This topic section relates to the advice given to patients, during and after a course of superficial radiotherapy.
X-rays of this energy range deposit their maximum dose either at the skin surface or up to 20mm below the skin surface; (see physics), consequently radiation skin reactions for patients undergoing superficial therapy can be severe, depending upon the daily dose, fractionation schedule and total prescribed dose [1]. It is therefore essential that patients are adequately advised and supervised, in terms of these reactions.
Most radiotherapy departments in the UK utilise the broad photon energy spectrum 30 kV, 50 kV, 100 kV, 150 kV and 220 kV for treatment of :
Basal Cell Carcinoma (BCC)
Squamous cell carcinoma (SCC)
Cutaneous Lymphoma
Keloid scar
Angio Sarcoma
Kaposi Sarcoma
Skin Reactions
Most commonly, treatment reactions begin approximately two weeks after the onset of treatment, peak 7-10 days after the final treatment fraction and begin to diminish between 4-6 weeks after the treatment has finished. During this acute phase, nursing care may be required.
The skin reactions can be classified into three different types:
Erythema; this is an inflammatory response to cell death in the epidermis as a result of the radiation and is characterised by the skin becoming red, hot and itchy - similar to sunburn.
Dry Desquamation; this type of skin reaction occurs due to premature keratinisation of the epidermis where repopulation of the cells damaged by radiation is less than the number of cells which are destroyed. This is characterised by the skin becoming dry, tender and itchy with flaking of the superficial layers [1].
Moist Desquamation; this is the most severe type of skin reaction and occurs due to insufficient new cell proliferation of the epithelial layer, leading to the exposure of the deeper dermal layer. This is characterised by painful, blistered skin and the production of sebaceous fluid [1].
Often during treatment, lesions will develop a scab which repeatedly forms, falls off and re grows. This usually occurs several times until healing is complete and can continue for several weeks following the end of treatment.
In addition to the skin reactions described above, patients who are receiving treatment to mucosal linings, such as nasal or mouth area, may experience an adverse reaction in the lining which is characterised by acute inflammation or ulceration of the mucosal membrane [2].
Late Effects
Following treatment there are several possible late effects which may occur to the skin of the treated area:
Pigmentation; a slight permanent change in skin colouring.
Skin atrophy; thinning of the top two layers of skin, the dermis and epidermis, often causing a depression in the skin.
Heightened photosensitivity; increased sensitivity to the sun.
Telangiectasia; dilation of thin walled blood vessels, close to the surface of the skin.
Necrosis; this rarely occurs although in certain cases tissue necrosis can be seen as a result of damage to the blood vessels.
Permanent alopecia; hair loss in treatment area.
Dacryostenosis; lacrimal duct damage after treatment to inner canthus.
Management
Prior to starting treatment, it is essential that all patients are given advice regarding skin care, as both verbal and written instructions. Assessment of the skin condition of the treatment area needs to be performed at each treatment attendance, additionally, patients who are receiving multiple fractions must be reviewed by either the nurse practitioner or oncologist. Special attention also needs to be given to the patient’s psychological and general physical condition as this will affect their general ability to manage.
Skin Care Advice
The most common advice given to patients undergoing superficial radiotherapy treatment is not to apply any liquids or lotions to the treatment area. Washing around the area of treatment is not recommended and also the use of perfumes, cosmetics or aftershave is not advisable, mainly due to the presence of trace metals which may intensify the skin reaction.
If the patient is unable to tolerate not washing the area they can be advised to wash using warm (not hot) water, using a simple unperfumed soap. Skin should be treated gently; patted dry and not rubbed as this could heighten the sensitivity and robustness of skin, causing it to be further compromised.
Patients who are having treatment to the scalp can be advised to wash hair using a mild baby shampoo. If possible hair should be left to dry naturally although a hair dryer on a cool setting is acceptable.
Patients are also advised to stay out of the sun.
Managing Skin Reactions
Erythema
Where cases of erythema occur, patients can be advised to apply an aqueous cream to the treatment area two to three times daily, to alleviate the discomfort of dry skin and defer the onset of damage to the epithelial cells. Evidence in current literature suggests the use of emollient creams to manage erythema significantly reduces the onset of more severe skin reactions [1].
Moist Desquamation
In the occurrence of cases of moist desquamation it is important to ensure that infection is avoided through good skin management. In these instances nursing care would be required, following moist wound care management principles and the resultant use of hydrocolloid gels and flexible dressings [1].
Often, during the course of treatment, the lesion can dry up, forming a scab over the healing wound which it is advisable to leave, allowing the scab to fall off naturally. However, in some instances, the formation of this scab could be so thick that it compromises the radiotherapy treatment, due to the photon beam being absorbed by the dead skin layers. In such cases, it may be necessary to remove the scab, to ensure correct treatment, using a hydrogel dressing which is placed on the scab overnight, allowing it to soften, for easy removal the following day.
In certain cases, if the lesion has been left unattended for a long period of time, it can thicken to form a ‘horn’ that cannot easily be removed using hydrogel. In order to expose the source of the growth, it is advisable to treat the lesion using enzyme intervention with a product containing streptokinase which, once injected into the lesion, will cause the growth to breakdown.
Complex Lesion Management
In certain instances, some lesions can present as moist and malodorous and these will therefore require daily attention. Current practice suggests absorptive dressings should be applied, with the use of hydrogel (covered with a non adhesive dressing) to facilitate moist wound care [4]. Where possible, dressing tape should be avoided as the use of such can increase the potential for further skin damage. It is also advisable to only clean the lesion if there is evidence of debris or infection. Malodorous lesions can cause great discomfort to the patient and removal of the offensive odour is therefore vital. Historically, charcoal based dressings were used, however these have now be replaced by topical antibiotic creams, allowing the surface bacteria to be killed and thereby providing positive results.
For bleeding lesions it is advisable to treat using an alginate dressing as this has haemostatic qualities which help to reduce minor bleeding.
Wound care is the primary concern when managing complex lesions although not the only; patients must be advised that general behaviour such as smoking, malnourishment, dehydration, diabetes, circulatory and respiratory problems can all compromise rapid healing.
Post Treatment Care
Post treatment patients are advised that there skin reaction will peak approximately seven days following the end of treatment, due to the accumulative nature of radiotherapy and therefore it is important that they continue with their recommended treatment area regime for this time.
Care needs to be given when exposing the area to the sun due to heightened sensitivity which, if not protected, could cause the area to react severely in cases of sunburn. If the area cannot be covered by a sunhat or other garment then the patient is advised to use a high factor SPF (sun protection factor) cream at all times.
References
Glean E, Edwards S, Faithful S, Meredith C, Richards C, Smith M and Colyer H. Intervention for acute radiotherapy induced skin reactions in cancer patients: the development of a clinical guideline recommended for use by the college of radiographers. Journal of Radiotherapy in Practice. 2001. 2; 75_84.
Naylor W and Mallett J. Management of acute radiotherapy induced skin reactions. A literature review. European journal of oncology nursing. 2001. 5; (4): 221-233.
