CareofRadiationSkinReactions.pdf

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm. Page 1 of 17

CARE OF RADIATION SKIN REACTIONS Definition Radiation skin reactions are a common side effect of radical ionizing radiation treatment. The pathophysiology of a radiation skin reaction is a combination of radiation injury and the subsequent inflammatory response and can occur at both the entrance and exit site of the irradiation. Ionizing radiation damages the mitotic ability of stem cells within the basal layer preventing the process of repopulation and weakening the integrity of the skin. Reactions are evident one to four weeks after beginning treatment and can persist for several weeks post treatment. Factors Contributing to the Severity of Radiation Skin Reactions Type of Radiation and Energy

A source of radiation used in cancer treatment is a linear accelerator. This high voltage machine generates ionizing radiation from electricity to deliver external beam radiation therapy in the form of photons or electrons

Radiation treatments delivered by external beam vary in depth depending on the energy of the beam produced

Photons penetrate more deeply with increasing energy and also partially spare the skin from the effect of radiation; while electrons have shallow depth and high skin dose

Treatment Technique There is evidence to suggest that specific treatment techniques such as Intensity Modulated Radiation Therapy (IMRT) are associated with a decreased severity of acute radiation skin reactions

Location of the Treatment Field

The radiation skin reaction may be more severe depending on the location of the treatment field i.e. sites where two skin surfaces are in contact such as the breast or buttocks

Volume of Treated Tissue

The total volume of the area treated is considered when the dose is prescribed because larger areas of body surface will be irradiated which may result in increased skin toxicity

Dose, Time and Fractionation Parameters

Radiation treatments are prescribed in units of measurement known as Gy (Gray) or cGy (centiGray) with 1 Gy equaling 100 cGy

In order to manage the toxicities associated with radiation therapy, the total dose is divided into multiple daily doses called fractions

Chemotherapeutic Agents

The effects of ionizing radiation therapy are enhanced by specific radiosensitizers such as doxorubicin, 5-fluorouracil and bleomycin

Co-existing Chronic Illnesses

Coexisting chronic illnesses such as anemia, diabetes mellitus and suppression of the immune system may contribute to the severity of the radiation skin reaction

Tobacco Use Smoking limits the oxygen carrying capacity of hemoglobin. Elevated carboxyhemoglobin levels have been associated with changes to the epithelium and increased platelet stickiness. Nicotine affects macrophage activity and reduces epithelialization

Age Vasculoconnective damage caused by ionizing radiation, when combined with the degenerative changes to the epidermis and dermis, leads to an exacerbation of radiation skin reactions as age increases

Nutritional Status Malignancy alone can compromise nutritional status. Patients who are poorly nourished may be at risk for poor wound healing


Consequences Radiation skin reactions commonly progress from erythema to dry desquamation to moist desquamation and rarely to ulceration. Additionally, with current technology and treatment delivery, necrosis is now also a rare occurrence. Patients may complain of tenderness, discomfort, pain or burning in the treated skin. Some patients note a change in activities of daily living as a consequence of the skin reaction. General Skin Care Recommendations Washing: Patients should be encouraged to wash the irradiated skin daily using warm water and non perfumed soap. The use of wash cloths may cause friction and are therefore discouraged. The use of a soft towel to pat dry is recommended. Use of Deodorants: Patients may continue to use deodorants during radiation therapy. Other Skin Products: Patients are discouraged from using any perfumed products which may possess chemical irritants and induce discomfort. Products such as gels or creams should be applied at room temperature. Patients should be encouraged to use products advocated by the radiation department. Hair Removal: The use of an electric shaver is recommended and wax or other depilatory creams are discouraged. Patients are asked not to shave the axilla if it is within the treatment field. Swimming: Patients may continue to swim in chlorinated pools but should rinse afterwards and apply a moisturizing lotion. Patients experiencing a radiation skin reaction which has progressed beyond dry desquamation should avoid swimming. Heat and Cold: Patients are encouraged to avoid direct application of heat or cold to the irradiated area i.e. ice or electric heating pads. Band-Aids, Tape and Clothing: Rubbing, scratching and massaging the skin within the treatment area causes friction and should be discouraged. The use of Band-Aids or tape on the skin should also be avoided. Wearing loose fitting cotton clothing may avoid traumatic shearing and friction injuries. The use of a mild detergent to wash clothing is also recommended. Sun Exposure: Patients should be instructed to avoid direct sun exposure and cover the irradiated skin. The use of sunscreen products with at least SPF 30 are recommended for at least one year following treatment. Care of Malignant Wounds During Radiation Therapy Malignant wounds are the result of cancerous cells infiltrating the skin and its supporting blood and lymph vessels causing loss in vascularity leading to tissue death. The lesion may be a result of a primary cancer or a metastasis to the skin from a local tumour or from a tumour in a distant site. It may take the form of a cavity, an open area on the surface of the skin, skin nodules, or a nodular growth extending from the surface of the skin. A malignant wound may present with odour, exudate, bleeding, pruritis and pain and interfere with the patients quality of life. Treating the underlying cause of a malignant wound may involve surgery, radiation therapy, chemotherapy or hormone therapy. Managing symptoms such as bleeding, exudate and pain, reducing tumor size and promoting wound healing whenever possible can be additional aims of treatment. A reduction in the impact of symptoms may contribute to the overall comfort of the patient. The goal of radiation therapy is to reduce tumour size. As the tumour becomes smaller, a radiation skin reaction may develop on surrounding tissue and the patient may experience erythema, dry desquamation and moist desquamation. Skin care practices During Radiation Therapy: If the malignant lesion is encapsulated, skin care practices are the same as for patients with intact skin. However, if the lesion erupts (as a result of the inflammatory response associated with radiation therapy) skin care practices for open wounds should be initiated. The principles of moist wound healing should be applied from the beginning of treatment to promote patient comfort and create an optimal wound environment in the open lesion and in any radiation skin reaction in surrounding tissues. Applying products which absorb drainage is essential to avoid infection and promote comfort. Protecting the surrounding intact skin is a priority therefore observing the general skin care recommendations is required. http://www.bccancer.bc.ca/NR/rdonlyres/0A61B812-801E-4F1E-8375-A89A8BD58377/51006/M30CareofMalignantWounds.pdf


Principle of Moist Healing Cell growth needs moisture and the principle aim of moist wound therapy is to create and maintain optimal moist conditions. Cells can grow, divide and migrate at an increased rate to optimize the formation of new tissue. During this phase of wound healing an aqueous medium with several nutrients and vitamins is essential for cell metabolism and growth.

The wound exudate serves as a transport medium for a variety of bioactive molecules such as enzymes, growth factors and hormones. The different cells in the wound area communicate with each other via these mediators, making sure that the healing processes proceed in a coordinated manner.

Wound exudate also provides the different cells of the immune system with ideal conditions to destroy invading pathogens such as bacteria, foreign bodies and necrotic tissues, diminishing the rate of infection. Moist wound treatment is known to prevent formation of a scab, allowing epithelial cells to spread horizontally outwards through the thin layer of wound exudate to rapidly close the wound.


Focused Health Assessment GENERAL ASSESSMENT SYMPTOM ASSESSMENT PHYSICAL ASSESSMENT Contact Information Physician name -

oncologist, general practitioner (GP)

Pharmacy (if applicable) - name and contact information

Home health care (if applicable) name and contact information

Consider Causative/Contributing Factors Cancer diagnosis (site) Cancer treatment: date of

last treatment/s, concurrent treatments, volume of tissue treated, technique, type of radiation and energy, location of treatment field, volume of tissue treated, dose, time and fractionation

Co-morbidities Nutritional status Tobacco use Recent lab or diagnostic

reports

Normal What is the condition of your skin normally? What are your normal hygiene practices? Onset When did the changes in your skin begin? Provoking / Palliating What makes it feel better or worse? Quality (in the last 24 hours) Do you have any pain, redness, dry or scaling skin,

blisters or drainage? Do you have any swelling? Severity / Other Symptoms Since your last visit, how would you rate the

discomfort associated with the skin reaction? between 0-10? What is it now? At worst? At best? On average?

Have you been experiencing any other symptoms: fever, discharge, bleeding

Treatment When was your last cancer treatment (radiation or

chemotherapy)? How have you been managing the radiation skin

reaction? (cream, ointments, dressings) Are you currently using any medications? How

effective are they? Any side effects? Understanding / Impact on You Is your skin reaction and treatment impacting your

activities of daily living (ADL)? Do you require any support to (family, home care

nursing) complete your skin care routine? Are you having any difficulty sleeping, eating,

drinking? Value What is your comfort goal or acceptable level for this

symptom?

Vital Signs Include temperature,

pulse, respiratory rate and blood pressure Frequency as clinically indicated

Physical Assessment Assess skin condition Location Colour Size Wound base (if present) Discomfort Drainage (if present) Signs of infection


DERMATITIS GRADING SCALE Adapted NCI CTCAE (Version 3.0)

GRADE 0 (Normal)

GRADE 1 (Mild)

GRADE 2 (Moderate)

GRADE 3 (Severe)

GRADE 4

Normal Faint erythema or dry desquamation

Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases; moderate edema

Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion

Skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site

GRADE 0 GRADE 1

NON URGENT Support, teaching, & follow-up as clinically indicated

Clinical Presentation Erythema Pink to dusky colouration May be accompanied by mild edema Burning, itching and mild discomfort Dry desquamation Partial loss of the epidermal basal cells Dryness, itching, scaling, flaking and peeling Hyperpigmentation Brisk Erythema Dry Desquamation

Reaction Assessment

Assessment to include: Location Size of area Colour Discomfort (burning, itching, pulling, tenderness) erythema Discomfort (dryness, itching, scaling, flaking, peeling) dry desquamation

Promote Cleanliness Use non-perfumed soap. Bathe using warm water and palm of hand to gently wash affected skin. Rinse well and pat dry with a soft towel

Wash hair using warm water and mild, non-medicated shampoo such as baby shampoo Patients receiving RT for perineal/rectal cancer, should use a sitz bath daily beginning at the

start of treatment Promote Comfort Apply hydrophilic (water based) body lotions or creams on affected area. Gently apply with

clean hand twice a day. Do not rub skin Avoid petroleum jelly based products Avoid irritant products containing alcohol, perfumes, or additives and products containing

Alpha Hydroxy Acids (AHA) Normal saline compresses up to 4 times daily

Reduce Inflammation Alleviate pruritus and inflammation. Corticosteroid creams may be used sparingly as ordered by the physician


GRADE 0 GRADE 1 Continued

NON URGENT Support, teaching, & follow-up as clinically indicated

Prevent Trauma to the Treatment Area

For facial and underarm shaving, use an electric razor Recommend loose, non-binding, breathable clothing such as cotton Protect skin from direct sunlight and wind exposure by wearing a wide brimmed hat and

protective clothing Remove wet swimwear, shower and apply moisturizer after swimming in pools and lakes Avoid extremes of heat and cold, including hot tubs, heating pads and ice packs Avoid adhesive tape. Extend dressing out of treatment area and adhere to intact skin with paper

tape. Secure dressing with cling gauze, net tubing or under clothing Follow-Up Patients to be assessed at each visit. If symptoms are not resolved, provide further information

regarding recommended strategies - Instruct patient/family to call back if radiation skin reaction worsens - Arrange for nurse initiated telephone followup

Document assessment, intervention and patient care plan Communicate with health care team as appropriate

Possible Referrals and Resources

Registered Nurse Physician


GRADE 2 GRADE 3

URGENT: Requires medical attention within 24 hours

Clinical Presentation

Moist Desquamation Sloughing of the epidermis and exposure of the dermal layer Blister or vesicle formation Serous drainage Pain Moist Desquamation

Reaction Assessment

Assessment to include: Location

- Moist areas - Dry areas

Size of area Wound base: granular tissue, eschar or necrotic tissue Exudate

- Type - Amount - Odour

Discomfort (burning, itching, pulling, tenderness) Signs of clinical infection

- fever - foul odour - purulent drainage - pain and swelling extending outside of radiation area

Promote Cleanliness

Cleanse with warm or room temperature normal saline Apply normal saline compresses up to 4 times daily Patients receiving RT for perineal/rectal cancer, should use a sitz bath daily beginning at the start

of treatment Maintain Principles of Moist Healing

Can use a moisture retentive protective barrier ointment after each saline soak Consider the use of hydrogels Use a non-adherent dressing Use absorbent dressings over non-adherent dressings. Change as drainage warrants Control drainage. Consider using hydrocolloid dressings

Manage Pain Cover open areas to protect nerve endings. To significantly decrease burning and tenderness use non-adherent or low adherent dressings

Assess pain at each appointment (Link to Pain SMG) Administer analgesics as ordered by the physician

Prevention of Infection

Regularly assess for signs of infection Culture wound if infection suspected Apply antibacterial/antifungal products as ordered by the physician



URGENT: Requires medical attention within 24 hours


For facial and underarm shaving, use an electric razor Recommend loose, non-binding clothing Protect skin from direct sunlight and wind exposure Discontinue swimming in pools and lakes Avoid extremes of heat and cold, including hot tubs Avoid adhesive tape. Extend dressing out of treatment area and adhere to intact skin with paper

tape. Other products include cling gauze and net tubing under clothing Follow-Up Patients to be assessed at each visit. If symptoms are not resolved, provide further information

regarding recommended strategies - Instruct patient/family to call back if radiation skin reaction worsens - Arrange for nurse initiated telephone followup




GRADE 4

EMERGENT: Requires IMMEDIATE medical attention

Clinical Presentation Rarely occurs Skin necrosis or ulceration of full thickness dermis May have spontaneous bleeding from the site Pain

Reaction Assessment







Promote Cleanliness Cleanse with warm or room temperature normal saline Apply normal saline compresses up to 4 times daily (or as required)


GRADE 4 Continued

EMERGENT: Requires IMMEDIATE medical attention

Maintain Principles of Moist Healing

Maintain a moist environment for healing Use a non-adherent dressing Layer dressings as appropriate. If dressings overlap, apply the dressing with the longest

wear time first. Label dressings with date May require debridement

Prevent Trauma Use a non-adherent dressing Secure products with appropriate secondary dressing Avoid adhesive tape. Extend dressing out of treatment area and adhere to intact skin with

paper tape. Other products include cling gauze and net tubing under clothing Manage Pain Cover open areas to protect nerve endings

Use non-adherent or low adherent dressings Assess pain at each appointment (Link to Pain SMG) Administer analgesics as ordered by the physician



Follow-Up Patients to be re-assessed at each visit Instruct patient/family to contact the Health Care Professional if the skin reaction worsens Document assessment, intervention, and patient care plan Communicate with health care team as appropriate




Potential Post-Radiation Skin Reaction Late Reactions

Definition Skin reactions occurring six or more months after completion of radiation therapy The clinical presentation and the degree of late reaction vary. Patient care will be

individualized and based on the degree of severity. Clinical Presentation Pigmentation changes

Permanent hair loss Telangectasia Fibrous changes Atrophy Ulceration

Reaction Assessment







Maintain Skin Flexibility

Apply hydrophilic (water based) body lotions or creams on affected area. Gently apply with clean hand twice a day. Do not rub skin

Prevent Injury Avoid excessive sun exposure. Wear protective clothing. Sunblocking creams or lotions with minimum SPF 30 recommended at all times

Manage Pain Assess pain at each appointment (Link to Pain SMG) Administer analgesics as ordered by the physician



Follow-Up Patients to be assessed at each visit. If symptoms are not resolved, provide further information regarding recommended strategies - Instruct patient/family to call back if radiation skin reaction worsens - Arrange for nurse initiated telephone followup





Potential Post-Radiation Skin Reaction Recall Phenomenon

Definition Recall phenomenon occurs when skin reactions manifest very rapidly within a previously treated radiation field, following the administration of chemotherapy drugs

Clinical Presentation Symptoms of moist desquamation Rapid onset and progression

Reaction Assessment







Promote Cleanliness Cleanse with warm or room temperature normal saline Apply normal saline compresses up to 4 times daily Patients receiving RT for perineal/rectal cancer, should use a sitz bath daily beginning at the

start of treatment Maintain Principles of Moist Healing

Can use a moisture retentive protective barrier ointment after each saline soak Consider the use of hydrogels Use an non-adherent dressing Use absorbent dressings over low-adherent dressings. Change as drainage warrants Control drainage. Consider using hydrocolloid dressings

Manage Pain Cover open areas to protect nerve endings Use non-adherent or low adherent dressings Assess pain at each appointment (Link to Pain SMG) Administer analgesics as ordered by the physician



Follow-Up Patients to be assessed at each visit. If symptoms are not resolved, provide further information regarding recommended strategies - Instruct patient/family to call back if radiation skin reaction worsens - Arrange for nurse initiated telephone followup





Treatment Procedures

Application of Topical Products Moisturizing Products

Instruct the patient to gently apply a thin layer of water soluble moisturizing ointment or cream using their clean hand 2 to 4 times daily to the skin in the treatment area

Corticosteroid Creams

A prescription for hydrocortisone cream is required Do not use hydrocortisone if a skin infection is suspected as it may mask signs of infection and increasing severity of the radiation skin reaction Do not use hydrocortisone on a long-term basis as it may cause problems resulting from

reduced blood flow to the skin Instruct patient to gently apply a very thin layer of hydrocortisone cream using their clean

hand as prescribed by the physician Instruct patient to apply to skin in the treatment area until discomfort decreases and to wash

hands after application Discontinue use of hydrocortisone if there is any exudate from the affected area

Barrier Creams Instruct patient to apply a thin layer of (water soluble) barrier cream to the treatment area Non-adhesive dressings may be applied, depending on the location of the skin reaction

Normal Saline Compresses

Indications To reduce discomfort due to inflammation or skin irritation To cleanse open areas To loosen dressings

Contraindication Increased discomfort during procedure Procedure Moisten gauze with warm or room temperature saline solution

Wring out excess moisture (ensure that gauze will not dry out and adhere to open area) Apply moist gauze to open areas for 10-15 minutes. Cover compress with abdominal pad or disposable under-pad to retain warmth and moisture Remove gauze and gently irrigate wound with normal saline if required to remove any debris Gently dry surrounding skin Apply dressing/other treatments as indicated Repeat up to 4 times daily or as required

Note Continuous moist saline compresses may be indicated for short term use (24-48hrs.) for a necrotic or heavily exudative wound. It is critical that the compress is replaced frequently enough that it does not dry out and adhere to the area. Moist gauze is applied only to the wound area to avoid maceration of intact skin

Sitz Baths

Purpose Perineal hygiene is the primary reason for using a sitz bath during/post RT when the area is tender and inflamed

Indications Use at onset of treatment for comfort and cleanliness Use at any time for any skin reaction in the perineal/peri-rectal area Discomfort with defecation Continuous discomfort due to perineal inflammation, hemorrhoids, radiation-induced diarrhea

Contraindication Discomfort during procedure Procedure Water should be warm (40-43C)

Hot water can cause increased drying of skin Warm water will increase vasoconstriction and may decrease the itching Do not add bath oils or other products to water A hand held shower with a gentle spray or bathtub may be appropriate alternatives Maximum 10-15 minutes, repeat up to 4 times daily and/or after each bowel movement Gently pat area dry with a soft towel or expose area to room air


Silver Sulfadiazine Cream (antibacterial) Purpose To reduce risk of infection

To reduce discomfort To maintain moist healing environment To reduce adherence of dressings

Indications The treatment and prophylaxis of infection in open wounds (moist desquamation) Contraindications Allergy to sulfa

Should not be used for patients with history of severe renal or hepatic disease or during pregnancy

Procedure Gently cleanse wound area with normal saline if area is small and dressing is easily removed Cleanse with tap water (sink, bathtub, shower or sitz bath) if area is large, difficult to cleanse

or adherence of dressing is a problem It is important to gently remove all residual cream from previous applications (saline

compresses may be required) Apply a thin layer of cream to area of affected skin only Apply appropriate secondary dressing Change dressing at least once daily

Hydrogels Hydrogel is a sterile wound gel for helping create or maintain a moist environment. Some hydrogels provide absorption, desloughing and debriding capacities to necrotic and fibrotic tissue. Hydrogel sheets are cross-linked polymer gels in sheet form

Purpose To increase comfort (cooling effect on skin) To increase moisture content To absorb small amounts of exudate

Indications Moist desquamation with minimal exudate Contraindication Not advised for infected wounds

Moderate to heavily exudating wounds Areas that need to be kept dry

Procedure Cleanse area with normal saline soaks or sitz baths Pat dry surrounding skin Either apply a thin layer of hydrogel directly onto the area of moist desquamation or apply with

a tongue depressor Cover with non-adhesive dressing (may be secured by clothing if patient is ambulatory) May be used in combination with transparent films, foams, hydrocolloids or other non-

adherents Reapply at least daily and always following normal saline soaks/sitz baths

Hydrocolloid Dressings Hydrocolloids are occlusive and adhesive water dressing which combine absorbent colloidal material with adhesive elastomeres to manage light to moderate amount of wound exudate. Most hydrocolloids react with wound exudate to form a gel-like covering which protect the wound bed and maintain a moist wound environment Purpose Maintain moist wound bed

To increase comfort Support autolytic debridement by keeping wound exudate in contact with necrotic tissue

Indications Moist desquamation with moderate exudate Contraindication Not advised for infected wounds

Heavily exudating wounds Procedure Cleanse area with normal saline soaks or sitz baths

Pat dry surrounding skin Choose a dressing that extends beyond the wound Remove backing and apply to wound Change dressing as required depending on causative factors, contributing factors and amount

of exudate


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Szumacher, E., Wighton, A., Franssen, E., Chow, E., Tsao, M., Ackerman, I., Kim, J., Wojcicka, A., Yee, U., Sixel, K., & Hayter, C., (2001). Phase II study assessing the effectiveness of biafine cream as a prophylactic agent for radiation-induced acute skin toxicity to the breast in women undergoing radiotherapy and concomitant CMF chemotherapy. International Journal of Radiation Oncology, Biology & Physics. 51(1), pp.81-86. Theberge, V., Harel, F., & Dagnault, A., (2008). Use of Axillary Deodorant and Effect on Acute Skin Toxicity During Radiotherapy for Breast Cancer: A Prospective Randomized Noninferiority Trial. International Journal of Radiation Oncology, Biology & Physics. 75 (4), pp. 1048-1052. Watson, L., Gies, D., Thompson, E., & Thomas, B., (2012). Randomized Control Trial: Evaluating Aluminum-Based Antiperspirant Use, Axilla Skin Toxicity, and Reported Quality of Life in Women Receiving External Beam Radiotherapy for Treatment of Stage 0, 1, and II Breast Cancer. International Journal of Radiation Oncology, Biology and Physics. 83 (1), pp. 29-34. Wells, M., Macmillan, M., Raab, G., MacBride, S., Bell, N., MacKinnon, K., MacDougall, H., Samuel, L., & Munro, A., (2004). Does aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomized controlled trial. Radiotherapy and Oncology. 73, pp.153-162. Wickline, M., (2004). Prevention and Treatment of Acute Radiation Dermatitis: A Literature Review. Oncology Nursing Forum. 31 (2), pp.237-244. Williams, M., Burk, M., Loprinzi, C., Hill, M., Schomberg, P., Nearhood, K., OFallon, J., Laurie, J., Shanahan, T., Moore, R., Uria, R., Kuske, R., Engel, R., & Eggleston, W., (1996). Phase III Double Blind Evaluation of an Aloe Vera Gel as a Prophylactic Agent for Radiation Induced Skin Toxicity. International Journal Radiation Oncology, Biology, & Physics. 36 (2), pp.345-349. Vuong, T., Franco, E., Lehnert, S., Lambert, C., Portelance, L., Nasr, E., Faria, S., Hay, J., Larsson, S., Shenouda, G., Souhami, L., Wong, F., & Freeman C., (2004). Silver Leaf Nylon Dressing To Prevent Radiation Dermatitis In Patients Undergoing Chemotherapy And External Beam Radiotherapy To The Perineum. International Journal of Radiation Oncology, Biology, & Physics.

59 (3), pp.809-814.

Date of Print: Revised July 18, 2012 Contributing Authors: Anne Hughes, Regional Professional Practice Leader, Nursing Alison Mitchell, Radiation Therapy Educator VIC June Bianchini, Assessment Module Leader CSI Frankie Goodwin, Assessment Module Leader Normita Guidote RN Rachelle Gunderson RN Ann Hulstyn RN Susan Kishore RT Krista Kuncewicz RT Sheri Lomas RT Gillian Long, Radiation Educator AC Heather Montgomery RN Dawn Robertson RN Jenny Soo, Radiation Educator VC Stacey Tanaka RN Victoria van le Leest RT Wendy Vanhoerden RN Tara Volpatti RT Dr. Frances Wong, Radiation Oncologist FVC Karen Yendley RT Reviewed By: British Columbia Cancer Agency Radiation Therapy Skin Care Committee Dr. Hosam Kader, Radiation Oncologist VIC Dr. Jonn Wu, Radiation Oncologist FVC BCCA Nursing Practice Committee

CARE OF RADIATION SKIN REACTIONS

Definition

Radiation skin reactions are a common side effect of radical ionizing radiation treatment. The pathophysiology of a radiation skin reaction is a combination of radiation injury and the subsequent inflammatory response and can occur at both the entrance and exit site of the irradiation. Ionizing radiation damages the mitotic ability of stem cells within the basal layer preventing the process of repopulation and weakening the integrity of the skin. Reactions are evident one to four weeks after beginning treatment and can persist for several weeks post treatment.

Factors Contributing to the Severity of Radiation Skin Reactions

Type of Radiation and Energy

A source of radiation used in cancer treatment is a linear accelerator. This high voltage machine generates ionizing radiation from electricity to deliver external beam radiation therapy in the form of photons or electrons

Radiation treatments delivered by external beam vary in depth depending on the energy of the beam produced

Photons penetrate more deeply with increasing energy and also partially spare the skin from the effect of radiation; while electrons have shallow depth and high skin dose

Treatment Technique

There is evidence to suggest that specific treatment techniques such as Intensity Modulated Radiation Therapy (IMRT) are associated with a decreased severity of acute radiation skin reactions

Location of the Treatment Field

The radiation skin reaction may be more severe depending on the location of the treatment field i.e. sites where two skin surfaces are in contact such as the breast or buttocks

Volume of Treated Tissue

The total volume of the area treated is considered when the dose is prescribed because larger areas of body surface will be irradiated which may result in increased skin toxicity

Dose, Time and Fractionation Parameters

Radiation treatments are prescribed in units of measurement known as Gy (Gray) or cGy (centiGray) with 1 Gy equaling 100 cGy

In order to manage the toxicities associated with radiation therapy, the total dose is divided into multiple daily doses called fractions

Chemotherapeutic Agents

The effects of ionizing radiation therapy are enhanced by specific radiosensitizers such as doxorubicin, 5-fluorouracil and bleomycin

Co-existing Chronic Illnesses

Coexisting chronic illnesses such as anemia, diabetes mellitus and suppression of the immune system may contribute to the severity of the radiation skin reaction

Tobacco Use

Smoking limits the oxygen carrying capacity of hemoglobin. Elevated carboxyhemoglobin levels have been associated with changes to the epithelium and increased platelet stickiness. Nicotine affects macrophage activity and reduces epithelialization

Age

Vasculoconnective damage caused by ionizing radiation, when combined with the degenerative changes to the epidermis and dermis, leads to an exacerbation of radiation skin reactions as age increases

Nutritional Status

Malignancy alone can compromise nutritional status. Patients who are poorly nourished may be at risk for poor wound healing

Consequences

Radiation skin reactions commonly progress from erythema to dry desquamation to moist desquamation and rarely to ulceration. Additionally, with current technology and treatment delivery, necrosis is now also a rare occurrence. Patients may complain of tenderness, discomfort, pain or burning in the treated skin. Some patients note a change in activities of daily living as a consequence of the skin reaction.

General Skin Care Recommendations

Washing: Patients should be encouraged to wash the irradiated skin daily using warm water and non perfumed soap. The use of wash cloths may cause friction and are therefore discouraged. The use of a soft towel to pat dry is recommended.

Use of Deodorants: Patients may continue to use deodorants during radiation therapy.

Other Skin Products: Patients are discouraged from using any perfumed products which may possess chemical irritants and induce discomfort. Products such as gels or creams should be applied at room temperature. Patients should be encouraged to use products advocated by the radiation department.

Hair Removal: The use of an electric shaver is recommended and wax or other depilatory creams are discouraged. Patients are asked not to shave the axilla if it is within the treatment field.

Swimming: Patients may continue to swim in chlorinated pools but should rinse afterwards and apply a moisturizing lotion. Patients experiencing a radiation skin reaction which has progressed beyond dry desquamation should avoid swimming.

Heat and Cold: Patients are encouraged to avoid direct application of heat or cold to the irradiated area i.e. ice or electric heating pads.

Band-Aids, Tape and Clothing: Rubbing, scratching and massaging the skin within the treatment area causes friction and should be discouraged. The use of Band-Aids or tape on the skin should also be avoided. Wearing loose fitting cotton clothing may avoid traumatic shearing and friction injuries. The use of a mild detergent to wash clothing is also recommended.

Sun Exposure: Patients should be instructed to avoid direct sun exposure and cover the irradiated skin. The use of sunscreen products with at least SPF 30 are recommended for at least one year following treatment.

Care of Malignant Wounds During Radiation Therapy

Malignant wounds are the result of cancerous cells infiltrating the skin and its supporting blood and lymph vessels causing loss in vascularity leading to tissue death. The lesion may be a result of a primary cancer or a metastasis to the skin from a local tumour or from a tumour in a distant site. It may take the form of a cavity, an open area on the surface of the skin, skin nodules, or a nodular growth extending from the surface of the skin. A malignant wound may present with odour, exudate, bleeding, pruritis and pain and interfere with the patients quality of life.

Treating the underlying cause of a malignant wound may involve surgery, radiation therapy, chemotherapy or hormone therapy. Managing symptoms such as bleeding, exudate and pain, reducing tumor size and promoting wound healing whenever possible can be additional aims of treatment. A reduction in the impact of symptoms may contribute to the overall comfort of the patient.

The goal of radiation therapy is to reduce tumour size. As the tumour becomes smaller, a radiation skin reaction may develop on surrounding tissue and the patient may experience erythema, dry desquamation and moist desquamation.

Skin care practices During Radiation Therapy: If the malignant lesion is encapsulated, skin care practices are the same as for patients with intact skin. However, if the lesion erupts (as a result of the inflammatory response associated with radiation therapy) skin care practices for open wounds should be initiated. The principles of moist wound healing should be applied from the beginning of treatment to promote patient comfort and create an optimal wound environmentin the open lesion and in any radiation skinreaction in surrounding tissues. Applying products which absorb drainage is essential to avoid infection and promote comfort. Protecting the surrounding intact skin is a priority therefore observing the general skin care recommendations is required.

http://www.bccancer.bc.ca/NR/rdonlyres/0A61B812-801E-4F1E-8375-A89A8BD58377/51006/M30CareofMalignantWounds.pdf

Principle of Moist Healing

Cell growth needs moisture and the principle aim of moist wound therapy is to create and maintain optimal moist conditions. Cells can grow, divide and migrate at an increased rate to optimize the formation of new tissue. During this phase of wound healing an aqueous medium with several nutrients and vitamins is essential for cell metabolism and growth.

The wound exudate serves as a transport medium for a variety of bioactive molecules such as enzymes, growth factors and hormones. The different cells in the wound area communicate with each other via these mediators, making sure that the healing processes proceed in a coordinated manner.

Wound exudate also provides the different cells of the immune system with ideal conditions to destroy invading pathogens such as bacteria, foreign bodies and necrotic tissues, diminishing the rate of infection. Moist wound treatment is known to prevent formation of a scab, allowing epithelial cells to spread horizontally outwards through the thin layer of wound exudate to rapidly close the wound.

Focused Health Assessment

GENERAL ASSESSMENT

SYMPTOM ASSESSMENT

PHYSICAL ASSESSMENT

Contact Information

Physician name - oncologist, general practitioner (GP)

Pharmacy (if applicable) - name and contact information

Home health care (if applicable) name and contact information

Consider Causative/Contributing Factors

Cancer diagnosis (site)

Cancer treatment: date of last treatment/s, concurrent treatments, volume of tissue treated, technique, type of radiation and energy, location of treatment field, volume of tissue treated, dose, time and fractionation

Co-morbidities

Nutritional status

Tobacco use

Recent lab or diagnostic reports

Normal

What is the condition of your skin normally?

What are your normal hygiene practices?

Onset

When did the changes in your skin begin?

Provoking / Palliating

What makes it feel better or worse?

Quality (in the last 24 hours)

Do you have any pain, redness, dry or scaling skin, blisters or drainage?

Do you have any swelling?

Severity / Other Symptoms

Since your last visit, how would you rate the discomfort associated with the skin reaction? between 0-10? What is it now? At worst? At best? On average?

Have you been experiencing any other symptoms: fever, discharge, bleeding

Treatment

When was your last cancer treatment (radiation or chemotherapy)?

How have you been managing the radiation skin reaction? (cream, ointments, dressings)

Are you currently using any medications? How effective are they? Any side effects?

Understanding / Impact on You

Is your skin reaction and treatment impacting your activities of daily living (ADL)?

Do you require any support to (family, home care nursing) complete your skin care routine?

Are you having any difficulty sleeping, eating, drinking?

Value

What is your comfort goal or acceptable level for this symptom?

Vital Signs

Include temperature, pulse, respiratory rate and blood pressure

Frequency as clinically indicated

Physical Assessment

Assess skin condition

Location

Colour

Size

Wound base (if present)

Discomfort

Drainage (if present)

Signs of infection

DERMATITIS GRADING SCALE

Adapted NCI CTCAE (Version 3.0)

GRADE 0

(Normal)

GRADE 1

(Mild)

GRADE 2

(Moderate)

GRADE 3

(Severe)

GRADE 4

Normal

Faint erythema or dry desquamation

Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases; moderate edema

Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion

Skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site

GRADE 0 GRADE 1

NON URGENT

Support, teaching, & follow-up as clinically indicated


Erythema

Pink to dusky colouration

May be accompanied by mild edema

Burning, itching and mild discomfort

Dry desquamation

Partial loss of the epidermal basal cells

Dryness, itching, scaling, flaking and peeling

Hyperpigmentation

Brisk Erythema Dry Desquamation

Reaction Assessment

Assessment to include:

Location

Size of area

Colour

Discomfort (burning, itching, pulling, tenderness) erythema

Discomfort (dryness, itching, scaling, flaking, peeling) dry desquamation

Promote Cleanliness

Use non-perfumed soap. Bathe using warm water and palm of hand to gently wash affected skin. Rinse well and pat dry with a soft towel

Wash hair using warm water and mild, non-medicated shampoo such as baby shampoo

Patients receiving RT for perineal/rectal cancer, should use a sitz bath daily beginning at the start of treatment

Promote Comfort


Avoid petroleum jelly based products

Avoid irritant products containing alcohol, perfumes, or additives and products containing Alpha Hydroxy Acids (AHA)

Normal saline compresses up to 4 times daily

Reduce Inflammation

Alleviate pruritus and inflammation. Corticosteroid creams may be used sparingly as ordered by the physician


NON URGENT

Support, teaching, & follow-up as clinically indicated


For facial and underarm shaving, use an electric razor

Recommend loose, non-binding, breathable clothing such as cotton

Protect skin from direct sunlight and wind exposure by wearing a wide brimmed hat and protective clothing

Remove wet swimwear, shower and apply moisturizer after swimming in pools and lakes

Avoid extremes of heat and cold, including hot tubs, heating pads and ice packs

Avoid adhesive tape. Extend dressing out of treatment area and adhere to intact skin with paper tape. Secure dressing with cling gauze, net tubing or under clothing

Follow-Up

Patients to be assessed at each visit. If symptoms are not resolved, provide further information regarding recommended strategies

Instruct patient/family to call back if radiation skin reaction worsens

Arrange for nurse initiated telephone followup

Document assessment, intervention and patient care plan

Communicate with health care team as appropriate


Registered Nurse

Physician

GRADE 2 GRADE 3

URGENT:

Requires medical attention within 24 hours


Moist Desquamation

Sloughing of the epidermis and exposure of the dermal layer

Blister or vesicle formation

Serous drainage

Pain

Moist Desquamation

Reaction Assessment


Location

Moist areas

Dry areas

Size of area

Wound base: granular tissue, eschar or necrotic tissue

Exudate

Type

Amount

Odour

Discomfort (burning, itching, pulling, tenderness)

Signs of clinical infection

fever

foul odour

purulent drainage

pain and swelling extending outside of radiation area

Promote Cleanliness

Cleanse with warm or room temperature normal saline

Apply normal saline compresses up to 4 times daily



Can use a moisture retentive protective barrier ointment after each saline soak

Consider the use of hydrogels

Use a non-adherent dressing

Use absorbent dressings over non-adherent dressings. Change as drainage warrants

Control drainage. Consider using hydrocolloid dressings

Manage Pain

Cover open areas to protect nerve endings. To significantly decrease burning and tenderness use non-adherent or low adherent dressings

Assess pain at each appointment (Link to Pain SMG)

Administer analgesics as ordered by the physician


Regularly assess for signs of infection

Culture wound if infection suspected

Apply antibacterial/antifungal products as ordered by the physician


URGENT:

Requires medical attention within 24 hours


For facial and underarm shaving, use an electric razor

Recommend loose, non-binding clothing

Protect skin from direct sunlight and wind exposure

Discontinue swimming in pools and lakes

Avoid extremes of heat and cold, including hot tubs

Avoid adhesive tape. Extend dressing out of treatment area and adhere to intact skin with paper tape. Other products include cling gauze and net tubing under clothing

Follow-Up







Registered Nurse

Physician

GRADE 4

EMERGENT:

Requires IMMEDIATE medical attention


Rarely occurs

Skin necrosis or ulceration of full thickness dermis

May have spontaneous bleeding from the site

Pain

Reaction Assessment


Location

Moist areas

Dry areas

Size of area


Exudate

Type

Amount

Odour



fever

foul odour

purulent drainage


Promote Cleanliness


Apply normal saline compresses up to 4 times daily (or as required)

GRADE 4 Continued

EMERGENT:

Requires IMMEDIATE medical attention


Maintain a moist environment for healing


Layer dressings as appropriate. If dressings overlap, apply the dressing with the longest wear time first. Label dressings with date

May require debridement

Prevent Trauma


Secure products with appropriate secondary dressing

Avoid adhesive tape. Extend dressing out of treatment area and adhere to intact skin with paper tape. Other products include cling gauze and net tubing under clothing

Manage Pain

Cover open areas to protect nerve endings

Use non-adherent or low adherent dressings







Follow-Up

Patients to be re-assessed at each visit

Instruct patient/family to contact the Health Care Professional if the skin reaction worsens

Document assessment, intervention, and patient care plan



Registered Nurse

Physician

Potential Post-Radiation Skin Reaction

Late Reactions

Definition

Skin reactions occurring six or more months after completion of radiation therapy

The clinical presentation and the degree of late reaction vary. Patient care will be individualized and based on the degree of severity.


Pigmentation changes

Permanent hair loss

Telangectasia

Fibrous changes

Atrophy

Ulceration

Reaction Assessment


Location

Moist areas

Dry areas

Size of area


Exudate

Type

Amount

Odour



fever

foul odour

purulent drainage


Maintain Skin Flexibility


Prevent Injury

Avoid excessive sun exposure. Wear protective clothing. Sunblocking creams or lotions with minimum SPF 30 recommended at all times

Manage Pain







Follow-Up







Registered Nurse

Physician

Potential Post-Radiation Skin Reaction

Recall Phenomenon

Definition

Recall phenomenon occurs when skin reactions manifest very rapidly within a previously treated radiation field, following the administration of chemotherapy drugs


Symptoms of moist desquamation

Rapid onset and progression

Reaction Assessment


Location

Moist areas

Dry areas

Size of area


Exudate

Type

Amount

Odour



fever

foul odour

purulent drainage


Promote Cleanliness


Apply normal saline compresses up to 4 times daily



Can use a moisture retentive protective barrier ointment after each saline soak

Consider the use of hydrogels

Use an non-adherent dressing

Use absorbent dressings over low-adherent dressings. Change as drainage warrants

Control drainage. Consider using hydrocolloid dressings

Manage Pain

Cover open areas to protect nerve endings

Use non-adherent or low adherent dressings







Follow-Up







Registered Nurse

Physician

Treatment Procedures

Application of Topical Products

Moisturizing Products

Instruct the patient to gently apply a thin layer of water soluble moisturizing ointment or cream using their clean hand 2 to 4 times daily to the skin in the treatment area

Corticosteroid Creams

A prescription for hydrocortisone cream is required

Do not use hydrocortisone if a skin infection is suspected as it may mask signs of infection

and increasing severity of the radiation skin reaction

Do not use hydrocortisone on a long-term basis as it may cause problems resulting from reduced blood flow to the skin

Instruct patient to gently apply a very thin layer of hydrocortisone cream using their clean hand as prescribed by the physician

Instruct patient to apply to skin in the treatment area until discomfort decreases and to wash hands after application

Discontinue use of hydrocortisone if there is any exudate from the affected area

Barrier Creams

Instruct patient to apply a thin layer of (water soluble) barrier cream to the treatment area

Non-adhesive dressings may be applied, depending on the location of the skin reaction

Normal Saline Compresses

Indications

To reduce discomfort due to inflammation or skin irritation

To cleanse open areas

To loosen dressings

Contraindication

Increased discomfort during procedure

Procedure

Moisten gauze with warm or room temperature saline solution

Wring out excess moisture (ensure that gauze will not dry out and adhere to open area)

Apply moist gauze to open areas for 10-15 minutes. Cover compress with abdominal pad or

disposable under-pad to retain warmth and moisture

Remove gauze and gently irrigate wound with normal saline if required to remove any debris

Gently dry surrounding skin

Apply dressing/other treatments as indicated

Repeat up to 4 times daily or as required

Note

Continuous moist saline compresses may be indicated for short term use (24-48hrs.) for a necrotic or heavily exudative wound. It is critical that the compress is replaced frequently enough that it does not dry out and adhere to the area. Moist gauze is applied only to the wound area to avoid maceration of intact skin

Sitz Baths

Purpose

Perineal hygiene is the primary reason for using a sitz bath during/post RT when the area is tender and inflamed

Indications

Use at onset of treatment for comfort and cleanliness

Use at any time for any skin reaction in the perineal/peri-rectal area

Discomfort with defecation

Continuous discomfort due to perineal inflammation, hemorrhoids, radiation-induced diarrhea

Contraindication

Discomfort during procedure

Procedure

Water should be warm (40-43C)

Hot water can cause increased drying of skin

Warm water will increase vasoconstriction and may decrease the itching

Do not add bath oils or other products to water

A hand held shower with a gentle spray or bathtub may be appropriate alternatives

Maximum 10-15 minutes, repeat up to 4 times daily and/or after each bowel movement

Gently pat area dry with a soft towel or expose area to room air

Silver Sulfadiazine Cream (antibacterial)

Purpose

To reduce risk of infection

To reduce discomfort

To maintain moist healing environment

To reduce adherence of dressings

Indications

The treatment and prophylaxis of infection in open wounds (moist desquamation)

Contraindications

Allergy to sulfa

Should not be used for patients with history of severe renal or hepatic disease or during pregnancy

Procedure

Gently cleanse wound area with normal saline if area is small and dressing is easily removed

Cleanse with tap water (sink, bathtub, shower or sitz bath) if area is large, difficult to cleanse or adherence of dressing is a problem

It is important to gently remove all residual cream from previous applications (saline compresses may be required)

Apply a thin layer of cream to area of affected skin only

Apply appropriate secondary dressing

Change dressing at least once daily

Hydrogels

Hydrogel is a sterile wound gel for helping create or maintain a moist environment. Some hydrogels provide absorption, desloughing and debriding capacities to necrotic and fibrotic tissue. Hydrogel sheets are cross-linked polymer gels in sheet form

Purpose

To increase comfort (cooling effect on skin)

To increase moisture content

To absorb small amounts of exudate

Indications

Moist desquamation with minimal exudate

Contraindication

Not advised for infected wounds

Moderate to heavily exudating wounds

Areas that need to be kept dry

Procedure

Cleanse area with normal saline soaks or sitz baths

Pat dry surrounding skin

Either apply a thin layer of hydrogel directly onto the area of moist desquamation or apply with a tongue depressor

Cover with non-adhesive dressing (may be secured by clothing if patient is ambulatory)

May be used in combination with transparent films, foams, hydrocolloids or other non-adherents

Reapply at least daily and always following normal saline soaks/sitz baths

Hydrocolloid Dressings

Hydrocolloids are occlusive and adhesive water dressing which combine absorbent colloidal material with adhesive elastomeres to manage light to moderate amount of wound exudate. Most hydrocolloids react with wound exudate to form a gel-like covering which protect the wound bed and maintain a moist wound environment

Purpose

Maintain moist wound bed

To increase comfort

Support autolytic debridement by keeping wound exudate in contact with necrotic tissue

Indications

Moist desquamation with moderate exudate

Contraindication

Not advised for infected wounds

Heavily exudating wounds

Procedure

Cleanse area with normal saline soaks or sitz baths

Pat dry surrounding skin

Choose a dressing that extends beyond the wound

Remove backing and apply to wound

Change dressing as required depending on causative factors, contributing factors and amount of exudate

Bibliography

Aistars, J., (2006). The Validity of Skin Care Protocols Followed by Women With Breast Cancer Receiving External Radiation. Clinical Journal of Oncology Nursing. 10 (4), pp. 487-492.

Archambeau, J., Pezner, R., & Wasserman, T., (1995). Pathophysiology of irradiated skin and breast. International Journal of Radiation Oncology, Biology, & Physics. 31, pp.1171-1185.

Atiyeh, B., Ioannovich, J., Al-Amm & El-Musa, K., (2002). Management of Acute and Chronic Open Wounds: The Importance of Moist Environment in Optimal Wound Healing. Current Pharmaceutical Biotechnology. 3, pp.179-195.

Atiyeh, B., Costagliola, M., Hayek, S., & Dibo, S., (2007). Effect of silver on burn wound infection control and healing: review of the literature. Burns. 33 (2), pp. 139-148.

Babin, E., Sigston, E., Hitier, M., Dehesdin, D., Marie, J., & Choussy, O., (2008). Quality of life in head and neck cancer patients: predictive factors, functional and psychosocial outcome. European Archives of Otorhinolaryngology. 265, pp.265-270.

Bentzen, S.M., & Overgaard, J., (1994). Patient to patient variability in the expression of radiation induced normal tissue injury. Seminars in Radiation Oncology. 4, pp.69-80.

Bolderston, A., (2003). Skin Care Recommendations during Radiotherapy: A Survey of Canadian Practice. The Canadian Journal of Medical Radiation Therapy. 34 (1), pp.3-11.

Bolderston, A., Lloyd, N., Wong, L., & Robb-Blenderman, L., (2006). The prevention and management of acute skin reactions related to radiation therapy: a systematic re

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