Radiation-induced dermatitis

Prevention

Minimise irritation and trauma to the skin

Irritation and trauma to the skin in the treatment area should be avoided as much as possible. Patients should be instructed to avoid in the treatment area:

• rubbing/scratching
• wearing jewellery
• the use of adhesives
• direct application of heat or cold (e.g., cold/heat packs, electric blankets).
• using moisturisers, skin care and make-up with products containing:
  • alcohol
  • perfumes
  • additives
  • alpha hydroxy acids (AHAs)
  • sucralfate.
• the use of corn starch, talcum/baby powder
• exposure to elements (wind and sun exposure):
  • avoid the use of sunscreens and ensure adequate cover from the sun (e.g., use a hat, protective clothing, etc.).
  • friction and trauma to the skin:
    • wear loose fitting clothes
    • wear natural breathable fibres (i.e., cotton).

Avoid waxing and the use of hair removal creams in the treatment area. Shaving in the treatment area should be done with caution. Avoid:

• wet shaving
• using straight edge or disposable razors (use an electric razor instead to minimise trauma to the skin)
• pre or aftershave products.

Silicone-based adherence films and gel dressings

There is some evidence to support the use of silicone-based dressings, such as silicone-based adherence films or gels, to prophylactically prevent or reduce the severity of RID in the treatment area. 

Silicone-based adherence films are a flexible, transparent covering that create a physical barrier to protect the skin from friction and external contamination. The film is applied by treatment staff at the start of treatment and is kept on the skin throughout the course of treatment. It may require partial or total reapplication if it peels off during treatment. 

Silicone-based gel dressings are applied to the skin and dry to form a thin, flexible, and transparent film that is gas permeable and waterproof. The gel is usually applied twice daily by the patients themselves. Like silicone-based adherence films, it creates a physical barrier to protect the skin from friction and external contamination. 

Some studies have shown a reduction in RID including moist desquamation when silicone-based dressings are used in whole breast, postmastectomy and H&N patients.^rr It is important to note that studies supporting the use of these dressings are generally small, non-randomised studies primarily in a subset of patients with H&N and breast cancer treated with radiation therapy. A silicone-based gel dressing was compared to Sorbolene in a single-blind randomised study in patients receiving head and neck irradiation.^r This study showed that it prevented, delayed and reduced the severity of skin toxicities in head and neck radiation therapy patients.

If a patient develops moist desquamation, then use of silicone-based adherence dressings in the area should cease and appropriate management for moist desquamation should commence. Silicone-based gel dressings can continue to be used along with commencing other appropriate management.

Skin care and hygiene

The treatment area should be kept clean and dry. Patients should wash the treatment area with lukewarm water using a mild unscented soap and gently pat dry.^r This can reduce itching and severity of RID.^rr

Deodorant use

There is no recent evidence to support the recommendation to avoid deodorants/antiperspirants during radiation therapy. Studies looking at axillary skin reactions in patients undergoing conventional breast radiation therapy using either aluminum-containing or non-aluminum containing deodorant use found no impact on skin toxicity compared to those that did not use deodorant.^rr

Topical therapies

Moisturisers

Recent evidence suggests the use of topical moisturising products may prevent, reduce the severity of, and improve RID in patients.^rrr There is insufficient evidence to make recommendations for what type of moisturiser. However, there are a range of national and international guidelines reporting that pure sorbolene cream is commonly used or recommended in the clinic.^rrr

• Patients should be advised to regularly moisturise the skin in the treatment area, including areas of exit dose, throughout the course of radiation therapy.
• Moisturiser can be applied immediately before or after a treatment session. There is inadequate evidence to guide the exact timing of application before each treatment. Some centres recommend not applying moisturiser just prior to a treatment session for practicality reasons (e.g. when positioning patients for treatment and applying skin markings), however this will not impact skin reactions.
• Very thick layers of moisturiser (greater than what is normally applied) may potentially increase the surface/skin dose.^r Patients should be advised to avoid thick layers of moisturiser on the skin immediately prior to a treatment session. If applied before a treatment session, the moisturiser should be gently massaged into the skin to ensure adequate absorption. This may be more significant to patients receiving KV treatment where superficial dose is more readily affected by changes to target depth.
• Moisturiser application may need to cease in the event of skin breakdown.

Corticosteroids

A systematic review found prophylactic use of corticosteroids in patients at high risk of RID had the highest efficacy compared to other interventions.^r They concluded that there is limited evidence for more modern radiation therapy techniques and advise against its use in patients undergoing hypo-fractionated breast radiation therapy. Caution is also advised when using corticosteroids as it may contribute to skin thinning and other late effects with prolonged use.^r

Bio dressings and stem cell therapies

There is ongoing research investigating the use of bio dressings which are highly advanced biomaterials that combine conventional fibers with bioactive molecules such as growth factors with the main objective of speeding up the healing process.^r There is also current ongoing research exploring stem cell based therapies. There is currently insufficient evidence to make recommendations on the clinical use of bio dressings and stem cell therapies.^rrrr

Treatment

There is significant variation in skin care practices and management in radiation therapy with no strong level 1 evidence for how to treat RID. Treatment should be tailored for each patient and guided by the severity of the RID, and it typically takes a step-up approach. Treatment options should take into consideration the availability of the therapeutic agent(s) and any associated costs to the patient. Patients with CTCAE grade 4 radiation induced skin reactions may require surgical review for consideration of surgical debridement or skin grafts. Generally accepted principles for radiation-induced dermatitis management are outlined below.

Maintain a moist (not wet) healing environment where skin is broken

To maintain a moist (not wet) healing environment where skin is broken, consider the use of non-adherent absorbent dressing e.g. hydrogel, hydrocolloid and silver containing dressings

Hydrogel or hydrocolloid dressings have been used in treating moderate and severe forms of acute RID that involve moist desquamation.^r They increase the healing rate and reduce infection and pain.^r They facilitate the maintenance of a wet environment over de-epithelialized skin (layer of skin removed from wound healing), and are considered to accelerate healing.^r

Common metallic ointments and dressings such as silver sulfadiazine, nylon silver dressings and silver-containing foam dressings with soft silicone adhesive technology that does not stick to the wound provide a moist healing environment that can effectively protect and repair skin damage without interfering with treatment outcomes.^rrrrrrr The use of silver dressings in managing RID has historically been contentious due to questions around the efficacy, cost-effectiveness and safety during radiation treatment.^rrrr However, the more recent publications demonstrate that silver containing dressings are associated with a lower total severity of RID.^rrr

Prevent and manage infection

• Monitor for signs of infection. This is particularly important in patients with moist desquamation as signs and symptoms can change rapidly over hours to days.
• Consider a protective barrier if skin is broken.
• Consider antibiotics if patient displays signs of cellulitis or other infection.^r For patients at high risk of infection, topical antimicrobial agents, such as silver sulfadiazine or silver-based dressings, may be of benefit.

Symptom management

To manage symptoms of RID consider:

• analgesics (e.g., paracetamol or low dose opiates) to manage pain and discomfort
• non-adherent dressings to reduce tenderness
• short-term use of topical corticosteroids from the low to medium potency groups, such as hydrocortisone 1% cream^r
• saline soaks in patients with moist desquamation. Guidelines recommend using saline soaked compresses up to four times a day followed by a moisture retentive barrier ointment, hydrogel, or absorbent dressing.^rr

Lymphoedema

Radiation therapy can result in secondary lymphoedema. This can result in the accumulation of lymphatic fluid and lead to swelling, inflammation, and skin changes as well as an increased risk of cellulitis. For further information see eviQ’s lymphoedema clinical resource.

Post radiation therapy management

Patients should have their skin reviewed and monitored during their post-treatment follow-up appointments, usually from 1-2 months following the completion of radiation therapy. Patients with, or at risk of developing, high grade skin reactions should be closely monitored at the completion of their treatment with regular follow-up reviews. To ensure appropriate ongoing care and management particularly as skin reactions can get worse following treatment completion.

Chronic dermatitis can result in decreased quality of life, limited function, and discomfort.^r During follow-up visits patients should be assessed for chronic dermatitis including degree of skin fibrosis, breakdown, and lymphoedema.^r The management of RIF often requires a multidisciplinary treatment approach that includes physical therapy, wound care, and pain management.^rr In case of necrosis or severe ulceration, surgical intervention may be considered.^r

Skin sensitivity to the sun

Skin which has been irradiated has increased sensitivity and risk of sun damage for the life of the patient. It is important that patients protect their skin from the sun and elements by using sunscreen, wearing wide brimmed hats, and covering the area as much as possible.^r

Radiation recall

Radiation recall is an erythematous or inflammatory skin reaction that can occur at the site of previous radiation when certain chemotherapy drugs are given. For further information see eviQ’s radiation recall side effect document.