative care - breathlessness for more information on prescribing benzodiazepines in the terminal phase of illness.

Basis for recommendation

These recommendations are based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], and expert opinion in palliative care textbooks [Regnard, 2010; Grocott, 2015; Twycross, 2021].

Ensuring appropriate wound management
  • These recommendations are based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a palliative care textbook [Twycross, 2021].
Minimizing bleeding risk
  • The recommendation to ensure appropriate dressing use is based on the UK consensus document [Ousey, 2024].
  • The recommendation to review and stop any potentially contributing drugs is based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a palliative care textbook [Twycross, 2021].
Managing acute ulcer bleeding
  • The recommendations about mild bleeding are extrapolated from the UK consensus document [Ousey, 2024] and the EWMA joint publication [Gethin, 2025]. Expert opinion in a palliative care textbook notes that applying firm pressure to a bleeding malignant skin ulcer may exacerbate bleeding if the tumour is friable [Twycross, 2021].
  • The recommendations about heavy bleeding are extrapolated from the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in palliative care textbooks [Regnard, 2010; Grocott, 2015].
    • The EWMA joint publication recommends 'seek emergency care if wound fails to stop bleeding after 30 minutes of direct pressure'. Expert opinion in palliative care textbooks notes that palliative radiotherapy or interventional radiology embolization of the ulcer may control spontaneous bleeding from eroding blood vessels in some cases [Regnard, 2010; Grocott, 2015].
    • CKS notes that expert opinion in a palliative care textbook recommends considering hospital admission for minor bleeds if the person and carers/family members find these frightening and wish for treatment [Regnard, 2010].
    • The information about the possible use of topical treatments or oral tranexamic acid following specialist advice is extrapolated from the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a palliative care textbook [Regnard, 2010].
Managing severe bleeding in the terminal phase of illness
  • The recommendation about the use of dark-coloured towels is based on the UK consensus document [Ousey, 2024] and expert opinion in a palliative care textbook [Regnard, 2010].
  • The recommendation to put the person in the recovery position if appropriate is based on the UK consensus document [Ousey, 2024].
  • The recommendation about the use of anticipatory medication for sedation is based on the UK consensus document [Ousey, 2024] and expert opinion in a palliative care textbook [Regnard, 2010]. 

How should I manage an exudative malignant skin ulcer?

If a person presents with an exudative malignant skin ulcer in the palliative care setting:

  • Assess the volume and appearance of the exudate, which may indicate the presence of infection.
  • Seek advice from a healthcare professional with expertise in wound management, to ensure the area is cleansed to clear visible debris, excess slough, and exudate, and to assess whether ulcer debridement is needed.
    • Ensure an appropriate dressing is used with an optimum frequency of dressing change. 
    • Dressings suitable for moderate-to-high exudate include alginate and hydrofibre dressings and foams. A secondary absorbent or super-absorbent dressing may also be needed, depending on the volume of exudate.
    • Autolytic debridement may be promoted by the use of specialist dressings. Specialist referral for surgical debridement may be needed.
  • Protect the peri-wound skin to reduce the risk of maceration and wound edge breakdown.
    • Advise on the regular use of a barrier film or cream to protect the surrounding skin. Alternative ways of securing dressings (such as netting or briefs) may be needed if the surrounding skin is damaged.
  • If there is persistent or refractory excess exudate:
    • Seek specialist advice, for example from the person's oncologist, palliative care team, or tissue viability team, as specialist treatments may be needed.
    • Consider arranging referral to a dietitian for nutritional support, as significant amounts of protein can be lost from a discharging wound. See the CKS topic on Adult malnutrition for more information.

Basis for recommendation

These recommendations are largely based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], and expert opinion in a palliative care textbook [Regnard, 2010].

Assessing for possible wound infection
  • This recommendation is based on the UK consensus document [Ousey, 2024].
Ensuring appropriate wound management
  • These recommendations are based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], and expert opinion in a palliative care textbook [Twycross, 2021].
    • The information about suitable dressings is based on the UK consensus document [Ousey, 2024].
Protecting the peri-wound skin
  • The EWMA joint publication states that 'management of the peri-wound area and nutrition is of critical importance as is the prevention of progression or deterioration, including infection prevention'. It notes the value of skin barrier products for peri-wound management and excess exudate. These products may also protect against skin stripping or skin tears due to removal of medical adhesives [Gethin, 2025]. This approach is supported by the UK consensus document [Ousey, 2024], and expert opinion in a palliative care textbook [Regnard, 2010]. The information about alternative ways to secure dressings is pragmatic, based on what CKS considers to be good clinical practice. 
Management of persistent or refractory excess exudate
  • The recommendation about seeking specialist advice is based on the UK consensus document [Ousey, 2024] and the EWMA joint publication [Gethin, 2025], which note that additional management strategies may be available, such as palliative radiotherapy to dry the wound, or use of a stoma appliance or collection pouch with drainage port, if conventional dressings cannot contain the level of exudate. This approach is supported by expert opinion in a palliative care textbook [Regnard, 2010].
  • The recommendation to consider arranging dietitian referral is based on the UK consensus document, which states that nutritional status can impact on wound healing [Ousey, 2024]. This approach is supported by the EWMA joint publication, which notes that malnutrition and sarcopenia (progressive loss of muscle mass) in the palliative care setting can affect wound healing and increase the risk of wound complications [Gethin, 2025].

How should I manage a malodorous malignant skin ulcer?

If a person has a malodorous malignant skin ulcer in the palliative care setting:

  • Manage any underlying cause of malodour, such as excess exudate and/or wound infection.
    • Ensure gentle wound irrigation and use of an appropriate dressing with an optimum frequency of dressing changes to remove soiled dressings and prevent leakage of exudate and malodour.
  • Advise about environmental strategies which may reduce malodour, such as:
    • Opening windows and ensuring adequate room ventilation.
    • Using room scents (for example room vaporizers, air fresheners, odour-neutralising sprays, vanilla or coffee scents; or shaving foam left in a bowl and replaced when needed). Be aware that strong scents may induce nausea.
    • Using external odour absorbers (for example, a tray of cat litter or activated charcoal can be placed under or near the bed).
    • Changing and cleaning of bed linen or curtains where odour can linger.
  • Prescribe topical or oral metronidazole if an appropriate dressing does not control the malodour.
    • Prescribe topical metronidazole 0.75% gel if there is low-level exudate.
      • Advise that it should be applied liberally to the skin ulcer once or twice a day for 7 days, and continued for a further 7 days if there is a partial response. Advise that it should not be used on wounds with significant exudate, as it may be 'washed off' the wound surface.
      • Do not recommend use of crushed metronidazole tablets as these may irritate the wound and increase pain.
      • See the section on Metronidazole in the section on Prescribing information for more information on the use of topical metronidazole.
    • Prescribe oral metronidazole if there is deep tissue infection causing malodour.
      • Prescribe 400 mg three times a day for 5 days. If there is a partial response, consider continuing treatment for a further 5 days.
      • See the section on Metronidazole in the section on Prescribing information for more information on the use of oral metronidazole.
    • If malodour recurs after a course of metronidazole, consider repeating another 10-day course of topical or oral treatment, depending on clinical judgement.
  • Consider seeking specialist advice from the oncology or palliative care team if the malodour persists or is not adequately controlled following primary care management.

Basis for recommendation

These recommendations are based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], expert opinion in palliative care textbooks [Regnard, 2010; Twycross, 2021], and expert opinion in a review article on malignant skin ulcers and end of life wounds [Young, 2017].

Managing underlying causes of malodour
  • These recommendations are based on the UK consensus document [Ousey, 2024] and the EWMA joint publication [Gethin, 2025].
Advising about environmental strategies
  • These recommendations are largely based on the UK consensus document [Ousey, 2024] and the EWMA joint publication [Gethin, 2025]. In addition, expert opinion in a palliative care textbook notes that attempts to mask malodour with room scents or essential oils may not be successful, as the person may associate the new odour with the unpleasant one [Regnard, 2010].
Prescribing topical or oral metronidazole
  • These recommendations are largely based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], expert opinion in palliative care textbooks [Regnard, 2010; Twycross, 2021], and expert opinion in a review article [Young, 2017].
    • The UK consensus document recommends use of topical or oral metronidazole for management of malodourous or infected malignant skin ulcers. It states that topical metronidazole can be considered when oral treatment is impractical or causes unacceptable adverse effects, the malignant skin ulcer is relatively small and easily accessible for topical application, and/or the lesion is poorly vascularised and very sloughy. Expert opinion in a palliative care textbook notes that topical metronidazole may make a wound excessively wet, and may be ineffective for large surface area wounds [Regnard, 2010].
    • The EWMA joint publication also recommends use of metronidazole for control of malodour, but notes this is based on very limited low-quality evidence in the literature. It states that 'systemic antibiotics are used to reduce bacterial colonisation and thereby to control the offensive odour from volatile metabolic end-products'.
    • The prescribing instructions for topical metronidazole are based on the expert opinion of previous external reviewers of this CKS topic. They are also pragmatic, based on what CKS considers to be good clinical practice. The recommendation not to use crushed metronidazole tablets on the wound is based on the EWMA joint publication [Gethin, 2025].
    • The prescribing instructions for oral metronidazole are extrapolated from expert opinion in palliative care textbooks [Regnard, 2010; Twycross, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.
    • The recommendation to consider giving a repeat course of topical or oral metronidazole is extrapolated from expert opinion in a palliative care textbook, which notes that maintenance treatment with oral metronidazole can be considered for refractory malodour, but it does not specify a duration of treatment [Regnard, 2010]. CKS recommends that if longterm antibiotic treatment is being considered, specialist advice may be helpful prior to starting this, to reduce the risk of antibiotic resistance.
Seeking specialist advice
  • This recommendation is pragmatic, based on what CKS considers to be good clinical practice.

How should I manage itch in a malignant skin ulcer?

If a person has itch in a malignant skin ulcer in the palliative care setting:

  • Advise to keep the nails short to avoid any additional abrasions and advise on gentle rubbing if needed.
  • Advise to avoid overheating and sweating where possible, for example in bed at night, and advise on the use of bed linen and clothing that wicks away heat and moisture.
  • Ensure the area is cleansed to clear visible debris, excess slough, exudate, and topical product residue which may irritate the peri-wound skin.
  • Treat any underlying cause of itch if possible, for example by managing exudate, avoiding soap, and using regular emollients for dry skin.
  • If there is suspected contact dermatitis:
  • Consider use of nonsteroidal anti-inflammatory drugs (NSAIDs) or antihistamines (which may have a helpful sedative effect), depending on clinical judgement. See the CKS topics on Itch - widespread and NSAIDs - prescribing issues for more information.
  • If there is refractory bothersome itch, consider seeking specialist palliative care or dermatology advice, as it may be difficult to treat.

Basis for recommendation

These recommendations are based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], expert opinion in palliative care textbooks [Regnard, 2010; Grocott, 2015; Twycross, 2021], and expert opinion in a review article on malignant skin ulcers [Young, 2017].

Keeping nails short
  • This recommendation is based on the EWMA joint publication [Gethin, 2025] and expert opinion in a palliative care textbook [Twycross, 2021].
Avoiding overheating and sweating
Ensuring appropriate wound management
  • This recommendation is based on the EWMA joint publication [Gethin, 2025].
Treating any underlying cause
Managing suspected contact dermatitis
Considering use of NSAIDs or antihistamines
  • Expert opinion in a palliative care textbook notes that itch associated with malignant skin ulcers may be caused by inflammatory substances such as prostaglandins, which may respond to use of nonsteroidal anti-inflammatory drugs (NSAIDs) [Twycross, 2021].
  • The EWMA joint publication notes that use of antihistamines relies mainly on their sedative rather than direct anti-itch effect, but they may be helpful for some people [Gethin, 2025].
Seeking specialist advice
  • This recommendation is based on the UK consensus document [Ousey, 2024], the EWMA joint publication [Gethin, 2025], expert opinion in palliative care textbooks [Regnard, 2010; Grocott, 2015], and expert opinion in a review article [Young, 2017].
    • The EWMA joint publication notes that there may be a role for drugs such as gabapentinoids or antidepressants for severe refractory itch. Expert opinion in a review article also notes that transcutaneous electrical nerve stimulation (TENS) on intact skin may play role in symptom relief [Young, 2017].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Metronidazole

Contraindications and cautions

  • Do not prescribe metronidazole to a person with:
    • Known metronidazole or nitroimidazole hypersensitivity.
    • Cockayne syndrome — potential for severe hepatotoxicity. Liver function tests (LFTs) must be performed before, during, and after treatment until liver function is within normal ranges or baseline values are achieved. Metronidazole should be discontinued if LFTs are markedly elevated during treatment. Patients should be advised to stop treatment and seek immediate medical attention if symptoms of liver injury occur.
  • Prescribe oral metronidazole with caution to a person:
    • Who is elderly (especially high dose).
    • With active or chronic severe central or peripheral nervous system disease — risk of neurological aggravation.
    • With severe liver disease and hepatic encephalopathy, due to risk of decreased metronidazole clearance. Reduce to one-third of daily dose (may be given once daily).
    • If treatment is planned for more than 10 days — regular clinical monitoring for peripheral or central neuropathy, and laboratory monitoring (particularly leucocyte count).
  • Prescribe topical metronidazole with caution:
    • Near the eyes as it can cause lacrimation. Contact with the eyes should be avoided.
    • In areas exposed to direct sunlight as it is inactivated by ultraviolet light exposure. Treatment sites should not be exposed to strong sunlight or ultraviolet light.

[EMC, 2025; BNF, 2026]

Adverse effects

Possible adverse effects associated with metronidazole include:

  • Oral
    • Agranulocytosis; ataxia; cerebellar syndrome; confusion; dizziness; drowsiness; encephalopathy; flushing; hallucination; headache; hepatic disorders; myalgia; neutropenia; pancreatitis; pancytopenia; psychotic disorder; seizure; severe cutaneous adverse reactions (SCARs); skin reactions; thrombocytopenia; urine dark; vision disorders (rare or very rare).
    • Angioedema; appetite decreased; depressed mood; diarrhoea; epigastric pain; epileptiform seizure (with long term or intensive therapy); gastrointestinal disorder; hearing impairment; leucopenia (with long term or intensive therapy); meningitis aseptic; nausea; nerve disorders; oral disorders; peripheral neuropathy (with long term or intensive therapy); taste altered; tinnitus; vertigo; vomiting (frequency not known).
  • Topical
    • Topical metronidazole may sting on application and cause skin reactions.
    • Lacrimation has been reported if topical metronidazole is applied too close to the eyes.

[EMC, 2025; BNF, 2026]

Drug interactions

Potential drug interactions associated with oral metronidazole include:

  • Alcohol — some people taking oral metronidazole experience a disulfiram-like reaction (flushing, increased respiratory rate, increased pulse rate, nausea, headache, and dizziness) with alcohol. Warn the person that they might experience this reaction, and avoid alcohol for at least 48 hours after stopping treatment.
  • Amiodarone — both metronidazole and amiodarone can increase the risk of peripheral neuropathy.
  • Anticoagulants — the anticoagulant effects of warfarin can be markedly increased by metronidazole. Monitor the international normalized ratio (INR) and adjust the warfarin dose accordingly. Warn the person of the possible risk of increased bruising and bleeding and advise when to seek medical help.
  • Ciclosporin — metronidazole has been reported to increase the concentration of ciclosporin. Manufacturer advises monitor.
  • Leflunamide — both metronidazole and leflunomide can increase the risk of peripheral neuropathy.
  • Lithium — metronidazole is predicted to increase the concentration of lithium. Manufacturer advises avoid or adjust dose.
  • Nitrofurantoin — both metronidazole and nitrofurantoin can increase the risk of peripheral neuropathy.
  • Phenobarbital — phenobarbital is predicted to decrease the exposure to metronidazole. Manufacturer makes no recommendation.
  • Phenytoin — both metronidazole and phenytoin can increase the risk of peripheral neuropathy.
  • Tacrolimus — metronidazole has been reported to increase the concentration of tacrolimus. Manufacturer advises monitor.

[EMC, 2025; BNF, 2026; Preston, 2026]

Pregnancy or breastfeeding

  • Pregnancy — manufacturer advises avoidance of high-dose oral metronidazole regimens; use only if potential benefit outweighs risk.
  • Breastfeeding — significant amount in milk; manufacturer advises avoid large single doses of oral metronidazole though otherwise compatible; may give milk a bitter taste.

[EMC, 2025; BNF, 2026]

Supporting evidence

This CKS topic is largely based on the UK consensus document Malignant wounds: management in practice [Ousey, 2024], the European Wound Management Association (EWMA) joint publication Palliative wound care. Recommendations for the management of wound-related symptoms [Gethin, 2025], and expert opinion in palliative care textbooks and review articles. The rationale for individual recommendations is discussed in the relevant basis for recommendation sections.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of malignant ulcer, with additional searches on the following:

  • metronidazole
  • dressings (including activated charcoal, alginate, foam, hydrogel and hydrocolloid)
  • silver sulfadiazine
  • topical opioids (morphine)
  • topical anaesthetics (lidocaine)
  • transcutaneous electrical nerve stimulation for itch
  • paroxetine for itch

Search dates

March 2021 - October 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • fungating.tw, ulcerated.tw, ulcerating.tw, smelly.tw, malodorous.tw, malignant ulcer.tw, skin ulcer/, wound healing/, wounds and injuries/, wound$.tw, exudates and transudates/, odors/, pruritus/, itch$.tw, pruritus.tw
  • palliative care/, exp terminal care/, terminally ill/, palliative.tw, terminal$.tw., cancer.tw., neoplasm$.tw, tumor$.tw tumour$.tw,
  • metronidazole/, metronidazole.tw
  • bandages, hydrocolloid/, biological dressings/, dressing$.tw, gauze.tw, hydrocolloid$.tw, alginat$.tw, hydrogel.tw, charcoal.tw, foam$.tw
  • sulfadiazine silver/, silver sulfadiazine.tw.
  • exp analgesics, opioid/, opioid$.tw, morphine.tw
  • exp anesthetics, local/, lidocaine.tw
  • transcutaneous electric nerve stimulation/, tens.tw, transcutaneous electrical nerve stimulation.tw
  • paroxetine/, paroxetine.tw

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • BNF (2026) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk [Free Full-text]
  • EMC (2025) SPC for Metronidazole 400 mg Film-Coated Tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk [Free Full-text]
  • Fang, L., Simman, R., Workman, L., Ayoub, S. et al. (2024) Malignant wound aetiology, diagnosis and management: a case series and literature review. Journal of Wound Care 33(2), 102-117. [Abstract]
  • Firmino, F., da Costa Ferreira, S., Franck, E.M., de Queiroz, W.M.S. et al. (2020) Malignant wounds in hospitalized oncology patients: prevalence, characteristics, and associated factors. Plastic Surgical Nursing 40(3), 138-144. [Abstract]
  • Gethin, G., Kottner, J., Lamza, A., Meaume, S. et al. (2025) Palliative wound care. Recommendations for the management of wound-related symptoms. European Wound Management Association. https://ewma.org [Free Full-text]
  • Grocott, P., Gethin, G. and Probst, S. (2015) Skin problems in palliative care. In: Cherny, N., Fallon, M., Kaasa, S., Portenoy, R. et al. (Eds.) Oxford Textbook of Palliative Medicin. 5th edn. Oxford: Oxford University Press, 715-723.
  • NICE (2020) Decision making and mental capacity Quality Standard. National Institute of Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • NICE (2021) Quality standard: End of life care for adults. National Institute for Health and Care Excellence. https://www.nice.org.uk [Free Full-text]
  • Ousey, K., Pramod, S., Clark, T., Dhoonmoon, L. et al. (2024) Malignant wounds: Management in practice. Wounds UK. https://wounds-uk.com [Free Full-text]
  • Preston, C.L. (2026) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical press. https://www.medicinescomplete.com
  • Regnard, C. and Dean, M. (2010) A guide to symptom relief in palliative care. 6th edn. Oxford: Radcliffe Publishing.
  • Starace, M., Carpanese, M.A., Pampaloni, M., Dika, E. et al. (2022) Management of malignant cutaneous wounds in oncologic patients. Supportive Care in Cancer 30(9), 7615-7623. [Abstract]
  • Twycross, R., Wilcock, A. and Toller, C.S. (Eds.) (2021) Introducing palliative care. London: Pharmaceutical Press.
  • Young, T. (2017) Caring for patients with malignant and end-of-life wounds. Wounds UK 13(5), 20-29. [Abstract]
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