It is important for a right management of the pain, to value the impact on the patient and on his family of the pathology and to address psychological issues and coping strategies.

The aim of this treatment is to manage with primary dressing symptoms such as odor, bleeding, and pain and with secondary dressings to contain exudate. It is important for the right management of the ulcer that these medications are accessible and easy to use with a few dressing changes and an appropriate social support to decrease stress and anxiety at home [44–46].

Cleansing may be proposed in cancer wounds, as in any wound type, using water or physiological saline solution. Showering under tap water is also encouraged for the comfort of the patient and to decontaminate the wound and the surrounding skin. Low-pressure hydrojets may provide a more efficient cleansing, without causing pain or discomfort [47, 48].

When exudates are moderate and the skin lesion is fresh (ulcerated nodules), the medication have the aim to prevent dressing adherence, bleeding, and crust formation or to hydrate skin which is fragile by the underlying tumor; nonadherent contact layers, amorphous hydrogels, sheet hydrogels, hydrocolloids, and semipermeable films may be useful [49]. When exudates are more excessive, we must absorb and contain exudates to prevent dressing adherence; this can be obtained using hydrofiber or alginate dressings, foams, starch copolymers, gauze, soft cotton pads, or multilayer dressings to increase the absorption capacity [49]. In the terminal phase, negative pressure therapy may be of interest, with a minimal pressure of 40–50 mmHg, in order to increase the drainage capacities and limit the number of dressing changes. Apart from this exceptional situation, negative-pressure therapy is contraindicated in tumor wounds as it has been reported to promote proliferation of tumor cells [50].

A slow capillary bleeding can be treated with alginates, silver nitrate, topical thrombin, gel foam, oxidized cellulose, collagen materials, tranexamic acid, sulfracrate paste, fibrinolytic inhibitors, or adrenalin diluted in saline (1:10) applied over the surface of the wound. When bleeding is provoked by dressing removal in spite of the gel formed by hydrofibers or alginate, Vaseline interface dressings or non-Vaseline interfaces, such as Mylar film, may be applied. If the lesion is associated to a major bleeding, then hemostatic radiotherapy, surgery cauterization or ligation, and embolization may be used. It is important to monitor hemoglobin to ensure anemia has not developed with persistent moderate to heavy bleeding [51, 52].

Infection and odor control is achieved by managing local bacterial colonization with an accurate wound cleansing and debridement, use of topical (efficacy only for superficial bacteria) and oral metronidazole or other antimicrobial agents, charcoal dressings placed above the primary dressing to adsorb the offensive volatile compounds, and Iodosorb gel [53]. Topical preparations may be most effective due to the decreased perfusion and vasculature throughout malignant wounds which decreases the effectiveness of systemic therapy. The silver sulfadiazine is used to control pseudomonas infection. Avoid antiseptics such as hydrogen peroxide, povidone iodine, and sodium hypochlorite, as they may cause tissue damage and pain. Consider use of slow-release iodine products, i.e., Iodosorb. Consider use of specialized antimicrobial dressing to control infection at site [13, 54–56].

It is essential to preserve peri-wound skin integrity with an attention prevention of pruritus, maceration, irritation and an adequate hydration using non-adherent fixing systems, or silicone adhesives applied without any tension over a limited surface [44, 45].

Pain management cannot be limited to local treatments. Pain has to be managed with oral therapy such as morphine or hydromorphone. There is also limited evidence to support the use of topical opioids and other analgesics because peripheral opioid receptors should be present [12, 15].

Secondary pain has to be avoided during the dressing changes. Hypnoanalgesia, MEOPA (mélange équimolaire d’oxygène et de protoxyde d’azote), general anesthesia, and techniques of local anesthesia for dressing changes may be used [57].

Locally, combined lidocaine/prilocaine or lidocaine is used with limited effect, linked to the low penetration of the product. In clinical practice, morphine mixed with hydrogel at a dosage between 10 and 30 mg for 15 g of gel can be applied and has been reported to be beneficial [58–60].