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Radiography 18 (2012) 21e27

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Radiography

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Radiotherapy skin care: A survey of practice in the UK

Rachel Harris a,*,1, Heidi Probst b,1, Charlotte Beardmore c,1, Sarah James c,1, Claire Dumbleton c,1,Amanda Bolderston d,1, Sara Faithfull e,1, Mary Wells f,1, Elizabeth Southgate g,1

a The Society and College of Radiographers, 207 Providence Square, Mill Street, London SE1 2EW, UKb Faculty of Health and Wellbeing, Sheffield Hallam University, UKc The Society and College of Radiographers, UKd Fraser Valley Cancer Centre, British Colombia, Canadae Faculty of Health and Medical Sciences, University of Surrey, UKf School of Nursing and Midwifery, University of Dundee, UKgBirmingham Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK

a r t i c l e i n f o

Article history:Received 27 May 2011Received in revised form11 October 2011Accepted 20 October 2011Available online 13 November 2011

Keywords:RadiotherapyRadiation therapySkin careRadiation dermatitisSkin reactionsEvidence based practice

* Corresponding author. Tel.: þ44 020 77407 250;E-mail address: rachelh@sor.org (R. Harris).

1 In collaboration with the Department of Psycholo

1078-8174/$ e see front matter � 2011 The College odoi:10.1016/j.radi.2011.10.040

a b s t r a c t

Aim: The primary objective of the survey was to evaluate clinical skin care practice in radiotherapydepartments across the United Kingdom.Methods and sample: A questionnaire containing sixty-one questions grouped into eight themed sectionswas developed and a link to an on-line survey, using the Survey Monkey� tool, was e-mailed to allradiotherapy department managers in the United Kingdom (N ¼ 67). Each recipient was invited toprovide one response per department.Key results: Fifty-four departments responded within the allocated timeframe giving a final response rateof 81%. Products and their use for skin conditions varied and some outdated and unfounded practiceswere still being used which did not always reflect the current evidence base. The amount of dataroutinely collected on skin toxicity was limited making it difficult to quantify the extent of skin morbidityfollowing radiotherapy.Conclusion: The survey demonstrated variability in skin care practice in radiotherapy departments acrossthe UK, with limited practice based on evidence or on skin toxicity measurement and monitoring.

� 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

The Society and College of Radiographers (SCoR) last reviewedUK radiotherapy centre skin care practice in 2000 and producedguidelines for radiotherapy departments.1 A decade later it wastimely to re-assess what was actually happening in clinical practicewith the aim of assessing current practices and subsequentlyupdating the information.

Skin reactions from external beam radiotherapy are one of themost common side-effects from treatment and a factor which canlimit radiation dose. Megavoltage linear accelerators with skinsparing capabilities have significantly reduced the severity ofreactions from radiotherapy,2 however accelerated dose scheduleswith combined radiation chemotherapy regimens3 have increasedthe condition. The most severe reactions tend to be in seen in thosepatients receiving high doses to large fields. Recently the use of

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gy, University of Exeter.

f Radiographers. Published by Else

intensity modulated radiotherapy (IMRT) has been shown to offerthe opportunity to reduce skin toxicity in some cases, especially therates of dry and moist desquamation when treating cancers in thehead and neck region.4e10

Despite changes in practice and published guidelines1,11,12

radiotherapy skin care appears to have changed little over theyears, with departments caring for their patients’ skin in differentways. Consequently, a plethora of agents is being used on the skinin a non-standardised fashion.13,14

Faithfull et al15 note ‘a growing awareness of the need forevidence based practice in radiotherapy’ but that there are ‘welldocumented disparities between clinical practice and researchfindings which could underpin care’; reflecting that supportive careis often based on no, little, or poor evidence. Comparing data acrossradiotherapy skin care studies is difficult as often the methods usedare unclear, patient allocations differ, different skin assessmentscales are used, and follow-up data is inconsistent.16

Although it is unlikely that radiation reactions can becompletely prevented, the current driver in clinical practice is tominimise and delay the onset of symptoms.

vier Ltd. All rights reserved.

Table 1Distribution of survey questions.

Section Number of questions

Pre-treatment e assessment 14Pre-treatment e prophylactic skin care 6During treatment e assessment 7During treatment skin care e erythema 8During treatment skin care - dry desquamation 8During treatment skin care e moist desquamation 9Post-treatment e assessment and skin care 5Review of guidelines 4

R. Harris et al. / Radiography 18 (2012) 21e2722

The extent of skin reaction is often dependent upon the clinicalsite being treated. For example, patients undergoing radiotherapyfor head and neck cancer require immobilisation and often receivecombination chemotherapy. This can make these patients veryvulnerable to intensified skin reactions and it is known that inter-ruptions in radiotherapy for this category can have a detrimentaleffect on treatment outcome.17

The use of an effective evidence-based skin care protocol andmonitoring system18,19 would assist in a researched approach toradiation skin care management, aiding product evaluation andjustification of practice.

Background

In Barkham’s 1993 assessment of radiotherapy skin reactionsand associated treatments,13 52% of UK radiotherapy departmentsreported dry desquamation as a common event and 85% ofdepartments reported moist desquamation as an occasional event.However, as Glean et al20 noted, the incidence of skin reactions hasnot been accurately quantified in departments and practices havechanged since Barkham’s survey.

Turesson et al21 demonstrated that the number of basal cells inthe epidermis declines during fractionated radiotherapy due toincreased cell cycle arrest and reducedmitosis. The reduction in thebasal cells causes a thinning of the epidermis and an inflammatoryreaction. The variation in the reaction appears to be a geneticpredisposition due to individual DNA repair capacity,22e27 geneticradiosensitivity,28e30 and/or intravascular thrombin generation.31

Specific genetic tests could therefore be used to predict thosepatients most likely to develop a severe radiotherapy reaction.32,33

Certain clinical factors can also help to predict the possibility ofa radiation reaction.34,35 Extrinsic factors are treatment related, i.e.dose; volume; fractionation; adjuvant treatment; treatment in a skinfold area (e.g. inframammary fold or rectal cleft); use of bolus mate-rial; type of immobilisation; treatment technique.36 These factorsneed to be under constant review with changing work practices; forexample, with the introduction of IMRT. Intrinsic factors are indi-vidual patient related, e.g. larger breast size2,36; higher body massindex (BMI)25,37,38; pre-existing conditions (e.g. psoriasis).21,39 Suchintrinsic factorsmay enhance a skin reaction and therefore should berecorded as a baseline and closely monitored.12,40e42

Gosselin43 notes that some skin care products did show prom-ising results but comparing data across studies is difficult becauseof the wide variety of differing assessment tools. By utilising skinassessment tools on at least a weekly review basis, it would bepossible to monitor and record a patient’s skin reaction throughoutthe treatment stage.

Naylor and Mallet44 undertook a literature review to investigatethe products being used for radiotherapy skin reactions and theevidence base behind their use. They identified certain productswhere evidence contraindicated use:

� Petroleum jelly45e47 as it may create a build up effect and isdifficult to remove;

� Topical antibiotics unless there is a proven infection18,46,47;� Topical steroids on broken skin due to the adverse effect on thewound healing process45,48e50;

� Gentian Violet due to potential carcinogenic side-effects.18,49,51

Another important aspect of skin care during radiotherapy isthat of patient well being. It may not be possible to stop or evenreduce the rates of skin reaction from occurring, but there may becomfort and psychosocial benefits that skin care products provide,such as empowerment and control.43 Recording of patient accept-ability/satisfaction and compliance (as incorporated into some

existing scales52) are helpful indicators of how appropriatea product will be for future use.

The survey

A panel of experts was consulted for the issues they felt requiredinvestigation in a survey of skin care practice. The panel consisted ofa team from the Society and College of Radiographers, two leadingnursing professionals, the Chair of the SCoRResearchGroup, and theauthors of the recent systematic reviews. Initially the survey waslarge andunfocussed as panelmembers had different aspects of carethey felt required exploration. Two previous surveys53,54 intoradiotherapy skin care practice aided this survey construction andfocus, as did an examination of the relevant literature.

D’haese et al53 evaluated skin care during radiotherapy practiceby nurses in Flanders. They designed a 58 item questionnairestructured into 4 main sections: preventative advice, advice forerythema, dry desquamation and moist desquamation. Dividingthe questionnaire into these key sections seemed a logical easy tofollow format which the project team adapted.

Swamy et al54 developed a questionnaire to explore variations inradiation oncologist practice across the USA in managing breastcancer, specifically related to skin reactions. Their main questionsfocussed on prophylactic skin care, risk factors, topical productsused, and percentages of patients with skin reactions. These themeswere also built into the survey tool.

This final survey comprised of 61 questions, grouped into 8sections (Table 1).

An advanced draft of the survey tool was reviewed by the SCoRPublic and Patient Liaison Group and was also piloted at one radio-therapy department. Comments returned were minor and aroundclarity. These were incorporated and the survey tool finalised.

The final survey is a comprehensive tool which is relevant to UKradiotherapy practice.

Sample

A link to an on-line survey, using the Survey Monkey� tool, wase-mailed to all radiotherapy department managers in the UnitedKingdom (N ¼ 67) and they were invited to provide one responseper department. A ‘back-up’ pdf file was also provided which couldbe printed off and a hard copy returned if required (2 departmentsused this option). Anonymity was maintained for all respondents.

Fifty-four departments responded within the allocated time-frame with a final response rate of 81%.

Main results

Not all departments responded to all questions, therefore nvalues stated for each result are associated with the number ofresponses to each particular question, as opposed to the number ofreturned responses.

Graph 1. Which guideline does your department follow.

Table 2Prophylactic skin care products.

Question 16 If yes, which prophylactic skin care product(s) does yourdepartment recommend? (please tick all that apply)

Answer options Response percent Response count

None 0.0% 0Aqueous cream 68.4% 26Chamomile and Almond oil 0.0% 0Aloe vera 13.2% 5Calendula 2.6% 1Biafine 0.0% 0Hyaluronic acid 0.0% 0Sucralfate cream 0.0% 0Diprobase cream 7.9% 3Skin sealant or barrier product i.e. Cavilon 5.3% 2Other 7.9% 3N/A 31.6% 12If other, please specify 9answered question 38skipped question 16

R. Harris et al. / Radiography 18 (2012) 21e27 23

Pre-treatment: assessment

All departments (n ¼ 54) stated they provide verbal and writteninformation to patients on how they should care for their skinduring their course of radiotherapy. Forty six (n ¼ 52 ¼ 88%)departments stated they had skin care guidelines and protocols.Twenty seven (n ¼ 52 ¼ 52%) departments use their own locallydeveloped guidelines or adaptations of existing national guidelines(Graph 1).

Skin assessmentThirty eight (70%) departments stated that skin assessment

prior to radiotherapy would be conducted by a radiographer.Only thirteen (24%) use a skin assessment tool on all patients

prior to radiotherapy; with 30 departments (55%) using noassessment tool at all (Graph 2).

The Radiotherapy Oncology Group (RTOG) skin assessmenttool55 is the most commonly used by 20 departments(n ¼ 30 ¼ 66%); 24 departments chose not to answer this question.

Thirty six respondents (67%) reported no formal documentationand 22 (41%) do not review skin care products that a patientcurrently uses.

Forty two departments (77%) stated they knew their hospitalhad a tissue viability nurse (TVN), or equivalent, but liaison withthis person was not commonplace.

Graph 2. Use of a skin assessment tool.

Pre-treatment: prophylactic skin care

Twenty six (n ¼ 38 ¼ 68%) departments use aqueous cream asa prophylactic treatment (Table 2).

Five (n ¼ 38 ¼ 13%) departments recommend aloe vera forprophylactic skin care.

Nine (n ¼ 38 ¼ 23%) use a range of other products, for example:calendula; diprobase�; sucralfate�; skin sealant.

Sixteen (29%) departments chose not to answer this question.

During treatment: assessment

The range of responses to the questions on assessment ofpatients’ skin during treatment was varied, demonstrating nosingle clear practice was followed by the majority of departments.The one area where it was possible to identity practice that wascomparable in several departments was the advice on using soapand deodorant, as shown below.

Forty-two (77%) departments specify the type of soap to use:‘simple�’, ‘dove�’ or ‘none’ being the most common answers.

Nine (16%) specify the type of deodorant to use: ‘Pitrok�’56 ora non-metallic being the most common answers.

Thirteen (24%) state no deodorant to be used.

During treatment: erythema

Aqueous cream is used by 49 (n ¼ 50 ¼ 98%) departments asa product to alleviate erythema (Table 3).

Aloe vera is used by 8 (n ¼ 50 ¼ 16%) departments.A variety of other products are also used to a lesser extent.

Evaluation and cost effectivenessOnly 1 (n ¼ 49) department is conducting a randomised

controlled trial into the clinical effectiveness of a topical agent forerythema.

There were no assessments into the cost effectiveness of usingcreams and topical agents for erythema.

During treatment: dry desquamation

Twenty four (n ¼ 44 ¼ 54%) departments are using hydrocor-tisone 1% for dry desquamation (Table 4).

A variety of other products are used to a lesser extent.Ten (18%) departments chose not to answer this question.

Table 5Skin care products for moist desquamation.

Question 45 If yes, which skin care product(s) does your departmentrecommend for moist desquamation? (please tick all that apply)

Answer options Response percent Response count

None 0.0% 0Paraffin or Lanolin Gauze 6.7% 3Hydrocolloid dressing 40.0% 18Silicone dressing e.g. Mepitel 46.7% 21Gentian violet 4.4% 2Dermofilm 0.0% 0Second skin 2.2% 1Hydrogel 73.3% 33Lyofoam 15.6% 7Other 28.9% 13N/A 0.0% 0If other, please specify 20answered question 45skipped question 9

Table 3Skin care products for erythema.

Question 29 If yes, which skin care product(s) does your departmentrecommend for erythema? (please tick all that apply)

Answer options Response percent Response count

None 0.0% 0Aqueous cream 98.0% 49Chamomile and Almond oil 0.0% 0Aloe vera 16.0% 8Calendula 0.0% 0Biafine 0.0% 0Hyaluronic acid 0.0% 0Sucralfate cream 0.0% 0Diprobase cream 14.0% 7Skin sealant or barrier product i.e. Cavilon 8.0% 4Other 16.0% 8N/A 0.0% 0If other, please specify 12answered question 50skipped question 4

R. Harris et al. / Radiography 18 (2012) 21e2724

During treatment: moist desquamation

A variety of products and dressings are used for moist desqua-mation but hydrogels were the most popular with 33(n ¼ 45 ¼ 73%) departments using them (Table 5).

The various other products used included: 18 departments usehydrocolloid dressings (n ¼ 45 ¼ 40%); 21 silicone dressings(n ¼ 45 ¼ 46%); 7 lyofoam � (n ¼ 45 ¼ 15%).

Three departments (n¼ 45¼ 6%) use lanolin and 2 (n¼ 45¼ 4%)gentian violet.

Nine (16%) departments chose not to answer this question.Twenty nine (n ¼ 47 ¼ 61%) departments stated that those

undertaking care of moist desquamation have received additionaltraining in wound care management (Graph 3).

Only 3 (n ¼ 46 ¼ 6%) departments are conducting randomisedcontrolled trials into the clinical effectiveness of a topical agent formoist desquamation.

There is one on-going assessment into the cost effectiveness ofa product.

Post-treatment: assessment and skin care

37 (n ¼ 47 ¼ 78%) departments stated they supplied postradiotherapy moist desquamation skin care products for up to twoweeks (2e3 days being themost common answer) after which theywould expect the community nurse to continue supply and care.

Table 4Skin care products for dry desquamation.

Question 37 If yes, which skin care product(s) does your departmentrecommend for dry desquamation? (please tick all that apply)

Answer options Response percent Response count

None 0.0% 0Aqueous cream 79.5% 35Hydrocortisone 1% 54.5% 24Mometasone Furoate cream 0.0% 0Biafine 0.0% 0Sucralfate cream 0.0% 0Hyaluronic acid 0.0% 0Other 18.2% 8N/A 2.3% 1If other, please specify 17answered question 44skipped question 10

Limitations of the survey

There are certain limitations to the survey that need to be rec-ognised and which may have affected results.

As the survey was sent to each radiotherapy departmentalmanager and they selected who completed the survey and anon-ymously returned data, it is unknown who and what departmentanswered. Therefore, it is also unknown if the responses expressedare individual views or departmental policy.

It is not possible to know if each question was fully understoodin the manner intended as there was no ‘face to face’ follow up. Thedisparity in results could be owing to misinterpretation of a ques-tion, although the authors believe this reflects the unknownstatistics as many departments do not routinely record this data.

It is unknown if all questions were answered honestly or if thesurvey was given the answer the respondent felt was correct. Forexample, do more departments use gentian violet in reality but feltthis was an incorrect response to declare?

Discussion

The survey highlights the need for departments to undertakea baseline assessment of the patient’s current skin condition.Despite papers emphasising the potential risk factors35,36 which

Graph 3. Training in wound care management.

R. Harris et al. / Radiography 18 (2012) 21e27 25

may exacerbate a skin reaction these are not routinely recorded.Over two thirds of the respondents to this survey did not routinelyassess and formally record the patient’s skin prior to radiotherapy.Without the collection of such data it is difficult to attaina complete picture of the extent of radiotherapy induced reactions,which will be essential for improved research and skin care studies.Furthermore, over a third of respondents failed to assess and recordskin care products currently being used by patients, hence it ispossible that unsuitable skin care practices may be being usedunmonitored by the health care team; potentially exacerbatingradiotherapy skin reactions.

The importance of linking with other sectors of care, especiallya Tissue Viability Nurse (TVN), or equivalent, would strengthenimproved communication, understanding and consistency ofradiotherapy skin care across the care pathway thereby avoidingpatient and staff confusion.57,58 It is disheartening that manydepartments did not know if their hospital had a TVN and did notcollaborate on skin care with this person.

A main area of variation across departments relates to washinginstructions and the use of soap and deodorant (also confirmed byother studies13,53,59). The traditional patient advice of not towash theaffected area with soap and water, or even use water alone is stillgiven, despite updated evidence that this is unnecessary36,60e62 andthere should be no restriction to using a specific type ofsoap.60,61,63e67 Over two thirds of respondents in this survey reportedwashing restrictions (i.e. either no soap, or limited to specific brandssuch as ‘simple�’ and ‘dove�’), this has the potential to unnecessarilycontrol choices and preferences an individual may have.

Still referencing traditional practice may be a factor affectingpatient social well being. For example, breast cancer patients whoare advised not to use a deodorant often cite this as one less area ofcontrol they have in their life.68 Additionally, we need to considerwhether or not patients actually comply with these instructions.43

The survey illustrates that there are numerous products forradiotherapy skin care available and there is no consensus as to thebest practice, causing an inconsistency of care.57

As noted by Russell34 if the underlying cause of a radiationreaction is physiological and the extent is genetically predisposedtopical agents are unlikely to realistically have any significant effect.Currently the quality and quantity of studies evaluating topicalagents appears to be insufficient to support or refute any specificproduct62,69 and the survey indicated there were minimal on-goingassessments into skin care products; therefore it would appearprogress into understanding what actually may work will be slow.

Aqueous cream is commonly recommended by most depart-ments and is a relatively cheap readily available moisturising agent,and recommended by the recently withdrawn College of Radiog-rapher’s 2000 guidelines.1 However, the evidence base indicatesthat type of regime applied preventatively and to erythema appearsto have no influence in a skin reaction occurring70e72. Therefore,there needs to be further debate about this aspect of care and theevidence base supporting actions. Furthermore, 16% of respondingdepartments reportedly advise patients to use topical aloe verawhichmay incur a substantial cost either to the institution or to theindividual, yet there is limited evidence73 as to any benefit obtainedusing this agent over another and therefore no justificationwithoutfurther detailed studies for this recommendation to patients.42,74

Hydrocortisone 1% is frequently used (over 50% of respondentsreported using this cream) for dry desquamation reactions, in linewith the College of Radiographer’s 2000 guidelines.1 This is despitecurrent contradictory evidence,47,75e77 further illustrating howclinical practice has not kept pacewith emerging research evidence.

Product use varies considerably, hydrogels are the mostcommonly used (over 70% of respondents) but there is conflictingevidence as to their effect on wound healing.78,79

Gentian violet and lanolin are still used (10% of respondentsreported using these products) despite contraindications foruse.18,80 In a small randomised controlled trial (n ¼ 30) comparinggentian violet and hydrogel dressings for moist desquamation80 thegentian violet was significantly less effective (p ¼ 0.0003) and alsoless well tolerated by patients.

This again demonstrates our propensity to continue withfamiliar traditional practice rather than an openness to test theeffectiveness of products.

There were no assessments into the cost effectiveness of usingcreams and topical agents for erythema or dry desquamation andonly one assessment of a product for moist desquamation.

With the introduction of more expensive skin care treatments toa vulnerable clientele market, health care professionals need toconsider if such products are more effective than their cheapercomparators and why centres choose one product overanother.40,54,81,82 This is an important facet of modern health carewith the necessity for justification for actions and seems to havebeen almost totally overlooked.

There may be problems with product supply and continuity ofcare after treatment. Not all departments routinely supplied skincare products for moist desquamation post-treatment. For thosethat did, the majority provided products for up to 2e3 days postradiotherapy, with an expectation that community careproviders would then take over skin care following this period.This means that about 20% of responding departments did notprovide skin care products post radiotherapy. Therefore, in theperiod when most skin reactions build up to their maximumthere may be variability and inconsistency in productavailability.

An evaluation into the treatment after care requires review toensure local continuity of care across the pathway; a general needhighlighted by a recent Department of Health cancer patientexperience survey.83 It is essential that the whole health carepathway of a patient is considered and reviewed to ensure bestpractice.

Conclusion

The survey appears to indicate that skin care advice to patientsundergoing radiotherapy in the UK is varied. Currently, some of theskin care provided may not alleviate the problem and indeed mayeven compound the effect. This area of patient care is timeconsuming and expensive, therefore it is important to understandwhat is being done and why.2

As Kedge16 noted, and as the results of this survey show, theCollege of Radiographers (CoR) guidelines1 need updating, payingparticular attention to advice about deodorant use, aqueouscream for erythema, use of hydrocortisone 1% for dry desqua-mation, and the use of hydrogels and hydrocolloids for moistdesquamation. Given that the survey shows that the CoR 2000guidelines1 were followed by the majority of departments, it isreasonable to assume that revised guidelines would be followedand so provide an appropriate base for future evaluation of skincare practices.

The results indicate that not all radiotherapy departments aremonitoring and documenting skin morbidity in a systematic way.Departments need to routinely monitor, assess and document skinreactions using standard grading systems, and noting intrinsic andextrinsic related factors. Although the majority of skin reactionstend to subside after a few weeks, some can be prolonged,uncomfortable and distressing, thereby affecting a patient’s qualityof life.84 As Gosselin et al noted, ‘patients prefer to take actionrather than do nothing’72 so the focus for skin care should be onalleviating symptoms and providing comfort.

R. Harris et al. / Radiography 18 (2012) 21e2726

Recommendations

� All radiotherapy departments should implement pre-treatment assessment and baseline, and weekly reviews ofskin condition using a validated tool and process. Skin carepractice should also be agreed across the cancer network, inline with the requirement for agreed radiotherapy protocols asrecommended within the Cancer Peer Review Measures forRadiotherapy (England).85

� New high quality trials to investigate interventions for dry ormoist desquamation are urgently required; enabling a moreconsistent approach for patients receiving radiotherapy and toinform guidelines.

� The College of Radiographers skin care guidelines1 must berevised as the evidence on which they were based is no longervalid.

� Evaluation of treatment after care requires review to ensurelocal continuity and consistency of care across the patientpathway.

� Research into patient preferences and compliance with skincare information and products should be undertaken in orderto inform future national guidelines.

Conflict of interestNone.

Acknowledgements

All the departments who responded to the surveyProfessor Audrey Paterson, The Society and College of Radiog-

raphers Dr Ian Frampton, University of Exeter

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