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7. Guideline recommendations

Overall, the evidence base is not strong enough to either support or refute the use of any particular product for topical application.  However, as Gosselin et al. (2010) noted, “patients prefer to take action rather than do nothing” so the focus for skin care should be on alleviating symptoms and providing comfort. Therefore the following guidelines are recommended.

1. The various factors that influence how people react to radiotherapy need to be considered in advice designed to be given to patients, particularly:

Intrinsic factors which include demographic or disease related characteristics such as age, hormonal status, infection, ethnic origin, smoking, obesity, and co-existing disease (eg   diabetes).

Extrinsic factors that are treatment related and influence the delivery of therapy.  They include treatment dose, volume, fractionation, site of treatment, beam energy, adjuvant chemotherapy, and targeted therapies. Combined modality treatment, in particular, may lead to an increased risk of skin reactions (Turesson, 1996; Porock et al., 1998; Porock and Kristjanson, 1999; Richardson et al., 2005; Barnett et al., 2011; McQuestion, 2011).

2. Before radiotherapy begins, it is essential that a baseline assessment of the patient’s current skin condition and care is documented, including what skin products are being used currently. Assessments and review of the skin should continue for all patients on a regular basis throughout treatment, and at least on a weekly basis (Richardson et al., 2005; Fisher et al., 2000; NHS Scotland, 2010).

3. Education and health promotion strategies and interventions given to patients pre-treatment such as nutritional advice and smoking cessation would be beneficial and are advised (Wells et al., 2004; Wan et al. 2012; Sharp et al. 2013(a)).

4. Within a radiotherapy department, a single validated assessment tool and scoring criteria such as the RTOG should be agreed upon and adopted. Using the agreed validated tool and scoring criteria, radiotherapy departments should standardise the initial assessment and continued regular monitoring of skin reactions, and ensure that these are recorded (Cox et al., 1995; Campbell and Lane, 1996; Harris, 2002b; O'Shea et al., 2003).

5. Recording of patient acceptability/satisfaction and compliance with skin care advice is recommended as such information can be used to evaluate the appropriateness of skin care products for future patients (Harris, 1997; Noble-Adams, 1999; Gosselin, 2010).

6. To reduce friction to the treatment area advise patients to:

  • wear loose fitting natural fibre clothing next to the skin, for example a cotton T-shirt (Harris, 2002b; Gosselin, 2010).
  • wash the skin gently with soap and water and gently pat dry (Aistars, 2006; Bolderston et al., 2006; Aistars and Vehlow, 2007; Butcher and Williamson, 2012).
  • use aqueous cream instead of soap if wished but it is NOT recommended as a leave-on moisturiser (British National Formulary).
  • wash hair gently with usual shampoo if the scalp is in the treatment field, but do not dry with a hairdryer (Westbury et al., 2000; Bolderston et al., 2006).
  • avoid rubbing, heat and cooling pads/ice, shaving if possible, wax for hair removal and all hair removing creams/products, adhesive tape (Harris, 2002b; Gosselin, 2010).

7. To reduce irritation to the treatment area, advise the patient to:

  • use a moisturiser that is sodium lauryl sulphate free (Tsang and Guy, 2013; Patel et al., 2013).
  • avoid topical antibiotics unless there is a proven infection (Campbell and Lane, 1996; Korinko and Yurick, 1997).
  • continue to use normal deodorant (unless this irritates the skin), but discontinue if the skin is broken (Bennett, 2009; Butcher and Williamson, 2012; Watson et al., 2012; Wong et al., 2013; Lewis et al., 2014).
  • avoid sun exposure and shield the area from direct sunlight and use a high SPF sunscreen or sun-block. (Harris, 2002b).

8. On broken skin staff should:

  • use appropriate dressings/products on broken skin to reduce further trauma and infection. Suitable products would be non-adhesive, silicone low adhesion, non- or low-paraffin/petroleum jelly based. (see Appendix 9).
  • NOT use Gentian Violet (Campbell and Lane, 1996; Rice, 1997; Boot-Vickers and Eaton, 1999).

9. Establish effective, on-going liaison with community care/G.P services on post treatment skin (and other) care (Harris, 1997; Cumming and Routsis, 2009; CoR, 2011).

The core and stakeholder groups also suggest the following are necessary to ensure consistent patient care:

  • Standardised skin care education of all staff caring for patients receiving radiotherapy. All radiotherapy departments should implement pre-treatment skin assessment with baseline observations and pre-radiotherapy review and health promotion strategies. This should be followed with regular reviews (at least weekly, and more often depending on individual needs).
  • This can be undertaken by members of the radiotherapy team who have been trained to use the tools, and inter-observer variability between clinicians, radiographers, and radiotherapy nurses should be assessed periodically.
  • Agreement on standardisation of assessment tools across departments in the United Kingdom would aid in gathering information nationally.
  • 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, based on expert consensus of the evidence base. 
  • Further investigations into the skin care reactions caused by superficial, orthovotlage, and proton beam radiotherapy are required.

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