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Radiation dermatitis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Radiation dermatitis (RD) is a common complication of cutaneous radiation exposure, most frequently from treatment of malignancies or interventional radiologic procedures. Acute radiation dermatitis (ARD) typically occurs within 2–3 weeks of radiation exposure and is caused by damage to the appendageal structures and basal keratinocytes. The damage gradually builds over the treatment course and peaks at 1–2 weeks after completion of radiation therapy (RT). ARD manifests as erythema, edema, epilation, dry or wet desquamation, and blistering (see figure). Pain and pruritus often accompany these changes. The most widely used tools for assessment are the National Cancer Institute’s Common Terminology Criteria for Adverse Events and the Radiation Therapy Oncology Group, which both grade ARD from 1 to 4. Chronic RD is defined as skin changes persisting 90 days after radiation exposure, and these changes result from radiation-induced dermal and vascular damage leading to atrophy, dyspigmentation, telangiectasia, fibrosis, ulceration, and necrosis. Radiation recall is a dermatitis developing at sites of prior radiation exposure, usually induced by chemotherapeutic drugs such as the anthracycline doxorubicin, taxanes (docetaxel >paclitaxel), and antimetabolites (gemcitabine >capecitabine).
Management Strategy
Despite advances in radiation technology aimed at reducing side effects, skin toxicity is still common. The goals of treatment consist of maintaining skin integrity, minimizing patient discomfort, and preventing trauma and infection. Patients should gently wash the skin with mild soap and water . Topical corticosteroids treat dry desquamation (painless peeling of the skin) and moist desquamation (painful, full-thickness loss of the epidermis), control pruritus, and reduce inflammation. Addition of silver nylon dressings or topical silver sulfadiazine may provide prophylaxis against infection and expedite healing. Thin or moderately applied topical agents have minimal influence on skin radiation dose; however, patients should avoid applying very thick amounts of a topical agent just before RT as this may increase the surface dose. Patients should also avoid friction from tight fitting clothing. Of note, topical corticosteroids have demonstrated the highest prophylactic and therapeutic efficacy for ARD when compared with other topical agents.
Chronic RD is treated symptomatically. Topical emollients or corticosteroids can be employed as needed. Skin necrosis or ulceration must be monitored for signs of infection and managed with appropriate wound dressings. For reduction of skin fibrosis, oral supplementation with pentoxifylline and vitamin E as well as physical massage are recommended . Telangiectasias can be treated with pulsed-dye laser.
Specific Investigations
Post radiation skin tumors: basal cell carcinomas, squamous cell carcinomas and angiosarcomas. A review of this late effect of radiotherapy
Cuperus E, Leguit R, Albregts M, et al. Eur J Dermatol 2013; 23: 749–57.
Basal cell carcinomas are the most common malignancies to develop in sites of radiation exposure. Patients with breast cancer treated with radiotherapy are also at risk for angiosarcomas.
Management of acute radiation dermatitis: a review of the literature and proposal for treatment algorithm
Rosenthal A, Israilevich R, Moy R. J Am Acad Dermatol 2019; 81: 558–67.
This article reviews the clinical efficacy and level of evidence of topical agents used in the management of ARD. Daily washing of skin within the radiation field with mild soap and water during RT to reduce pruritus and severity is supported by randomized controlled trials (RCTs). RCTs also support the application of a mid-potency topical corticosteroid, twice a day from the first day of RT through 2 weeks following completion of RT, to reduce rates of wet desquamation. Evidence shows that silver nylon dressings used daily and for 2 weeks after completion of RT reduce pruritus, pain, and burning.
A randomized trial of mometasone furoate 0.1% to reduce high-grade acute radiation dermatitis in breast cancer patients receiving postmastectomy radiation
Ho AY, Olm-Shipman M, Zhang Z, et al. Int J Radiat Oncol Biol Phys 2018; 101: 325–33.
Mometasone furoate (MF) 0.1% cream was compared to Eucerin Original (E) cream in this double-blind randomized trial of 124 breast cancer patients receiving postmastectomy radiation (PMRT). The creams were applied twice daily from day 1 of PMRT for 2 weeks. The rate of moist desquamation was significantly reduced in the MF arm compared to the E arm. The MF arm had a lower incidence of maximum-grade ARD and longer time to development of grade 3 ARD.
The impact of skin washing with water and soap during breast irradiation: a randomized study
Roy I, Fortin A, Larochelle M. Radiother Oncol 2001; 58: 333–9.
Ninety-nine patients treated for breast cancer were prospectively randomized prior to receiving radiotherapy to the breast into two groups: no washing (49) and washing with soap and water (50). Moist desquamation was seen in 33% of non-washing patients, but only 14% of washing patients. The median scores of pain, itching, and burning of the treated skin were higher in the non-washing group, although this was not statistically significant.
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