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1. Introduction

1.1 How was the topic identified?

This guideline progresses work initiated in 2010 and resulting in the publication in 2011 of the Society and College of Radiographers (SCoR) radiotherapy skin care guidelines. This work was undertaken in partnership with the SCoR Public and Patient Liaison Group (PPLG) and six of its members participated in developing and shaping the questions for the original survey of professional practice into radiotherapy skin care.

Since that time, a variety of new skin care products has emerged on the market, while some previously used products have been removed from pharmacy suppliers. A recent, (2014) updated SCoR survey of current practice in the United Kingdom indicates diversity of skin care practice across radiotherapy centres, prompting the need for this review.

1.2 Why is it important? 

Skin reactions from external beam radiotherapy are one of the most common side-effects from treatment (Brown and Rzucidlo, 2011; Ryan, 2012), which may cause distress to some patients, and in certain cases may be a factor which can limit radiation dose and treatment schedules. Megavoltage linear accelerators with skin sparing capabilities have significantly reduced the severity of reactions from radiotherapy (Harris, 2002b); however accelerated radiation dose schedules with concurrent chemotherapy, and the use of biological agents such as epidermal growth factor receptor EGFR) inhibitors, have led to an increase in certain skin reactions (Bernier et al., 2008). The most severe reactions tend to be seen in those patients receiving high doses to large fields and where there are folds of skin (for example inframammary fold, groin, axilla) (Porock et al., 1998; Richardson et al., 2005). More recently the use of intensity modulated radiotherapy (IMRT) and hypofractionation have shown to offer the potential to reduce skin toxicity in some cases, especially the rates of dry and moist desquamation when treating cancers in the head and neck region (Freedman et al., 2004; Price et al., 2006; Freedman et al., 2006; Harsolia et al., 2007; Pignol et al., 2008; Freedman et al., 2009; Ciammella et al., 2014). Despite changes in radiotherapy practice and numerous published skin care guidelines (NHS, 2004; CoR, 2000; NHS, 2010; CoR, 2011) patient skin care appears to have changed little over the years, with no consensus amongst centres using different skin care regimens, product use and approaches (Barkham, 1993; Harris, 2002a; Harris et al., 2012).

Although it is unlikely that radiation reactions can be completely prevented, the current driver is to delay the onset and minimise the severity of a skin reaction, to reduce symptom related discomfort, and prevent further complications. Most skin reactions tend to peak towards the end of the treatment course and are often at their worst in the first two weeks after treatment has completed. The majority of skin reactions are acute and have significantly improved, if not resolved, by four weeks post treatment (McQuestion, 2011; Ryan, 2012;), however the extent of a skin reaction is often dependent upon the clinical site being treated. For example, patients undergoing radiotherapy for head and neck cancer usually require immobilisation and often receive concurrent chemotherapy or biological agents. These factors can make patients more vulnerable to intensified skin reactions and possible interruptions in radiotherapy and for these patients this can have a detrimental effect on treatment outcome (RCR, 2008).  

1.3 How does it fit with existing radiotherapy practice?

The Society and College of Radiographers (SCoR) and The United Kingdom Oncology Nurses Society (UKONS) offer advice and guidance for professional development to promote patient-centred care and the highest quality services. The SCoR document library contains all of its policies, advice and guidance. 

1.4 The policy context

The NHS England Radiotherapy Clinical Reference Group (and equivalent groups where in existence in the countries), with input from the UK-wide Radiotherapy Board and UKONS, should aim to provide national guidance. This guidance should be based on expert consensus of the evidence base, and support the need for further research into new products before they are introduced on an ad-hoc basis into skin care regimens. Radiotherapy services in England are now within NHS England Specialised Services, and it is stated that all patients should receive care to the same standard, irrespective of where they receive their treatment.

Despite the publication of best practice guidelines for radiotherapy skin care in 2011 and the results of two surveys conducted by the College of Radiographers, a wide variety of practices are undertaken in radiotherapy departments in the United Kingdom (UK) with respect to both the prevention and management of radiation induced skin reactions by external beam megavoltage radiotherapy. There also remains disparity within the published research, with no one topical application or medical intervention being clearly deemed superior over another. 

The extent of radiotherapy reactions across departments also appears to be unclear and unquantified. In Barkham’s (1993) assessment of radiotherapy skin reactions and associated treatments, 52% of UK radiotherapy departments reported dry desquamation as a common event and 85% of departments reported moist desquamation as an occasional event. However, as Glean et al. (2001) noted, the incidence of skin reactions has not been accurately collected in departments and practices have changed since Barkham’s (1993) survey. All patients receiving external beam radiotherapy are at a potential risk of developing a reaction but the results of the 2011 SCoR survey indicate that limited data is still collected by clinical departments and therefore actually quantifying the extent of the problem is difficult.

1.5 Background information

Turesson et al. (1996) demonstrated that the number of basal cells in the epidermis declines during fractionated radiotherapy due to increased cell cycle arrest and reduced mitosis. The reduction in the basal cells causes a thinning of the epidermis and an inflammatory reaction and the variation in the reaction appears to be a genetic predisposition related to individual DNA repair capacity (Tucker et al., 1992; Lopez et al., 2002; Twardella et al., 2003; Popanda et al., 2003; Chang-Claude et al., 2005; Pinar et al., 2007; Andreassen and Alsner, 2009), genetic radiosensitivity  (Barber et al., 2000; Burrill et al., 2000; Suga et al., 2007), and/or intravascular thrombin generation (Lincz et al., 2009). Specific genetic tests could therefore be used to predict those patients most likely to develop a severe radiotherapy reaction (Badie et al., 2008; Iwakawa et al., 2006; Andreassen and Alsner, 2009).

Certain clinical factors can aid in the prediction of which patients are more likely to experience a significant radiation reaction (Russell et al., 1994; Russell, 2010). Extrinsic factors, which are treatment related, include: dose; volume; fractionation; adjuvant treatment; treatment in a skin fold area (e.g. inframammary fold or anal cleft); use of bolus material; type of  immobilisation; and treatment technique (Porock and Kristjanson, 1999). These factors need to be under constant review with changing work practices; such as introducing IMRT, hypofractionation, or dose escalation treatments. 

Intrinsic factors, which are individually patient related, include: larger breast size (Porock et al. 1998; Harris, 2002b); higher body mass index (BMI) (Kouvaris et al., 2001; Twardella et al., 2003; Wells et al., 2004); and/or pre-existing conditions and co-morbidities, such as diabetes (Turesson et al., 1996; Porock et al., 1999b). Such intrinsic factors may enhance an individual’s propensity to experience a skin reaction and therefore should be recorded by baseline observations and closely monitored throughout, and after, a course of radiotherapy (Porock et al., 1998; Fisher et al., 2000; Richardson et al., 2005; NHS Scotland, 2010). Smoking has also been shown to be an independent risk factor, and patients should be advised about this and supported to stop smoking wherever possible (Wells et al. 2004; Wan et al. 2012; Sharp et al. 2013).

Gosselin (2010) noted that some skin care products showed promising results but comparing data across studies is difficult because of the wide variety of assessment tools. By utilising a validated skin assessment tool on at least a weekly basis, it would be possible to monitor and record an individual patient’s skin reaction. An example of a validated assessment scale is the one developed by the Radiation Therapy Oncology Group (RTOG) (Cox et al., 1995). The use of an effective evidence-based skin care protocol and monitoring system (Campbell and Lane, 1996; O'Shea et al., 2003) would assist in a robust approach to radiation skin care management, aiding product evaluation and justification of practice.

Another important aspect of skin care during radiotherapy is that of quality of life. Patients often have fears and misconceptions about radiotherapy therefore consistent, current and relevant reinforced information can help to alleviate some of these concerns (Harris, 1997). It may not be possible to stop or reduce the rates of skin reactions, but skin care products may provide comfort and enhance self care (Gosselin, 2010). Recording of patient symptoms, acceptability/satisfaction and compliance, as incorporated into some existing scales (Noble-Adams, 1999), would also be helpful indicators of how appropriate a product will be for future use. 

Of significant note is the identification of certain products contraindicated for use on radiotherapy skin reactions:

  • Topical antibiotics, unless there is a proven infection (Sitton, 1992; Campbell and Lane, 1996; Korinko and Yurick, 1997);
  • Topical steroids on broken skin due to the adverse effect on the wound healing process (Blackmar, 1997; Rice, 1997; Jones, 1998);
  • Gentian Violet due to potential carcinogenic side effects (Campbell and Lane, 1996; Rice, 1997; Boot-Vickers and Eaton, 1999).

Petroleum (Sitton, 1992; Blackmar, 1997; Korinko and Yurick, 1997) and silver sulfadiazine (Fackrell, 2013) based products have been considered to create a build up effect due to their radiation attenuation properties. However, more recent evaluation (Morley et al. 2013) of dosimetric considerations has shown that the amount of product layering required to cause a problem would be far in excess of normal skin care use.

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