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Background

Skin may react to radiotherapy in a number of ways. There are, however, three main levels of skin reaction routinely encountered in the modern radiotherapy department:

  • erythema dry
  • desquamation
  • moist desquamation

Erythema is a reddening of the skin and is the first sign that the skin has been affected by radiation. This resembles a ‘sun reaction’ and the skin tends to feel warm, sensitive and tight18. Erythema reactions tend to occur at doses of 2000- 4000 cGy19.

Dry desquamation is an atypical keratinisation of the skin owing to the reduction of the clonogenic cells in the basal layer of the epidermis and the accompanying erythema is an inflammatory reaction20: the skin will appear dry and scaly. In dry desquamation there is no transgression of skin integrity but this can be an irritating and itchy condition. Dry desquamation occurs mainly at doses of 3000 cGy and higher19.

Moist desquamation is the loss of the epidermis and has the potential to be a more serious situation as there is an open wound with potential for infection. The skin will look red and inflamed and the wound will secrete exudate. This can be a very uncomfortable and distressing condition. Moist desquamation tends to occur at doses of 4000 cGy and higher19.

In Barkham’s 1993 assessment13, 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 al21 note, the incidence of skin reactions has not been accurately quantified in departments and practices have changed since Barkham’s survey. Therefore, the extent of the problem appears to be largely unknown.

Turesson et al22 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. The variation in the reaction appears to be a genetic predisposition due to individual DNA repair capacity23-28, genetic radiosensitivity29-31 and/or intravascular thrombin generation32. Specific genetic tests could therefore be used to predict those patients most likely to develop a severe radiotherapy reaction33,34.

Certain clinical factors can also help to predict the possibility of a radiation reaction35,36. Extrinsic factors are treatment-related, such as dose; volume; fractionation; adjuvant treatment; treatment in a skin fold area (ie inframammary fold or rectal cleft); use of bolus material; type of immobilisation; treatment technique37. These factors need to be under constant review with changing work practices; for example, with the introduction of IMRT. Intrinsic factors are individual patient-related such as larger breast size;20,37 higher Body Mass Index (BMI);26,38,39 pre-existing conditions (eg psoriasis)22,40. Such intrinsic factors may enhance a skin reaction and therefore should be recorded as a baseline and closely monitored12, 41-43.

Gosselin44 notes that some studies of skin care products did show promising results but comparative data across studies has not been assisted by the use of various assessment tools. By utilising skin care assessment tools on at least a weekly review basis, it would be possible to monitor and record a patient’s skin reaction throughout the treatment stage. This would provide valuable data which could be audited and would contribute to the growing knowledge-base in order to develop skin care practice and determine when and for whom intervention is required.

Naylor and Mallet45 undertook a literature review to investigate the products being used for radiotherapy skin reactions and the evidence base behind their use. They identified certain products where evidence contraindicated use:

  • petroleum jelly46-48 as it may create a build up effect and is difficult to remove
  • topical antibiotics unless there is a proven infection16,47,48
  • topical steroids on broken skin owing to the adverse effect on the wound healing process46,49-51
  • Gentian Violet owing to potential carcinogenic side effects16,50,52.

Another important aspect of skin care during radiotherapy is that of patient well being. It may not be possible to stop or even reduce the rates of skin reaction from occurring, but there may be comfort and psychosocial benefits that skin care products provide44. Therefore, there is a need for evaluation into the cost effectiveness of products being used on the skin. Recording of patient acceptability/satisfaction and compliance (as incorporated into some existing scales53 are helpful indicators of how appropriate a product will be for future patients.

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