Checked: 05-04-2018 by
vicky.ryan Next Review: 06-09-2019
EOL Skin problems NS MOM
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
Steroids’ wide range of actions means they have multiple uses in the palliation of patients with advanced illnesses, but also multiple potential adverse effects. As with any treatment, careful consideration must be given to the individual benefit versus burden of steroids in each patient.
In some instances, such as malignant spinal cord compression, superior vena cava obstruction (SVCO) and raised intracranial pressure, there is a reasonable body of evidence to support their use and to guide optimal dosing regimens etc. However, for most other indications, such as the palliation of fatigue, poor appetite and pain, the evidence is less clear. Consequently, prescribing practices may vary considerably between centres / settings.
Dexamethasone is frequently the steroid ‘of choice’ in palliative care since compared with prednisolone, it causes less fluid retention and the typical tablet burden for a given dose is less, despite carrying a potentially increased risk of proximal myopathy.
See the Bristol Palliative Care Collaborative Guidelines for the use of steroids in patients with cancer for specific information about corticosteroids, which is available from St Peters Hospice - :Steroid Guidelines
These can be divided into general causes of pruritus and those specifically related to malignancy, and in either case pruritus may be localised or generalised.
Generalised pruritus in the absence of a skin rash may be due to:
anaemia (iron deficiency)
myeloma, lymphoma and polycythaemia rubra vera
The commonest cause in advanced malignancy is probably cholestatic jaundice, although there is not a clear association between the level of bilirubin and severity of pruritus.
There is often dry, scaling skin, which will itself cause pruritus through the itch/scratch cycle. Topical treatment with aqueous cream or emulsifying ointment is an essential part of the treatment, and is sometimes sufficient on its own.
Paraneoplastic syndrome: breast, colon, lung, stomach carcinomas and others
This is experienced by 50-70% of those over the age of 70 years. The majority have xerosis and skin atrophy, in others the cause is unknown. It is best treated with general measures (see below) and the application of emollient cream.
The following drugs are common causes: opioids, aspirin, amphetamines, and drugs that can cause cholestasis such as erythromycin, hormonal treatment and phenothiazines.
Iron deficiency with or without anaemia can cause pruritus and responds to iron replacement.
Pruritus occurs in up to 11% of patients with thyrotoxicosis, particularly those with long-term untreated Graves disease, and less commonly in hypothyroidism. The link between diabetes mellitus and pruritus is controversial.
Avoid exacerbating factors such as heat, dehydration, anxiety and boredom
Patients should wear light clothes, use fans to maintain a passage of air, take tepid bath/showers and use emulsifying ointment or aqueous cream instead of soap
Skin hydration should be maintained with regular use of emollients- see BNSSG Formulary for emollients formulary range.
Avoid alcohol and spicy foods
Advise patients to gently rub the skin rather than scratch, to keep nails short and to wear cotton gloves at night to limit damage to skin
Sweating may exacerbate itch; the general measures described above may help; otherwise, an antimuscarinic agent may be required
Sedatives such as benzodiazepines do not directly relieve itch but may help improve associated anxiety and insomnia
Behavioural treatments and hypnotherapy may help ease associated psychological issues and break the cycle of itching and scratching
Transcutaneous electrical nerve stimulation (TENS) and acupuncture have been successful in case reports
Cancer per se is an infrequent but important cause of generalised pruritus. The mechanism is unknown. Pruritus is particularly associated with haematological malignancies such as Hodgkin’s lymphoma and polycythaemia rubra vera.
There are no medications specifically listed on the BNSSG Formulary for pruritis in palliative care, however the Palliative Care Guidelines suggest trialling Paroxetine to relieve itch. Second line agents in this setting include mirtazapine, ondansetron, gabapentin, buprenorphine patches
Opioid induced pruritus
Itch is a well recognised side effect of opioids (occurring in around 1% of patients after systemic administration of opioids) and may be more common with the naturally occurring opioids.
switch to an alternative opioid
Cholestasis may occur in the cancer population as a result of gallstones, drugs or intrahepatic disease, as well as obstruction from primary or secondary tumours involving the pancreas and biliary tree.
The BNSSG Formulary does not include specific guidelines regarding cholesasis treatment in palliative care, however the Palliative Care Guidelines includes more information but it is likely specialist advice is needed.
In palliative care, patients may have chronic kidney disease alone or in association with, for instance, cancer. Renal failure may develop due to ureteric obstruction caused by primary tumours, metastases or lymph nodes. It may sometimes not be possible, or clinically appropriate, to relieve the obstruction and the pruritus.
Specialist advice may be needed for further guidance.
Management of Pruritus
Removal of causative agents (e.g. drugs), as well as the appropriate investigation and treatment of underlying disease are essential first-line measures in the treatment of pruritus.
Local anaesthetic creams can be helpful but may cause skin sensitisation. Lidocaine is the least likely to have this effect but systemic absorption prevents its use over large areas or for prolonged periods.
H1 receptor antagonists are often used as the first choice for any form of generalised pruritus, however there is little evidence for their use other than in urticaria or allergy.
The more sedative agents such as chlorphenamine are believed to be more effective either because of a more potent central action or because the sedation itself helps to improve the insomnia caused by the itch.
Patients with cancer and other illnesses are subject to fever and sweating, which can cause considerable distress and result in drowsiness, fatigue and confusion. Drenching sweats at night can cause discomfort and sleep interruption for both patient and carers. Although the two symptoms are often related, sweating may occur without fever and vice versa.
Neoplastic fever is experienced by up to 60% of patients and is particularly common in patients with lymphoma, leukaemia, renal cancer and tumours with liver metastases. Episodic fever and sweating is also associated with hormone-secreting (breast and prostate) tumours and their treatments.
Causes of fever and sweating
Paraneoplastic phenomena - most likely with Hodgkins lymphoma, renal cell carcinoma, solid tumours, liver metastases
Medication (e.g. opioids, antidepressants)
Alcoholism (i.e. specifically alcohol withdrawl)
Hormonal (e.g hormonal cancer treatment, iatrogenic menopause)
Neuroleptic malignant syndrome
Neutropenic sepsis in a patient having active oncological treatment is a medical emergency .
It is worth considering the probable causes for fever and sweating so that the most effective symptom control can be started.
Infection: Look at common sites such as urine and chest, and treat with antibiotics if symptomatic
Paraneoplastic fever: treatment of neoplasm or consider paracetamol, NSAIDs, corticosteroids or thalidomide. Also consider antimuscarinic drugs, propranolol, cimetidine and olanzapine
Treatment related: opioids, ondansetron and some oncology treatments (i.e. cisplatin, bleomycin, interferon) may just require explanation and reassurance
Serotonin and neuroleptic malignant syndrome are rare but associated with many medications used in palliative care
Hot flushes: Experienced by two thirds of patients with breast and prostate cancer. Discussion with the patient’s oncologist may be required regarding hormonal therapy. Other options include SSRIs (citalopram, paroxetine), venlafaxine, gabapentin 300mg t.d.s., and clonidine 50µg b.d.
Antimuscarinics such as oxybutinin may help
Regular sponging and washing
Encouraging oral fluids/ice clips
Removing excess clothing
Use of a fan
Wearing cotton/ silk next to the skin
Towel on bed
Frequent cleaning of clothes/old clothes
Avoiding spicy foods and alcohol
Classes of drugs used to moderate sweating
β receptor antagonists
Treatment hormonally-induced hot flushes ± sweats (seeking specialist advice)
Sweating ± hot flushes - other causes
1.Take appropriate steps to diagnose and treat infection; consider empirical course of antibiotics if infection suspected.
2.Review dose of opioid and consider reducing if appropriate or try alternative opioid
3.Exclude thyroid or hypoglycaemic causes.
Wound care in cancer
Skin infiltration with subsequent ulceration or fungating wounds can be distressing. A small metastatic skin nodule is a visual reminder of disease progression and a fungating carcinoma with malodour, discharge and bleeding add to the misery of advanced and uncontrolled metastatic disease.
Loco-regional skin involvement (e.g. breast fungation) should be distinguished from generalised skin metastases which imply very late disease. Local extension of malignant tumour leads to embolisation of blood and lymphatic vessels compromising tissue viability. Infarction of the tumour leads to necrosis with subsequent infection, particularly anaerobic.
The ideal aim is complete healing through either local or systemic treatment, which may involve surgery, radiotherapy, hormonal manipulation or chemotherapy. If such treatment is inappropriate or unsuccessful (often the case), then care is directed to the minimisation of pain, infection, bleeding, odour and psychological trauma. Treatment should be realistic and acceptable to the patient and carers. The primary aim is the promotion of comfort (as opposed to healing) and the enhancement of quality of life which may hitherto have been severely impaired.
Following assessment of the problems, choose a dressing regimen to meet the needs of the patient. Be prepared to change if it does not work well for the patient. The aim is to contain problems and improve quality of life.
See 'Wound Care' page on BNSSG Formulary for North Somerset for information regarding Formeo- which is the way that GP Practices and nursing homes acquire dressings for their surgeries and for patients.
See 'Wound Care' page on BNSSG Formulary for North Somerset for information regarding Formeo- which is the way that GP Practices and nursing homes acquire dressings for their surgeries and for patients
PAIN:- Ensure that pain is caused neither by infection nor the dressing itself. Try to stick to simple regimens, limiting the frequency of dressing changes. Non-stick and sealed dressings may be useful.
Prior to applying the dressing, use short acting analgesia, e.g. liquid morphine or fast-acting fentanyl, or relaxation techniques after discussing the options with the patient.
EXUDATE:- Use dressings, e.g. hydrocolloid fibres such as Aquacel® with high absorbency, and further packing on top, in addition to plastic pads to protect clothing. Change the top layer as often as necessary, avoiding frequent changes of dressings placed directly over the wound. Alternatively use non-stick dressings. Protect the surrounding good skin with barrier cream or Cavilon® no-sting barrier film spray.
NECROTIC TISSUE:- Surgical debridement may be necessary to remove dead tissue, otherwise use desloughing agents.
BLEEDING:- Gauze soaked in adrenaline 1:1000 or sucralfate liquid or alternatively Sorbsan Plus® may be used over bleeding points. Gentle removal of dressing with normal saline spray (Irriclens®), Normasol® or irrigation using a syringe containing warm sodium chloride 0.9% prevent trauma at dressing changes. Sorbsan® dressings become liquefied and can be washed off with sodium chloride 0.9%. It is preferable to use dressings that can be left in place for a few days to prevent frequent dressing changes - these include the alginates Sorbsan and Sorbsan Plus®.
ODOUR:- Use systemic or topical metronidazole (or both). Charcoal dressings are useful (e.g. Clinisorb® and the wound should be sealed.
INFECTION:- Wounds on the skin can become colonised with bacteria. Colonisation refers to a wound containing multiplying bacteria that do not cause a host reaction or delay healing. A colonised wound therefore may not show signs of visible infection.
Colonisation may lead to critical colonisation which leads to delayed healing. At this point there may still not be any visible signs of clinical infection.
See 'Wound Care' page on BNSSG Formulary for North Somerset for information regarding Formeo- which is the way that GP Practices and nursing homes acquire dressings for their surgeries and for patients
Clinically infected wounds
For true infection to be diagnosed (i.e. the invasion of bacteria and their multiplication in the tissues, clinical signs and symptoms must be observed:
Increased exudates/purulent discharge
Malodour (acrid smell may indicate anaerobic infection)
Systemic signs - pyrexia/rigor or tachycardia and increased neutrophil count
Swabs must be taken when a wound is showing two or more of these clinical signs of infection. Gently clean the wound with sterile water or saline to remove the slough before swabbing.The commonest organisms grown in fungating, cancerous wounds and in pressure sore areas include coliforms, anaerobes, staphylococcus aureus and group G beta-haemolytic streptococcus. Staphylococcus aureus is probably the commonest pathogen.
Antibiotics such as flucloxacillin or, failing this, trimethoprim or erythromycin should cover most common infections but metronidazole may be needed for anaerobic infections and topical metronidazole gel is particularly useful for eradicating the associated noxious smell. Methicillin-resistant Staphylococcus aureus (MRSA) is difficult to eradicate. It may not necessarily result in morbidity to the patient but there is clearly a transmission risk to other immunocompromised individuals. Present guidelines for inpatients suggest isolation of patients who are MRSA infected or colonised and the observance of strict ‘standard’ isolation precautions. Aquacel Ag® is useful for infective exudative wounds in patients with MRSA
Remember that agents such as cephalosporins, which cover a wider spectrum of bacterial infections, increase the risk of Clostridium difficile diarrhoea.
COMFORT:- By trial and error, a combination of dressings and top packing that will be most comfortable will need to be found for an individual patient.
COSMESIS:- The best cosmetic effect possible should be achieved, in order to boost confidence.
LIFESTYLE:- Patients may need different approaches for different occasions.
For social occasions;
Avoid bulky unsightly dressings.
Large sheet hydrocolloids may be more appropriate.
Avoid using communal showers or baths
Daily relaxing baths, perfumes and cosmetics should be encouraged to promote well-being and confidence. Use minimal skin strapping by fixing dressings with vests, cling film, Netelast or incontinence pads (which may be more comfortable).
PSYCHOLOGICAL EFFECTS:- Attention to detail and in particular ensuring leakproof/odourproof appliances and giving information and explanation will lessen the sense of isolation and enhance confidence and morale.
Remember the PRINCIPLES
Address the PROBLEMS
Consult a nurse with specialist experience of wound management.
Lymphoedema is defined as an excess accumulation of fluid in the body tissues caused by inadequate lymphatic drainage. It is a chronic condition usually affecting the limbs but it can affect the trunk, head or genital area.
Lymphoedema differs from other forms of chronic oedema in that the swelling is not due to fluid accumulation alone. In lymphoedema fibrosis leads to the skin becoming hard and thickened. Over time these progressive changes can result in the limb becoming grossly swollen with coarsening, folding and distortion of the skin and elephantiasis. A common complication of lymphoedema is an acute inflammatory episode (AIE) including infection of the skin (cellulitis). Angiosarcoma is a rare late complication of lymphoedema.
Although increase in size is the most obvious feature of lymphoedema, many patients experience pain and discomfort and lymphoedema has a significant impact on an individual’s quality of life with particular emphasis on the ability to function physically and socially. The ability to perform simple activities of daily living such as dressing may be impaired and many patients also suffer from associated psychological and emotional problems.
Lymphoedema is more common in women than in men and there is a clear increase in rate with age. Other risk factors are obesity and reduction of mobility / activity levels.
Primary lymphoedema is due to either congenital abnormality or absence of lymph tissue. It can present for the first time at birth, at puberty or over the age of 35. Secondary lymphoedema, seen commonly within the palliative care setting, generally develops as a result of damage or obstruction to the lymphatic system. The commonest cause is cancer or its treatments although it may also be caused by trauma or infection. It may also arise as a secondary consequence of chronic venous disease including previous deep venous thrombosis, post- cellulitis, trauma and other inflammatory conditions such as arthritis.
Lymphoedema is generally an under-diagnosed problem and the true prevalence figures are probably not known, however studies have estimated a prevalence of 1.33 per 1,000 population. Only 63% of these patients were actively receiving treatment for their lymphoedema.
Differential diagnosis for limb swelling:
Chronic venous insufficiency
Drug-induced e.g. steroids, calcium channel blockers
A holistic lymphoedema assessment should be performed and an individualised treatment plan formulated.
Management is based on the four corner stones of lymphoedema care: skin care, massage, compression and exercise
The aim of lymphoedema treatments is to encourage lymphatic drainage by physical therapies. The skin is kept soft and infection free, and limb shape and functional ability are restored and maintained as much as possible. The patient is supported in developing a self help programme to maintain benefits from treatment and to come to terms with and adapt to a disabling condition.
The evidence base for lymphoedema treatments is sparse due to the lack of well designed clinical trials.
The following elements of therapy are ideally combined in an intensive treatment phase on a daily basis for 2-4 weeks. This is closely followed by a maintenance phase, where exercise and skin care are combined with compression hosiery ± bandaging, with additional MLD as required.
Complex Decongestive Therapy (CDT)
This is the recognised treatment for lymphoedema and includes:
1.Skin care regime / daily cleansing and moisturising
2.Exercise programme and maintenance of mobility
3.Manual lymphatic drainage
4.Compression (bandaging and hosiery)
Lymphoedema therapies should be provided by practitioners who have had recognised training in lymphoedema. The cornerstones of lymphoedema treatment are:
Explanation and information about lymphoedema, its causes, consequences and treatments
Scrupulous skin care to prevent dryness, cracking and infection
Avoidance of trauma, including sunburn, venepuncture or vaccinations on the affected limb in order to minimise the risk of infection
A multidisciplinary approach sometimes involving clinical psychology, dietetics, physiotherapy and bariatric services to address obesity and mobility issues where relevant
Manual lymphatic drainage (MLD) is the use of specific massage techniques by a qualified therapist, which produce a mild mechanical stimulus to increase lymphatic flow. The aim is to move lymph from a congested area towards an area where the lymphatics are functioning normally. This is typically used in the intensive phase of treatment. Simple lymphatic drainage is a modified form of MLD, and can be performed by the patient or carer in the maintenance phase of treatment.
Multilayer lymphoedema bandaging (MLLB) is provided by bandaging the swollen limb with short stretch bandages. This results in a significant increase in lymph drainage when the limb is exercised. It is used daily in the intensive phase of treatment and helps to break down fibrosis and to re-shape the limb. It may also be taught to patients to use at night as part of their maintenance self management therapy.
These are used during the maintenance phase to prevent increasing swelling and may be either a sleeve, stocking or tights. They require specialist measurement and fitting and some patients require custom made compression garments. They should be replaced on a regular basis as they have a lifespan of about six months.
Patients should be instructed regarding the use of exercise, which can help with lymphatic flow. An exercise programme may be provided on an individual or group basis. It is important that the limb is exercised when bandaged or wearing compression garments.
Management at the End of Life
Lymphoedema may occur in the terminal stage of a cancer illness and treatments may need to be modified to meet the changing needs of the patient. Pain should be actively treated. Lymphorrhoea can be controlled by palliative MLLB. These oedemas are normally complex and could include lymphatic and venous obstruction, hypoproteinaemia, anaemia and decreased mobility as causes which may influence management choices. Rarely are they due to lymphoedema alone.
Compression pumps have been used in the treatment of lymphoedema but may cause problems with skin integrity and misdirect oedema into unwanted areas, for example leg & arm pumps may cause genital oedema and breathlessness respectively.
Contraindications to MLD and MLLB are acute cellulitis, active heart failure and acute deep venous thrombosis. When using multilayer bandaging or compression hosiery caution should be used in the presence of peripheral arterial disease, acute heart failure and severe peripheral neuropathy.
Cellulitis should be treated promptly with amoxicillin for at least two weeks, unless there is evidence of Staph aureus (e.g. if skin is broken) in which case add flucloxacillin or use this instead. NB. This is different to non-lymphoedema cellulitis http://www.lymphoedema.org/images/pdf/CellulitisConsensus.pdf .
Diuretics are not recommended unless short courses when there is mixed aetiology.
Cellulitis should be treated promptly with amoxicillin for at least two weeks, unless there is evidence of Staph aureus (e.g. if skin is broken) in which case add flucloxacillin or use this instead. NB. This is different to non-lymphoedema cellulitis.