The impact of radiodermatitis on cancer patients

Radiation oncologist, Dr Yastira Ramdas, unpacks the impact of radiodermatitis on cancer patients.

Radiation therapies are a common treatment modality for patients diagnosed with cancer, used exclusively or in combination with other types, such as surgery and chemotherapy. 

Radiotherapy administers high-energy photons at or near the tumour site, killing cancer cells by creating free radicals in the cells leading to cell death.^1,2

One of the common side effects of radiation therapy is radiodermatitis (radiation dermatitis, radiation-induced skin reactions) by exposure to high-energy photons which is experienced by 95% of patients. 

Grades of radiodermatitis

Common types of radiodermatitis include: moist and dry desquamation (peeling), skin necrosis (dead tissue), bleeding ulceration and skin erythema (redness).

These are divided into grades: ^1,2

Grade 1: Faint or minimal skin erythema and dry skin desquamation.

Grade 2: Moderate skin erythema, patchy moist desquamation and moderate oedema (excess of watery fluid collection of the body).

Grade 3: Moist desquamation, physical abrasions and minor bleeding.

Grade 4: Skin necrosis.

Risk of patient

While predicting radiodermatitis is not an exact science, the risk to a patient depends on a myriad of factors, such as radiation dose strength, volume, number of fractions, age, ethnic origin, co-existing diseases, ultraviolet exposure, co-morbidities, hypertension and other genetic factors.³

Radiodermatitis, in severe cases, can lead to decrease in quality of life, lower treatment adherence and stalling of radiation treatments. Due to the need of curing the underlying cancer, limited research is spent testing and developing guidelines to limit its appearance.³

Skin assessments

Normally during radiation sessions, skin assessments are done by the oncologists, and dermatologists in exceptional circumstances. The main aim being to manage negative skin side effects and improve quality of life and improve outcome.

Numerous studies exist detailing the various skin care products. However, there is no clear consensus on the type and regiments.  

During radiotherapy when patients experience mild symptoms, they are given steroids and silver-based gauze to alleviate symptoms.⁴

General advice includes⁴

Skin cleansing

• Liquid soap or dermatological soap bar with a pH close to 5, without perfume, plant or fruit extracts. 
• Dry skin – delicately but meticulously.

Skin hydration

• Apply a non-comedogenic emollient cream without perfume, lanoline, one or two times per day, preferably after the radiotherapy session.
• Avoid applying topical creams to the radiation zone at least one hour before the radiotherapy session. This will avoid a bolus effect (increased radiation dose delivered to the epidermis). 

Photoprotection

• Protect the irradiated skin zone from sun exposure.
• Apply a sunscreen SPF 50+ with UVA/UVB protection to non-radiated areas. 

Clothing

• Wear ample, soft cotton clothing.
• Avoid wearing synthetic clothes. 

Additional advice

• Use an electric razor and do not shave too close to the skin.
• Avoid applying products that contain alcohol (perfume, eau de toilette, ether, and talcum powder).
• Don’t use sticky plasters.
• Avoid rubbing or scratching.

In acute cases of radiodermatitis, consult the radiation oncologist and dermatologist which will tailor the required treatments. Some patients experience late or chronic radiodermatitis which can appear from six months up to 30 years later after the first treatment.

Here the science is inconclusive when predicting the severity or date of onset but affected by treatment factors, such as total dose rates, treatment durations and treatment sized with external issues being repetitive trauma, sun exposure and further irradiation.^4,5

References

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin 2018; 68:7.
2. Pisters PWT, Weiss M, Maki R. Soft-tissue sarcomas. In: Haller DG, Wagman LD, Camphausen C, Hoskins WJ, eds. Cancer management: a multidisciplinary approach. 14th ed. Norwalk, Conn: UBM Medica, 2011
3. Schray MF, Gunderson LL, Sim FH, Pritchard DJ, Shives TC, Yeakel PD. Soft tissue sarcoma: integration of brachytherapy, resection, and external irradiation. Cancer1990;66(3):451–456
4. Baldini EH, Lapidus MR, Wang Q et al. Predictors for major wound complications following preoperative radiotherapy and surgery for soft-tissue sarcoma of the extremities and trunk: importance of tumor proximity to skin surface
5. O’Sullivan B, Griffin AM, Dickie CI, et al. Phase 2 study of preoperative image-guided intensity-modulated radiation therapy to reduce wound and combined modality morbidities in lower extremity soft tissue sarcoma. Cancer 2013; 119:1878.
6. Wang D, Zhang Q, Eisenberg BL, et al. Significant Reduction of Late Toxicities in Patients With Extremity Sarcoma Treated With Image-Guided Radiation Therapy to a Reduced Target Volume: Results of Radiation Therapy Oncology Group RTOG-0630 Trial. J Clin Oncol 2015; 33:2231.

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