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6. Radiotherapy skin care

Faithfull et al. (2002) noted ‘a growing awareness of the need for evidence based practice in radiotherapy’ but that there are ‘well documented disparities between clinical practice and research findings’; reflecting that supportive care is often based on no, little, or poor evidence. Comparing data across radiotherapy skin care studies is difficult as the methods used are often unclear, patient randomisations differ, different skin assessment scales are used, and follow-up data is inconsistent (Kedge, 2009). The findings from recent SCoR surveys would support such a view.

The surveys highlighted that few departments are following updated national guidelines and undertaking baseline assessment of a patient’s current skin condition. Despite papers emphasising the potential risk factors (Russell et al., 1994; Porock and Kristjanson, 1999; McQuestion, 2011) which may exacerbate a skin reaction, 52% of departments (2014 SCoR data) stated they did not record this information. Without the collection of such data it is difficult to attain a complete picture of the extent of radiotherapy induced reactions, which will be essential for improved research and skin care studies. Furthermore, 49% of departments (2014 SCoR data) failed to assess and record skin care products currently being used by patients.

Linking with other sectors of care, Tissue Viability Nurses (TVN), or equivalent, and district nursing staff, with an understanding of radiation induced skin reactions, would strengthen improved communication. Understanding and consistency of radiotherapy skincare across the care pathway is needed to reduce patient and staff confusion (Harris, 1997; Cumming and Routsis, 2009).  

A main area of variation across departments relates to washing instructions and the use of soap and deodorant (also confirmed by other studies by Barkham, 1993; Lavery, 1995; D'haese et al., 2009). The traditional patient advice of ‘not to wash’ the affected area with soap and water, or even to use water alone, is still given, despite updated evidence that this is unnecessary and there should be no restriction to using a specific type of soap (Campbell and Illingworth, 1992; Burch et al., 1997; Westbury et al., 2000; Roy et al., 2001; Rudd and Dempsey, 2002; Aistars, 2006; Bolderston et al. 2006; Aistars and Vehlow, 2007; Butcher and Williamson 2012). Seventy four percent of departments (2014 SCoR data) reported washing restrictions (i.e. either no soap, or limited to specific brands such as ‘Simple®’ and ‘Dove®’); this has the potential to control unnecessarily the choices and preferences that an individual may have.

Expecting patients to follow traditional practice advice of ‘not to wash’ and ‘not to use deodorant’, may affect their social well being. For example, breast cancer patients who are advised not to use a deodorant often cite this as one less area of control they have in their life and they note concern regarding body odour (Komarnicki, 2010). In the past it was felt that the metallic compounds, particularly aluminium, within deodorants might cause a secondary radiation effect (Korinko and Yurick, 1997); however more recent studies contradict this advice as unfounded and outdated (Bennett, 2009; Watson et al., 2012; Wong et al., 2013; Lewis et al.,2014). Currently 55% of departments advise patients not to use a deodorant under the axilla of the affected side being treated for breast cancer (2014 SCoR data). Patient compliance with these requests has not been assessed (Gosselin, 2010). 

The 2014 survey illustrates that there are numerous products being recommended and supplied for radiotherapy skin care with no consensus as to the best practice, causing an inconsistency of care (Harris, 1997).  As noted by Russell (2010), if the underlying cause of a radiation reaction is physiological, topical agents are unlikely to have any significant effect on the level of skin reaction. However, skin care products may not be effective at eliminating or limiting radiation induced skin reactions, but they may have certain therapeutic effects relating to patient comfort and the alleviation of symptom induced irritation. Currently the quality and quantity of studies evaluating topical agents appears to be insufficient to support or refute any specific product and there are few evaluations of skin care products; therefore progress into understanding what works is likely to be slow.

Aqueous cream is currently recommended and issued by 81% of departments (2014 SCoR data) as a prophylactic skin care product and by 65% of departments (2014 SCoR data) to alleviate erythema.  The rationale behind the recommendation for this product was to aid patient comfort by ensuring the treatment area is moisturised and hence reducing the feeling of taut dry skin.  Aqueous cream is a relatively cheap, readily available product and was advised in the now withdrawn College of Radiographer’s 2000 guidelines (CoR, 2000).  However, the evidence base indicates that aqueous cream applied preventatively and to erythema appears to have no influence in a skin reaction occurring (Schreck et al., 2002; McQuestion, 2006; Gosselin et al., 2010); although there may be patient comfort benefits. Some departments are also stating that aqueous cream is being withdrawn by their pharmacy suppliers; possibly because of recent studies which have indicated that aqueous cream containing sodium lauryl sulphate may actually compromise skin integrity and have shown it to be an irritant (Tsang and Guy, 2010; Patel et al., 2013); although it should be noted that these were not studies of radiotherapy patients. Therefore, there needs to be further debate about this aspect of care and the evidence-base supporting actions. If sodium lauryl sulphate is a known irritant, departments need to investigate alternatives that do not contain it. 

Furthermore, 11% of departments (2014 SCoR data) advise patients to use topical aloe vera for erythema which may incur a substantial cost either to the institution or to the individual, yet there is limited evidence (Haddad et al., 2013) as to any benefit obtained using this agent over another and therefore no justification without further detailed studies for this recommendation to patients (Kaufman et al., 1988; Richardson et al., 2005; McQuestion, 2011).

Hydrocortisone 1% is used by 10% of departments (2014 SCoR data) for dry desquamation reactions, in line with the withdrawn College of Radiographer’s 2000 guidelines (CoR, 2000) and supported by recent Multinational Association of Supportive Care in Cancer (MASCC) guidelines (Wong et al., 2013). However, some studies have produced evidence to support the use of steroid creams prophylactically and some have cited contradictory evidence (Sitton, 1992; Dunne-Daly, 1995; Sperduti et al., 2006; Bostrom et al., 2001; Miller et al., 2011; El Madani et al., 2012; Hindley and Dunn, 2013) and again this is an area of clinical practice that requires further investigation.  

There appears to be a propensity to continue with familiar traditional practice rather than an openness to test the effectiveness of products. In the recent SCoR survey there was no evidence of any assessments into the cost effectiveness of using creams and topical agents for erythema or dry desquamation, and only four departments (2014 SCoR data) stated they were assessing products for moist desquamation. With the introduction of more expensive skin care treatments to a vulnerable clientele, health care professionals need to consider if such products are more effective than their cheaper comparators and why they choose one product over another (Fisher et al., 1999; Fisher et al., 2000; Pommier et al., 2004; Swamy et al., 2009). This is an important facet of modern healthcare with the necessity for justification for actions, particularly as 65% of departments stated they supplied the recommended prophylactic product and 78% of departments supplied the recommended product for erythema (2014 SCoR data).  If a patient suffers an adverse reaction to a product that has been ‘issued’, the ‘issuer’ is likely to have to produce evidence to support the use of that product.

An evaluation into the treatment after care also requires review to ensure local continuity of care across the pathway; a general need highlighted by a recent Department of Health cancer patient experience survey (DH, 2012). 

Radiation induced skin reactions can be uncomfortable and distressing, thereby affecting a patient’s quality of life (Lawton and Twoomey, 1991). Skin care advice to patients undergoing external beam megavoltage radiotherapy in the UK is varied. Currently, some of the skin care provided may not alleviate the problem and indeed may even cause skin irritation. This area of patient care is time consuming and expensive, therefore it is important to understand what is being done and why (Harris, 2002b).

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