Table 2 Radiation dermatitis: grading and general management recommendations
Grade of radiation dermatitis | Grade 1 | Grade 2 | Grade 3 | Grade 4 |
|---|---|---|---|---|
Definition of radiation dermatitis (NCI CTCAE, v3.0) | Faint erythema or dry desquamation | Moderate to brisk erythema; patchy, moist desquamation, mostly confined to skin folds and creases; moderate oedema | Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion | Skin necrosis or ulceration of full thickness of dermis; spontaneous bleeding from involved site |
General management approaches | See General management | |||
Maintain hygiene and gently clean and dry skin in the radiation field shortly before radiotherapy | ||||
Topical moisturisers, gels, emulsions and dressings should not be applied shortly before radiation treatment as they can cause a bolus effect, thereby artificially increasing the radiation dose to the epidermis | ||||
Grade-specific management approaches | Use of a moisturiser is optional | Keep the irradiated area clean, even when ulcerated | Verify that radiation dose and distribution are correct | |
If anti-infective measures are desired, antibacterial moisturisers (e.g. triclosan or chlorhexidine-based cream) may be used occasionally | In the absence of clinical signs of infection, one or combinations of the following topical approaches may be used: | Requires specialised wound care with the assistance of the radiation oncologist, dermatologist and nurse, and should be treated on a case by case basis | ||
•- Drying gels, possibly with the addition of antiseptics (e.g. chlorhexidine-based creams) | ||||
•- An anti-inflammatory emulsion, such as trolamine | ||||
•- Hyaluronic acid cream | ||||
•- Hydrophilic dressings, applied after radiotherapy to the cleaned, irradiated area, which may provide symptomatic relief | ||||
•- Zinc oxide paste, if easy to remove prior to radiotherapy | ||||
•- When used, silver sulfadiazine or beta glucan cream should be applied after radiotherapy (possibly in the evening) after cleaning the irradiated area | ||||
•- Where infection is suspected: | ||||
•- The treating physician should use best clinical judgement for identifying infection, including the consideration of swabbing the area for identification of the infectious agent | ||||
•- Topical antibiotics (should not be used prophylactically) | ||||
•- Doxycycline is not recommended at this stage | ||||
•- Blood granulocyte counts should be checked, particularly if the patient is receiving concomitant chemotherapy | ||||
•- Blood cultures should be carried out if there are additional signs of sepsis and/or fever | ||||
Management team | Can be managed primarily by nursing staff | Can be managed by an integrated management team comprising the radiation oncologist, nurse, medical oncologist (where appropriate) and dermatologist, as required | Should be managed primarily by a wound specialist, with the assistance of the radiation oncologist, medical oncologist (where appropriate), dermatologist and nurse, as required | |
Skin reactions should be assessed at least once a week | ||||