Can anyone help with this skin ulcer? ***Warning*** Gross photo attached

[Fedupandpoor]

Dad has terminal cancer and is receiving care at home. He has a skin ulcer on his ankle that flares up now and again but this time it appears to be growing and causing him a lot of pain.

He had a swab which showed a mild bacterial infection and has had antibiotics for that. The district nurse did put some sort of mesh over it but it reacted badly and got worse.

For full disclosure, my Dad has always been cantankerous old git and is now blaming the poor nurses for being unable to treat it. I really want to help him but I don't know what treatment to suggest. The nurses come and dress it twice per day. I looked into a private dermatologist but the initial consultation is £250 so well out of my reach. Anyone ever dealt with this before?

Sorry I've no idea, but your poor dad. That looks so painful.

Has his oncologist seen it?

GP and specialist need to see this - its not acceptable to just be dressing and saying mild infection etc - things like that don't happen for no reason

Skin cancer?

Your next port of call is a GP, for the pain management. Sorry you are going through this.

Ask the district nurses to seek advice from their would care service (sometimes called tissue viability). If your dad is housebound the DNs can probably share pictures of the wound with them via their electronic records system, or the wound care team may do a home visit.
Ask if they have assessed to see if it is an arterial or a venous ulcer, or mixed. The treatment will vary depending on this. Venous ulcers generally hee conpression bandaging to heal, but some patients find this hard to tolerate/uncomfortable.

Whilst that looks nasty, it does appear to be healing and drying up? Is there a reason it isn't dressed? I would enquire about dressing and application of Manuka honey - it really isn't woo, it works and is used in veterinary medicine all the time.

Wound healing is likely to be slowed due to the chemo.

I'm so sorry you are having to deal with this

The black stuff is necrotic (dead) tissue and the yellow/green slough is just debris in the wound. They need removing. They could do this various ways but easiest/way that needs least specialist skills is do add moisture to the wound through various dressings. Can't fully assess the wound until theres a clean wound bed and can reassess, it's not obvious how deep it goes. The red skin surrounding it might indicate infection, if accompanied by other signs such as heat, malodour, increased pain etc. If he starts feeling unwell (cold/flu like symptoms) he needs to seek medical attention and maybe change antibiotics. If he's feeling well in himself they could treat it topically with antimicrobial rather than antibiotics however as he's already been prescribed them he should finish the course. Has he been referred to a tissue viability nurse or a leg ulcer clinic or something? If not can u ask for a referral? Has he had a doppler on his ankles to check blood flow?
Poor thing looks sore, hope u get answers soon!

Also, it is worth bearing in mind that other issues like immobility and poor nutrition can make it harder to heal complex wounds like this. So worth thinking about whether your dad is getting enough calories and enough protein in his diet. GP could potentially support with prescribing some nutritional supplements if he is losing weight/not eating well. Ask the DNs if they have done a MUST score (malnutrition risk score) and referred to the GP if his score is 2 or above. Also the GP needs to prescribe andequate analgesia for the wound pain. If he is diabetic that will also complicate healing and his diabetes needs to be optimally controlled too (if relevant) .

The skin around the wound is red which can suggest infection but if he doesn't have a fever or any other signs of systemic illness it could also be chronic skin changes which are also associated with leg ulcers, so needs to be assessed in context really.

You still need to get to the root cause of the ulcer though or it won't heal. In my experience GPs tend to refer back to nursing services for most wound management issues, unless there are vascular issues (i.e. problems getting blood supply through the blood vessels to the leg/foot) in which case they refer on to vascular surgery in secondary care. Which is why I suggested the wound care service rather than going back to GP. Good luck

(Disclosure: I'm a community nurse but not a district nurse, and wounds are not my speciality. But this is what I'd expect to happen if I saw a patient with a wound like this in the first instance)

The GP needs to see that again.

Have the tissue viability nurses been involved? They should be. They are best placed to assess what type of ulcer and best treatment/dressing.

Thank you so much for all the replies.

He has a vitamin D deficiency and has been told he is anemic. He uses a wheelchair to move around the house as he cannot walk.

He did have those manuka honey dressings when the first ulcer came last year but now he reacts to them. He is very sensitive to everything now since the chemo and reacts to most creams, antibiotics, dressings, etc.

I am noting down all the suggestions and will speak with the district nurse tomorrow.

If he has an abdominal cancer or terminal cancer, the growths slowly put more and more pressure on the abdominal blood vessels, and this decreases blood supply to the lower extremities. Leg ulcers thrive in poorly oxygenated tissue, and to be honest, are probably not going to improve if the above is the case.

Ask for a referral to the Tissue Viability Nurse at the Trust.

Manuka works in the early stages but after while it burns. I would imagine it needs cleaning to get it to slough all the dead tissue and an iodine putty inserting and then a dressing.

Sometimes these have a mild fungal element to them that stops the healing so it might be worth lavaging it with a mild fungicidal but District Nurses are trained in wound management so he needs to be got into that loop ASAP. They are absolute agony though. My DDad (RIP) was as hard as nails but he got to the point that he would feel nauseous if he just saw something the same colour as the iodine putty they used on him. It healed eventually though.

Agree with much that has been said. Much of that tissue is dead and sloughy and needs debriding. It won't heal until that can be removed and it's imposible to know the depth and extent of the wound until it's gone. It could actually be much bigger. Some dressings will liquify the hard black tissue and remove the yellowy sloughy stuff - the tissue viability nurses would be able to advise if the district nurses can't. Also it depends what's caused it in the first place - a simple skin tear or a venous leg ulcer - the latter in particular need specific treatment. Also anaemia, dehdration, poor dietary intake, diabetes and things like heart failure can massively impact on wound healing.

Impossible to confirm without assessing the wound but just from photo and the pain I would guess that the wound is arterial. That means that there is a problem with his arteries that there is not enough blood able to get to the wound to heal it. So it doesn't matter what dressing is put on really as it needs to be getting that oxygenated blood flow from the heart to heal. I would try and have a discussion with the district nurse, they are usually excellent and would tell you what assessments have been done to check if it is an arterial wound. They will also be able to tell you whether any treatments are available and if not what they can do to manage the pain that he is experiencing.

Beseen19 is right. A lot of these don't heal until a blood vessel is diverted to the area. They often heal like magic then.