Skin conditions in palliative care are often overlooked because they are not immediately life-threatening. However, they cause immense suffering — itching disrupts sleep, foul odours isolate patients socially, and pressure sores cause pain and infection. As a nurse, your skin care interventions restore comfort, dignity, and human connection.

Pruritus is an unpleasant sensation that provokes the urge to scratch. Near the end of life, it can be relentless, disrupting sleep, causing skin damage from scratching, and leading to infection.

Hyperhidrosis is excessive sweating beyond what is needed for temperature regulation. In palliative care, it causes discomfort, dehydration, skin maceration, and embarrassment.

Oedema is the accumulation of fluid in tissues. In palliative care, it signals advanced disease — tumour obstruction, heart failure, liver failure, or malnutrition. The pattern of oedema (where it is, whether one-sided or both-sided) tells you the cause.

Kaposi's Sarcoma (KS) is a common cause of swelling in Uganda, particularly in HIV-positive patients. It causes woody, hard infiltration of the skin by tumour, leading to:

• Distension of tissues
• Blockage of small vessels and lymphatics
• Fluid retention

KS is one of the most common cancers in HIV-positive patients. Nurses should recognise the purple/brown skin lesions and woody hard swelling as classic signs. ART is the cornerstone of treatment.

Ascites is the accumulation of excessive fluid in the peritoneal cavity (the space within the abdomen). Malignancy accounts for approximately 10% of all adult ascites cases.

Ascites results from an imbalance between fluid influx and efflux in the peritoneal cavity:

• Increased fluid influx: Peritoneal metastasis (cancer spread to peritoneum); increased peritoneal permeability.
• Reduced fluid efflux: Lymphatic vessels blocked by tumour infiltration; liver metastasis causing low albumin.
  [Expansion: Low albumin drastically drops intravascular oncotic pressure, meaning fluid leaks out of blood vessels into the abdomen and cannot be pulled back in].

• Paracentesis: Removal of fluid from the peritoneal cavity using a needle or catheter. Provides rapid relief but fluid reaccumulates.
• Low-sodium diet: Reduces fluid retention.
• Small, frequent meals: Reduces early satiety.

• Spironolactone: 75–400 mg daily. Potassium-sparing diuretic; first-line for ascites.
• Frusemide: 40–200 mg daily. Loop diuretic; added if spironolactone alone insufficient.

Fungating tumours are malignant wounds where the tumour grows through the skin surface, creating an ulcerated, bleeding, malodorous mass. They most commonly occur in Breast cancer, Head and neck cancers, Melanoma, and Sarcoma.

• Fungating skin cancers: Breast cancer, sarcoma, squamous cell carcinoma, melanoma.
• Poor wound healing: Debility, malnutrition, anaemia, immunosuppression.
• Pressure sores: Due to immobility, incontinence, poor nutrition.

• Normal saline: Boil water, add a pinch of salt (or 1 teaspoon per 500 ml). Used for general wound cleaning.
• Saltwater baths: For perineal wounds (soothes and cleanses).
• What NOT to use: Hydrogen peroxide, iodine, or other caustic agents — these damage healthy granulating tissue and severely delay healing.

• Old cotton cloths: Washed, cut to size, boiled to sterilise (Simple, affordable dressings).
• Non-adherent dressings: For painful wounds — do not stick to wound bed.
• Absorbent dressings: For heavily exuding wounds.
• Honey or sugar: For de-sloughing necrotic wounds. Apply to dressing, change twice daily.
  [Expansion: Sugar creates an intense hyperosmotic environment that draws water out of bacteria, killing them, while drawing nutrient-rich lymph fluid to the surface to heal the wound].

• Use non-adherent dressings (Soak off old dressings with saline before removing — never rip dry dressings off a wound).
• Give analgesia 30 minutes before dressing change (Oral morphine or paracetamol).
• Consider topical lignocaine if available.

• Crushed metronidazole tablets or Metronidazole gel.
• Natural yogurt (Locally available; contains probiotics that compete with odour-causing bacteria).
• Papaya (pawpaw) (Contains enzymes that chemically debride necrotic tissue).
• Honey or sugar (For de-sloughing; also reduces odour).

• Absorbent dressings (Change frequently — may need several times daily).
• Barrier cream around wound (Protects surrounding skin from maceration).
• Consider pouching systems.

• Radiotherapy or surgery (Definitive treatment).
• Dark cloths to soak blood: Reduces panic for patient and family. Blood on white fabric is terrifying; dark colours are calming.
• Gentle cleaning (Avoid trauma).
• Crushed topical tranexamic acid (500 mg applied directly to wound promotes clotting).
• Adrenaline-soaked gauze (for local haemostasis) or Sucralfate paste.

Question: A patient with HIV has generalised itching and purple-brown skin lesions on the legs. What is the likely diagnosis, and what is the cornerstone of treatment?

Answer: Kaposi's Sarcoma. The cornerstone of treatment is Antiretroviral Therapy (ART) — immune reconstitution often causes regression of KS lesions. Analgesia and chemotherapy may be added.

Question: A patient with advanced liver cancer has intense generalised itching, worse on the palms and soles. What is the cause, and what drugs would you use?

Answer: Obstructive jaundice — bile salts accumulate in the skin. Use dexamethasone 2 mg BD (reduces inflammation) and chlorpheniramine 4 mg TDS (antihistamine). Biliary stenting is definitive if available.

Question: A dying patient has a fungating breast wound with foul odour. The family is embarrassed to have visitors. What can you do?

Answer: Clean gently with saline daily. Sprinkle crushed metronidazole tablets on the wound to treat anaerobic infection and reduce odour. Use absorbent dressings and change frequently. Reassure the family that the odour is from infection, not poor hygiene.

Question: Why should you avoid anticoagulants for DVT in a terminally ill patient?

Answer: Terminal patients often have bleeding tendencies due to low platelets, liver dysfunction, or tumour invasion of vessels. The risk of major bleeding outweighs the benefit of anticoagulation. Use elevation, gentle compression, and analgesia instead.

Question: A patient with ascites is prescribed spironolactone and frusemide. What electrolyte imbalance should you monitor for?

Answer: Spironolactone is potassium-sparing and can cause hyperkalaemia (high potassium). Frusemide is potassium-wasting and can cause hypokalaemia (low potassium). Monitor serum potassium and watch for cardiac arrhythmias, muscle weakness, and confusion.

Question: A nurse is about to change a dressing on a painful fungating wound. What should she do first?

Answer: Give analgesia 30 minutes before the dressing change. Soak off the old dressing with saline — never rip it off dry. Use non-adherent dressings for the new dressing. Be gentle — tumour tissue is fragile and bleeds easily.

• Pruritus has many causes — always look for the underlying cause (HIV, jaundice, dry skin, uraemia).
• Hydrocortisone 1% cream and chlorhexidine rinses are first-line for HIV-related skin pruritus.
• Hyperhidrosis from infection or liver metastases responds to treating the cause, antipyretics, and frequent sponging.
• Kaposi's Sarcoma is common in Uganda — recognise purple lesions and woody swelling; ART is essential.
• Bilateral arm oedema = think SVCO; bilateral leg oedema = think heart failure, hypoalbuminaemia, or pelvic tumour. (Mnemonic: U-B-B-A for oedema locations).
• Avoid anticoagulants for DVT in terminal patients — bleeding risk is too high.
• Ascites causes early satiety and breathlessness — small frequent meals and diuretics help; paracentesis for severe cases.
• Fungating tumours cause social isolation through odour — metronidazole is your best friend for odour control.
• Wound cleaning should be gentle — saline only; never hydrogen peroxide or harsh antiseptics.
• Pressure sores are preventable — turn every 2 hours, keep skin dry, ensure nutrition, and use simple pressure-relieving devices.
• Always give analgesia before painful dressing changes — and soak off dressings, never rip them.
• Dark cloths reduce panic during bleeding wounds — prepare them in advance.

• World Health Organization (WHO) Guidelines on Palliative Care.
• Uganda Ministry of Health - Clinical Guidelines for Palliative Care.
• Oxford Textbook of Palliative Medicine.