Introduction
Clinical Manifestations
Acute Radiation Dermatitis
Observed acute skin reaction | Radiation dose (Gy) | Onset of findings |
---|---|---|
Transient erythema | 2 | Hours |
Faint erythema and epilation | 6–10 | 7–10 days |
Defined erythema and hyperpigmentation | 12–20 | 2–3 weeks |
Dry desquamation | 20–25 | 3–4 weeks |
Moist desquamation | 30–40 | 4 weeks or more |
Ulceration | >40 | 6 weeks or more |
Grade | |||
---|---|---|---|
1 | 2 | 3 | 4 |
Faint erythema or dry desquamation | Moderate to brisk erythema or patchy moist desquamation, mostly confined to skin folds and creases; moderate erythema | Moist desquamation other than skin folds; pitting edema, bleeding from minor trauma or abrasion | Skin necrosis or ulceration of full-thickness dermis; may have spontaneous bleeding from affected area |
Radiation Burns
Radiation Recall
Chronic Radiation Dermatitis
Late reaction or complication | Clinical manifestations |
---|---|
Textural changes | Xerosis |
Scale | |
Hyperkeratosis | |
Persistent poikilodermatous changes (indicate severe RT damage) | Dyspigmentation |
Atrophy | |
Telangiectasia | |
Absence of hair follicles and sweat glands | Alopecia |
Decreased or absent sweating | |
Destruction or permanent loss of nail appendages | Friable nails |
Longitudinal striations | |
Cutaneous breakdown | Epidermal atrophy |
Slow-healing, painful erosions and ulcerations | |
Necrosis of soft tissue, cartilage, and bone | |
Cutaneous and subcutaneous tissue fibrosis | Pain, limited range of motion, contractures |
Secondary malignancy | Primarily SCC and BCC |
Radiation-induced Fibrosis
Secondary Cutaneous Malignancies
Pathophysiology
Acute Cutaneous Reactions
Chronic Cutaneous Reactions
Epidemiology
Risk Factors
Extrinsic |
---|
Total radiation dose |
Fractionation schedule |
Type of radiation |
Quality of radiation beam |
Concurrent chemotherapy |
Antibiotics |
Anti-tuberculosis medications |
Intrinsic |
---|
Advanced age |
Female sex |
Obesity |
Comorbidities (diabetes mellitus, connective tissue disease) |
Chronic sun exposure |
Radiosensitive disorders |
Ataxia telangiectasia |
Xeroderma pigmentosa |
Previous breast reconstruction/implants |
Nutritional status |
Immunocompromised |
Smoking |
Extrinsic Factors
Particle type | Penetration | Effect on skin |
---|---|---|
Alpha | Large amount of ionization, but minimal skin penetration | Not able to penetrate stratum corneum when emitted |
Beta | Greater penetration than alpha particle, but less ionization | Shallow penetration of skin |
Gamma | Low ionization, but high penetration | More penetration in skin with damage inversely proportional to the energy |
X-ray | Similar to Gamma ray; longer wave length providing more penetration | Effect on skin is proportional to energy of X-ray |
Neutron | High penetration due to size and neutral charge | Can be lethal; high energy transfer destroying basal layer of skin leading to necrosis |
Intrinsic Factors
Prevention
General Preventive Measures
Prevention | Level of evidence |
---|---|
Proper skin hygiene | Wash with mild soaps and lukewarm water to help maintain skin barrier |
Protection of skin from additional trauma | Use of topical steroids; use before development of radiation dermatitis to slow progression to radiation dermatitis (Grade B) Oral Wobe-Mugus can decrease odds of developing radiation dermatitis (Grade C) Wear loose fitting clothing, avoid sun exposure, avoid metallic based topical products, use water based lanolin-free moisturizers |
Treatment of | Level of evidence |
---|---|
Dry desquamation | Low- to mid-potency topical steroids; decrease progression and severity of itching, burning and irritation (Grade C) Use of hydrophilic moisturizers |
Moist desquamation | Wound care management with hydrogel and hydrocolloid dressings |
Radiation burns | Removal of necrotic debris and mesenchymal stem cell injections to area to increase healing Mesenchymal stem cell injections around lesions to enhance wound healing (Grade D) |
Topical Corticosteroids
Other Adjuvants
Management
Acute Cutaneous Reactions
Grade 1
Grades 2 and 3
Grade 4
Chronic Cutaneous Reactions
Late reaction or complication | Management |
---|---|
Ulcers and erosions | Non-specific, follows general wound care guidelines, including |
Hydrophilic or lipophilic barrier creams with or without hydrogel or hydrocolloid dressings | |
Careful and selective debridement, eschar removal | |
For infected or at-risk wounds, antibacterial agents as needed and silver-based dressings | |
Surgical intervention for nonhealing ulcers with skin flaps, less commonly with staged skin-muscle or axial-pedical flaps | |
Grade D | |
Artificial or bioengineered skin | |
Low-intensity helium laser | |
Fibrosis | Supportive measures: physical therapy, massage, and pain management |
Grade 2C | |
Pentoxifylline with or without tocopherol | |
Grade D | |
Superoxide dismutase | |
Interferon gamma (IFNγ) | |
Hyperbaric oxygen therapy | |
Laser therapy with epidermal grafting | |
Telangiectasias | Grade D Pulse dye laser |
Secondary skin cancers and radiation-induced keratoses | Surgical excision preferred for skin cancers |
Grade 2C | |
Radiation-induced keratoses: | |
Cryosurgery | |
Mechanical destruction (peel, laser, or dermabrasion) | |
Grade D | |
Topical 5-fluorouracil | |
Diclofenac | |
Photodynamic therapy | |
Imiquimod |