Radiation-induced Skin Reactions Research Articles

Radiotherapy-induced skin reactions: assessment and management

Radiotherapy, the use of high-energy rays to either kill cancer cells or treat some benign tumours, is undoubtedly a positive intervention. However, as the primary mode of action in radiotherapy treatment is the killing of cells to prevent replication, other non-cancerous cells may be affected. For example, up to 85% of patients will experience some form of skin reaction, which will range from local erythema to moist desquamation. Such reactions are not only distressing and painful for the patient, if severe enough, they may warrant a halt in treatment. This article outlines the aims and nature of radiotherapy, and then discusses the aetiology of skin reactions, risk factors for reaction, and assessment tools. Management interventions will also be shown, with emphasis on silicone dressings.

Prevention and treatment of acute radiation-induced skin reactions: a systematic review and meta-analysis of randomized controlled trials.

BackgroundRadiation-induced skin reaction (RISR) is a common side effect that affects the majority of cancer patients receiving radiation treatment. RISR is often characterised by swelling, redness, pigmentation, fibrosis, and ulceration, pain, warmth, burning, and itching of the skin. The aim of this systematic review was to assess the effects of interventions which aim to prevent or manage RISR in people with cancer.MethodsWe searched the following databases up to November 2012: Cochrane Skin Group Specialised Register, CENTRAL (2012, Issue 11), MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1806), CINAHL (from 1981) and LILACS (from 1982). Randomized controlled trials evaluating interventions for preventing or managing RISR in cancer patients were included. The primary outcomes were development of RISR, and levels of RISR and symptom severity. Secondary outcomes were time taken to develop erythema or dry desquamation; quality of life; time taken to heal, a number of skin reaction and symptom severity measures; cost, participant satisfaction; ease of use and adverse effects. Where appropriate, we pooled results of randomized controlled trials using mean differences (MD) or odd ratios (OR) with 95% confidence intervals (CI).ResultsForty-seven studies were included in this review. These evaluated six types of interventions (oral systemic medications; skin care practices; steroidal topical therapies; non-steroidal topical therapies; dressings and other). Findings from two meta-analyses demonstrated significant benefits of oral Wobe-Mugos E for preventing RISR (OR 0.13 (95% CI 0.05 to 0.38)) and limiting the maximal level of RISR (MD -0.92 (95% CI -1.36 to -0.48)). Another meta-analysis reported that wearing deodorant does not influence the development of RISR (OR 0.80 (95% CI 0.47 to 1.37)).ConclusionsDespite the high number of trials in this area, there is limited good, comparative research that provides definitive results suggesting the effectiveness of any single intervention for reducing RISR. More research is required to demonstrate the usefulness of a wide range of products that are being used for reducing RISR. Future efforts for reducing RISR severity should focus on promising interventions, such as Wobe-Mugos E and oral zinc.

Prophylactic use of Mepitel Film prevents radiation-induced moist desquamation in an intra-patient randomised controlled clinical trial of 78 breast cancer patients

PurposeSafetac-based soft silicone dressings used in a management setting decrease the severity of radiation-induced acute skin reactions but do not affect moist desquamation rates. Here we investigate the prophylactic use of another Safetac product, Mepitel Film, on moist desquamation rates. Material and methodsA total of 80 breast cancer patients receiving radiation therapy were recruited between October 2012 and April 2013; 78 participants contributed data for analysis. Lateral and medial halves of the skin areas to be irradiated were randomised to Mepitel Film or aqueous cream; skin dose was measured using thermoluminescent dosimeters; skin reaction severity was assessed using RISRAS and RTOG scales. ResultsOverall skin reaction severity was reduced by 92% (p<0.0001) in favour of Mepitel Film (RISRAS). All patients developed some form of reaction in cream-treated skin which progressed to moist desquamation in 26% of patients (RTOG grades I: 28%; IIA: 46%; IIB: 18%; III: 8%). Only 44% of patients had a skin reaction under the Film, which did not progress to moist desquamation in any of the patients (RTOG grades I: 36%; IIA: 8%). ConclusionsMepitel Film completely prevented moist desquamation and reduced skin reaction severity by 92% when used prophylactically in our cohort.

TH-A-WAB-10: Blood Perfusion of the Skin as An Indicator of Radiation-Induced Skin Reaction

Purpose: The oxygenation state of tissue is known to correlate with radiation‐induced effects. We hypothesize that local blood perfusion of skin is directly related to the local oxygen concentration; thus blood perfusion may serve as an effective indicator for radiation‐induced skin reactions. Recent advances in near‐infrared laser imaging allows near real time non‐invasive detection of blood perfusion in the skin. We report a preliminary study of laser imaging for its ability to detect variations in blood perfusion under different environmental, physical, and physiological conditions. Methods: A Moor instrument utilizing near‐infrared laser (Moor Instruments, Devon, UK) is utilized for the investigation of perfusion in both motile phantom and human palm. The device projects a speckle pattern on the skin and measure the degree of speckle sharpness in real time. The phantom consists of two cylinders one filled with a motile standard and the other is a static reflector. The phantom is shaken for 10 seconds then is allowed to settle for 2 minutes prior to imaging. We performed laser imaging under conditions such as skin scratching, cold, or exercise. Results: The 10 second scan from the phantom scan shows a higher perfusion than the 20 and 30 seconds but has a lower standard deviation than that of the 20 and 30 second scans. This is probably due to the settling down of the particles in the phantom over time resulting in reduced perfusion for the 20 and 30 measurements. The palm images shows a decreased perfusion following the application of the cold pack and an increased perfusion after exercise. Conclusion: We have demonstrated the feasibility of using near‐infrared imaging to monitor skin blood perfusion. It may provide a useful tool to monitor and mitigate radiation‐induced skin reactions. CMCR/NIAID/NIH

PD-0269: Mepilex Lite dressings decrease the severity of acute radiationinduced skin reactions post-mastectomy

PD-0269: Mepilex Lite dressings decrease the severity of acute radiationinduced skin reactions post-mastectomy

Randomized Intra-Patient Controlled Trial of Mepilexlite Dressings vs. Aqueous Cream in Managing Radiation-Induced Skin Reactions Post-Mastectomy

Randomized Intra-Patient Controlled Trial of Mepilexlite Dressings vs. Aqueous Cream in Managing Radiation-Induced Skin Reactions Post-Mastectomy

It's A Kind Of Magic! The Unexpected Impact of a Systematic In-Patient Controlled Clinical Trial on Patient Well-Being

Breast cancer is the most common malignancy for women in New Zealand, the majority receiving radiation therapy as part of their treatment regimen. Radiation-induced skin toxicities occur in a large proportion of patients yet currently there is no standard treatment for them, practice largely being based on historical and anecdotal evidence. As radiation therapy techniques become increasingly complex and practice focuses on the greater good of the patient, some crossing of professional boundaries will occur. In a first for New Zealand, we instigated radiation therapist (RT)-led on-treatment review clinics for breast cancer patients which saw us step into an area that is traditionally considered the domain of medics. This led to clinical trials, initiated and managed by RTs, aimed at providing the authentication for our emerging evidence-based practice. One trial in particular had significant ramifications for our practice. The randomised controlled multi-centre trial compared the efficacy of silicon foam dressing with the standard treatment of aqueous cream. A total of 104 patients were enrolled, the majority receiving 50Gy in 25 fractions. Toxicities were assessed three times a week using the Radiation-Induced Skin Reaction Scale with patients doubling as their own controls to eliminate confounding patient and treatment-related factors. The trial endpoint was moist desquamation (MD). Statistical analysis, using ANOVA design of repeated measurement of paired patches together with the non-parametric Wilcoxon signed rank test, clearly demonstrated a significant toxicity decrease (42%; p<0.001). An intriguing incongruity emerged when the percentage of our patients progressing to MD - 14% control; 0% trial area - was compared with those from other centres - 44% control; 24% trial area. Analysis of this disparity resulted in a substantial change in our practice, allowing us to capitalise on these enhanced patient outcomes. Further research examining the correlation between the levels of holistic care afforded to patients and the intensity of reactions experienced/observed is also underway.

A double-blind randomised controlled trial of a natural oil-based emulsion (Moogoo Udder Cream®) containing allantoin versus aqueous cream for managing radiation-induced skin reactions in patients with cancer

BackgroundRadiation-induced skin reaction (RISR) is one of the most common and distressing side effects of radiotherapy in patients with cancer. It is featured with swelling, redness, itching, pain, breaks in skin, discomfort, and a burning sensation. There is a lack of convincing evidence supporting any single practice in the prevention or management of RISR.Methods/DesignsThis double-blinded randomised controlled trial aims to investigate the effects of a natural oil-based emulsion containing allantoin (as known as Moogoo Udder Cream®) versus aqueous cream in reducing RISR, improving pain, itching and quality of life in this patient group. One group will receive Moogoo Udder Cream®. Another group will receive aqueous cream. Outcome measures will be collected using patient self-administered questionnaire, interviewer administered questionnaire and clinician assessment at commencement of radiotherapy, weekly during radiotherapy, and four weeks after the completion of radiotherapy.DiscussionDespite advances of radiologic advances and supportive care, RISR are still not well managed. There is a lack of efficacious interventions in managing RISR. While anecdotal evidence suggests that Moogoo Udder Cream® may be effective in managing RISR, research is needed to substantiate this claim. This paper presents the design of a double blind randomised controlled trial that will evaluate the effects of Moogoo Udder Cream® versus aqueous cream for managing in RISR in patients with cancer.Trial registrationACTRN 12612000568819

Randomized Intra-patient Controlled Trial of Mepilex Lite Dressings versus Aqueous Cream in Managing Radiation-Induced Skin Reactions Postmastectomy

Objective: Severe acute radiation-induced skin reactions occur in a significant proportion of women who receive radiation therapy for breast cancer. We previously showed that Mepilex Lite dressings decreased the severity of erythema. Here we report their effect on the full range of skin reactions in 74 breast cancer patients post-mastectomy. Methods: A total of 80 women were recruited from four hospitals in New Zealand with 74 women contributing a full data set for analysis. The first skin area on the chest wall to develop erythema was randomly divided into two similar halves; one half was treated with Mepilex Lite dressings, the other half with aqueous cream. Skin reactions were assessed using the Radiation-Induced Skin Reaction Assessment Scale. Results: Compared with aqueous cream, Mepilex Lite dressings did not significantly reduce the incidence of moist desquamation but did reduce the overall severity of skin reactions by 41% (p<0.001), the average moist desquamation score by 49% (p=0.043) and the sum of the moist desquamation time for all patches by 28% from 25 to 18 weeks. Most patients preferred the dressings, found them easy to use and very comfortable to wear.

C-reactive Protein Levels and Radiation-Induced Skin Reaction in Breast Cancer

C-reactive Protein Levels and Radiation-Induced Skin Reaction in Breast Cancer

Generation of a project proposal for an undergraduate literature review: one dimension of critical thinking

Alan Castle Background: Higher education is concerned with developing the critical thinking skills of undergraduate students through academic study so that they are able to improve the delivery of health care in a dynamic and changing world of work. To continue his series on critical thinking from the July 2010 issue, the author discusses a second component of critical thinking. Contents: The generation component of critical thinking encourages students to develop skills of independent thinking and produce original and creative work. The worked example of a project proposal for an undergraduate literature review to evaluate the effectiveness of a range of topical preparations in the treatment of radiation-induced skin reactions, has been used to illustrate how students might go about demonstrating these skills. Conclusions: The worked example demonstrates how undergraduate students can be encouraged to analyse arguments, clarify their thinking and generate new ideas which constitutes the generation component of critical thinking.

Vitamin E-Deficiency Did Not Exacerbate Partial Skin Reactions in Mice Locally Irradiated with X-rays

We previously showed that free radicals and oxidative stress are involved in radiation-induced skin reactions. Since vitamin E (VE) is a particularly important lipophilic antioxidant, VE-deficient mice were used to examine its effects on radiation-induced skin damage. The VE content of the skin was reduced to one fourth of levels of normal mice. Neither the time of onset nor the extent of the reactions quantified with a scoring system differed between normal and VE-deficient mice after local X-irradiation (50 Gy). Similarly, there was no difference in the levels of the ascorbyl radical between the groups, although they were higher in irradiated skin than non-irradiated skin. X-irradiation increased the amount of Bax protein in the skin of normal mice both in the latent and acute inflammatory stages, time- and dose-dependently. The increase was associated with an increase in cytochrome c in the cytosolic fraction, indicating that apoptosis was also promoted by the irradiation. The increase in Bax protein correlated well with the thickness of the skin. Although a deficiency in VE should lower resistance to free radicals in the mitochondrial membrane and thus enhance radiation-induced Bax expression and apoptosis, it actually attenuated the increase in Bax protein caused by irradiation.

Association ofXRCC1Variants with Acute Skin Reaction After Radiotherapy in Breast Cancer Patients

After irradiation results in cytotoxic effects by DNA damage, base excision repair (BER) pathway is involved in the repair of single-strand breaks and nonhomologous end joining and homologous repair of double-strand breaks caused by radiotherapy. Alterations in the function of BER DNA repair genes may affect DNA repair proficiency and influence the response of patients with cancer to radiotherapy. The association of single nucleotide polymorphisms of BER DNA repair X-ray repair cross-complementing group 1 protein (XRCC1) and risk of radiotherapy-induced ≥grade 2 acute skin reaction in patients with breast cancer was examined. It was found that the risk of ≥grade 2 acute skin toxicity after radiotherapy could be increased by 2.86-fold in patients carrying the XRCC1 -77TC and CC genotypes (p = 0.016). However, the other three coding XRCC1 variants did not influence the risk of ≥grade 2 acute skin toxicity for patients with breast cancer after radiotherapy. Our results suggested that the XRCC1 polymorphism is associated with increased risk of radiation-induced acute skin reaction in a Chinese population.

A Randomized, Controlled, Double-Blind Study of Light Emitting Diode Photomodulation for the Prevention of Radiation Dermatitis in Patients with Breast Cancer

Radiation dermatitis occurs in a majority of patients with breast cancer who receive radiation therapy (RT), causes significant pain, and may necessitate treatment delay. Light emitting diode (LED) photomodulation has been reported to minimize radiation dermatitis. This study sought to further evaluate the efficacy of LED photomodulation in lessening radiation dermatitis. After surgery, patients with breast cancer received LED photomodulation or sham treatments in conjunction with three-dimensional conformal RT. Reactions were evaluated using standardized photographs graded according to National Cancer Institute criteria. In the LED treatment group (n=18), no patients had grade 0 reactions, six (33.3%) had grade 1 reactions, 12 (66.7%) had grade 2 reactions, and none had a grade 3 reaction. In the sham treatment group (n=15), one (6.6%) patient had a grade 0 reaction, four (26.7%) had grade 1 reactions, 9 (60.0%) had grade 2 reactions, and one (6.7%) had a grade 3 reaction. Two (11.1%) patients in the LED treatment group and one (6.7%) in the control group had to interrupt treatment. Differences between groups were not statistically significant. LED photomodulation did not reduce the incidence of radiation-induced skin reactions or interruptions in therapy. .

Prophylaxis and Management of Acute Radiation-Induced Skin Reactions: A Systematic Review of the Literature

Radiation therapy is a common treatment for cancer patients. One of the most common side effects of radiation is acute skin reaction (radiation dermatitis) that ranges from a mild rash to severe ulceration. Approximately 85% of patients treated with radiation therapy will experience a moderate-to-severe skin reaction. Acute radiation-induced skin reactions often lead to itching and pain, delays in treatment, and diminished aesthetic appearance-and subsequently to a decrease in quality of life. Surveys have demonstrated that a wide variety of topical, oral, and intravenous agents are used to prevent or to treat radiation-induced skin reactions. We conducted a literature review to identify trials that investigated products for the prophylaxis and management of acute radiation dermatitis. Thirty-nine studies met the pre-defined criteria, with thirty-three being categorized as prophylactic trials and six as management trials.For objective evaluation of skin reactions, the Radiation Therapy Oncology Group criteria and the U.S. National Cancer Institute Common Toxicity Criteria were the most commonly used tools (65% of the studies). Topical corticosteroid agents were found to significantly reduce the severity of skin reactions; however, the trials of corticosteroids evaluated various agents, and no clear indication about a preferred corticosteroid has emerged. Amifostine and oral enzymes were somewhat effective in preventing radiation-induced skin reactions in phase II and phase III trials respectively; further large randomized controlled trials should be undertaken to better investigate those products. Biafine cream (Ortho-McNeil Pharmaceuticals, Titusville, NJ, U.S.A.) was found not to be superior to standard regimes in the prevention of radiation-induced skin reactions (n = 6).In conclusion, the evidence is insufficient to support the use of a particular agent for the prevention and management of acute radiation-induced skin reactions. Future trials should focus on comparing agents and approaches that, in phase I and II trials, suggest efficacy. These future phase III randomized controlled trials must clearly distinguish between preventive and management strategies for radiation-induced dermatitis. Only then can evidence-based guidelines be developed, with the hope of standardizing the approach across centres and of improving the prevention and management of radiation-induced dermatitis.

Mepilex Lite dressings for the management of radiation-induced erythema: a systematic inpatient controlled clinical trial

Erythema occurs in 80-90% of women treated for breast cancer with radiation therapy. There is currently no standard treatment for radiation-induced skin reactions. This study investigates the clinical efficacy of Mepilex Lite dressings in reducing radiation-induced erythema in women with breast cancer. A total of 28 patients were recruited; of these, 24 participants presented with 34 erythematous areas of skin for analysis. When erythema was visible, each affected skin area was randomly divided into two similar halves: one half was treated using Mepilex Lite dressings, the other half with standard aqueous cream. Skin reactions were assessed by the Radiation-Induced Skin Reaction Assessment Scale. We also evaluated any potential dose build-up by the dressings using a white water phantom, the dose distribution over the breast via thermoluminescent dosimeters (TLDs) and the surface skin temperature with an infrared thermographic scanner. Mepilex Lite dressings significantly reduced the severity of radiation-induced erythema compared with standard aqueous cream (p <0.001), did not affect surface skin temperature and caused only a small (0.5 mm) dose build-up. TLD measurements showed that the inframammary fold was exposed to significantly higher doses of radiation than any other breast region (p <0.0001). Mepilex dressings reduce radiation-induced erythema.

A nationwide survey of radiation oncologists' management practices of radiation-induced skin reaction (RISK)

AbstractPurpose:A questionnaire was developed to explore variations among radiation oncologists in managing early-stage breast cancer, specifically radiation-induced skin reaction (RISK).Materials and methods:A survey was designed to target a database of 962 radiation oncologists, self-identified as ‘interested in treatment of breast cancer’. This database was obtained from the American Society of Therapeutic Radiology &amp; Oncology (ASTRO). Participants submitted the survey online or by mail. Overall response to the survey was 282 out of 962 (29.3%). Data were handled as rates.Results:Out of 282 respondents, 275 (97.5%) agreed on delivering 4500–5040 cGy. The most frequently employed dose was 5040/180 cGy. Three-dimensional-conformal (3DCRT) treatment was used by 55.4%, intensity-modulated radiotherapy (IMRT) by 24.5%, and conventional by 20.1%. Almost all (92.5%) agreed on using boost in ductal carcinoma in situ (DCIS). Image-guided boost placement (IGBP) was used by 87.3%. Boost dose included variations: 50.2, 7.3, and 18% used 1000, 1200, and 1400 cGy, respectively; the remaining used higher doses. In management of RISK, Aquaphor was the most popular agent (72.1%). Other agents were utilized either alone or in combination. Almost all (99%) agreed that large breast size increases RISK.Conclusion:This survey offers a glimpse of management practices in early-stage breast cancer amongst a cross-section of radiation oncologists in the United States. Although there appears to be an overall congruence on the doses and techniques of radiation delivery, the management of RISK is varied. Additional efforts are warranted to standardize practices in order to practice evidence based medicine in a cost-effective manner.

A Drug-Related Phototoxic Reaction and Its Possible Relationship to a Radiation-Induced Skin Reaction

Abstract Reported is a case of an acute atypical radiation-induced dermatologic reaction in a patient with a recent history of two courses of levofloxacin within 90 days prior to starting radiotherapy.

Thrombin generation as a predictor of radiotherapy induced skin erythema

Background and purpose Biological mechanisms underlying radiation induced erythema remain largely unknown, with no simple way to accurately predict or prevent extreme cases. Based on the recent findings in patients suffering from chronic urticaria, we sought to determine if similar mechanisms of hypercoagulation contributed to comparable skin reactions during radiotherapy. Materials and methods Plasma levels of prothrombin factor 1+2 (F1+2), D-dimers and plasminogen activator inhibitor-1 (Pai-1) were tested in 32 women undergoing irradiation following breast conserving surgery for early breast cancer. Reflectance spectrophotometry was used to objectively assess erythema throughout the treatment by measuring the amount of light reflected from the skin surface as a function of wavelength. Correlations between peak levels of erythema and plasma biomarkers were then assessed. Results Individual peak reflectance readings generally occurred between day 29 of treatment and 2 weeks post radiotherapy, and represented a median increase of 66% (range: 11–146%; p < 0.001) from baseline. Peak reflectance correlated with F1+2 and Pai-1 levels measured both at baseline and day 29 of treatment, and multivariate analysis indicated that these two baseline measurements were the best predictors of peak reflectance, accounting for 59% of the variability in erythema ( p = 0.000004). Conclusions Patients with signs of intravascular thrombin generation are at higher risk of radiotherapy-induced skin reactions, providing a new therapeutic avenue for possibly predicting and preventing this side effect of cancer treatment.

A systematic review of honey uses and its potential value within oncology care

To synthesise the evidence regarding honey's role in health care and to identify whether this evidence applies more specifically to cancer care. Systematic review. The inclusion and exclusion criteria were agreed by two reviewers and a keyword strategy was developed. EMBASE, CINAHL, AMED, MEDLINE, COCHRANE and PUBMED databases were screened to identify suitable articles. The citation list from each included study was also screened for potentially suitable papers. The key findings from each study were entered onto a data extraction sheet. In total, 43 studies were included in the systematic review, which included studies in relation to wounds (n = 19), burns (n = 11), skin (n = 3), cancer (n = 5) and others (n = 5). In addition, a systematic review regarding honey use in wound care was also included. While the majority of studies noted the efficacy of honey in clinical use, five studies found honey to be equally as effective as the comparator and three found honey to be less effective than the comparator treatment. Other research did not illustrate any significant difference between standard treatment regimes vs. honey treatment. Studies were generally poor in quality because of small sample sizes, lack of randomisation and absence of blinding. Honey was found to be a suitable alternative for wound healing, burns and various skin conditions and to potentially have a role within cancer care. In the cancer setting, honey may be used for radiation-induced mucositis, radiotherapy-induced skin reactions, hand and foot skin reactions in chemotherapy patients and for oral cavity and external surgical wounds.