The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline

Abstract

Goals of work

To develop a practice guideline report on the questions: What are the optimal methods to prevent acute skin reactions (occurring within the first 6 months of irradiation) related to radiation therapy? What are the optimal methods to manage acute skin reactions related to radiation therapy?

Materials and methods

Cancer Care Ontario’s Supportive Care Guidelines Group (SCGG) conducted a systematic review of literature on this topic. Evidence-based recommendations were formulated to guide clinical decision making, and a formal external review process was conducted to validate the relevance of these opinions for Ontario practitioners.

Main results

Twenty-eight trials meeting the inclusion criteria were identified. Of the twenty-three trials that evaluated preventative methods, washing was the only practice which significantly prevented skin reaction. Some evidence suggested topical steroid creams and calendula ointment might be effective. None of the five trials evaluating skin reaction management detected a positive effect using steroid cream, sucralfate cream, or dressings.

Conclusions

Skin washing, including gentle washing with water alone with or without mild soap, should be permitted in patients receiving radiation therapy to prevent acute skin reaction. There is insufficient evidence to support or refute specific topical or oral agents for the prevention or management of acute skin reaction. In the expert opinion from the SCGG, the use of a plain, non-scented, lanolin-free hydrophilic cream may be helpful in preventing radiation skin reactions. In addition, a low dose (i.e., 1%) corticosteroid cream may be beneficial in the reduction of itching and irritation.

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Notes

  1. 1.

    “Gentle washing” involves using lukewarm water and taking care not to rub the skin. Showers should also be lukewarm and should have low pressures.

  2. 2.

    “Mild soap” is defined as a pH-balanced, non-scented product that does not contain lanolin. There is no evidence to suggest that one type of mild soap is preferable to another. However, in one study that rated the irritant quality of 18 soaps, “Dove” was the only soap classified as mild and may, therefore, be considered [17].

References

  1. 1.

    Balzarini A, Felisi E, Martini A et al (2000) Efficacy of homeopathic treatment of skin reactions during radiotherapy for breast cancer: a randomized, double-blind clinical trial. Br Homeopath J 89:8–12

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Barkham AM (1993) Radiotherapy skin reactions and treatments. Prof Nurse 8:732–736

    PubMed  CAS  Google Scholar 

  3. 3.

    Bolderston A (2002) Skin care recommendations during radiotherapy: a survey of Canadian practice. Can J Med Radiat Technol 34:3–11

    Article  Google Scholar 

  4. 4.

    Bostrom A, Lindman H, Swartling C et al (2001) Potent corticosteroid cream (mometasone furoate) significantly reduces acute radiation dermatitis: results from a double-blind, randomized study. Radiother Oncol 59:257–265

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    British Columbia Cancer Agency (2000) Cancer management manual: supportive care—guidelines for the care of radiation skin reactions. Available at: http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/SupportiveCare/RadiationSkinReactions/default.htm. Accessed: February 18, 2004

  6. 6.

    Browman GP, Levine MN, Mohide EA et al (1995) The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 13:502–512

    PubMed  CAS  Google Scholar 

  7. 7.

    Burch SE, Parker SA, Vann AM et al (1997) Measurement of 6-MV X-ray surface dose when topical agents are applied prior to external beam irradiation. Int J Radiat Oncol Biol Phys 38:447–451

    PubMed  CAS  Google Scholar 

  8. 8.

    Campbell IR, Illingworth MH (1992) Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial. Clin Oncol 4:78–82

    Article  CAS  Google Scholar 

  9. 9.

    Campbell J, Lane C (1996) Developing a skin-care protocol in radiotherapy. Prof Nurse 12:105–108

    PubMed  CAS  Google Scholar 

  10. 10.

    Canadian Cancer Society (2003) [document online]. Available at: http://www.cancer.ca/ccs/internet/standard/0,3182,3172_369269_429281_langId-en,00.html. Accessed: November 17, 2003

  11. 11.

    Dale PS, Tamhankar CP, George D et al (2001) Co-medication with hydrolytic enzymes in radiation therapy of uterine cervix: evidence of the reduction of acute side effects. Cancer Chemother Pharmacol 47:S29–S34 (Suppl)

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Delaney G, Fisher R, Hook C et al (1997) Sulcrafate cream in the management of moist desquamation during radiotherapy. Australas Radiol 41:270–275

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    Dunst J, Semlin S, Pigorsch S et al (2000) Intermittent use of amifostine during postoperative radiochemotherapy and acute toxicity in rectal cancer patients. Strahlenther Onkol 176:416–421

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Evensen JF, Bjordal K, Jacobsen A et al (2001) Effects of Na-sucrose octasulfate on skin and mucosa reactions during radiotherapy of head and neck cancers. Acta Oncol 40:751–755

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Fenig E, Brenner B, Katz A et al (2001) Topical biafine and lipiderm for the prevention of radiation dermatitis: a randomized prospective trial. Oncol Rep 8:305–309

    PubMed  CAS  Google Scholar 

  16. 16.

    Fisher J, Scott C, Stevens R et al (2000) Randomized phase III study comparing best supportive care to biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: radiation therapy oncology group (RTOG) 97-13. Int J Radiat Oncol Biol Phys 48:1307–1310

    PubMed  CAS  Google Scholar 

  17. 17.

    Frosch PJ, Kligman AM (1979) The soap chamber test: a new method for assessing the irritancy of soaps. J Am Acad Dermatol 1:35–41

    PubMed  CAS  Article  Google Scholar 

  18. 18.

    Gujral MS, Patnaik PM, Kaul R et al (2001) Efficacy of hydrolytic enzymes in preventing radiation therapy-induced side effects in patients with head and neck cancers. Cancer Chemother Pharmacol 47:S23–S28 (Suppl)

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Halperin EC, Gaspar L, George S et al (1993) A double-blind, randomized, prospective trial to evaluate topical vitamin C solution for the prevention of radiation dermatitis. Int J Radiat Oncol Biol Phys 26:413–416

    PubMed  CAS  Google Scholar 

  20. 20.

    Hazuka MB, Goebel RH, McCutchan S et al (1997) A new approach to the prevention of radiation-induced skin desquamation using a polymer adhesive skin sealant (PASS): final results of a prospective study (meeting abstract). Proc Am Soc Clin Oncol 16:A239

    Google Scholar 

  21. 21.

    Heggie S, Bryant GP, Tripcony L et al (2002) A phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nurs 25:442–451

    PubMed  Article  Google Scholar 

  22. 22.

    Kaul R, Mishra BK, Sutradar P et al (1999) The role of Wobe-Mugos in reducing acute sequele of radiation in head and neck cancers—a clinical phase III randomized trial. Indian J Cancer 36:141–148

    PubMed  CAS  Google Scholar 

  23. 23.

    Korinko A, Yurick A (1997) Maintaining skin integrity during radiotherapy. Am J Nurs 97:40–44

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Koukourakis MI, Frangiadaki C, Stavroulaki A et al (2000) Subcutaneous amifostine during fractionated radiotherapy: a randomized phase II study in pelvic tumours J Clin Oncol 18:2226–2233

    PubMed  CAS  Google Scholar 

  25. 25.

    Kouvaris JR, Kouloulias VE, Plataniotis GA et al (2001) Dermatits during radiation for vulvar carcinoma: prevention and treatment with granulocyte-macrophage colony-stimulating factor impregnated gauze. Wound Repair Regen 9:187–193

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Lievens Y, Haustermans K, Van den Weyngaert D et al (1998) Does sucralfate reduce the acute side-effects in head and neck cancer treated with radiotherapy? A double-blind randomized trial. Radiother Oncol 47:149–153

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Liguori V, Guillemin C, Pesce GF et al (1997) Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy. Radiother Oncol 42:155–161

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Løkkevik E, Skovlund E, Reitan JB et al (1996) Skin treatment with bepanthen cream versus no cream during radiotherapy. Acta Oncol 35:1021–1026

    PubMed  Article  Google Scholar 

  29. 29.

    Maiche AG, Grohn P, Maki-Hokkonen H (1991) Effect of chamomile cream and almond ointment on acute radiation skin reaction. Acta Oncol 30:395–396

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Maiche A, Isokangas O, Grohn P (1994) Skin protection by sucralfate cream during electron beam therapy. Acta Oncol 33:201–203

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Mak SS, Lolassiotis A, Wan W et al (2000) The effects of hydrocolloid dressing and gentian violet on radiation-induced moist desquamation wound healing. Cancer Nurs 23:220–229

    PubMed  Article  CAS  Google Scholar 

  32. 32.

    Olsen DL, Raub W, Bradley C et al (2001) The effect of aloe vera gel/mild soap alone in preventing skin reaction in patients undergoing radiation therapy. Oncol Nurs Forum 28:543–547

    PubMed  CAS  Google Scholar 

  33. 33.

    Oncology Nursing Society (ONS) (1998) Manual for radiation oncology nursing practice and education. Oncology Nursing Society, Pittsburgh, PA

    Google Scholar 

  34. 34.

    Perez CA, Brady LW (1998) Principles and practice of radiation oncology, 3rd edn. Lippincott-Raven, Philadelphia, PA, p 11

    Google Scholar 

  35. 35.

    Pommier P, Gomez F, Sunyach MP et al (2004) Phase III randomized trial of calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. J Clin Oncol 22:1447–1453

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Potera ME, Lookingbill DP, Stryker JA (1982) Prophylaxis of radiation dermatitis with a topical cortisone cream. Radiother Oncol 143:775–777

    CAS  Google Scholar 

  37. 37.

    Roy I, Fortin A, Larochelle M (2001) The impact of skin washing with water and soap during breast irradiation: a randomized study. Radiother Oncol 58:333–339

    PubMed  Article  CAS  Google Scholar 

  38. 38.

    Schmuth M, Wimmer MA, Hofer S et al (2002) Topical corticosteroid therapy for acute radiation dermatitis: a prospective, randomized, double-blind study. Br J Dermatol 146:983–991

    PubMed  Article  CAS  Google Scholar 

  39. 39.

    Schreck U, Paulsen F, Bamberg M et al (2002) Intraindividual comparison of two different skin care conceptions in patients undergoing radiotherapy of the head-and-neck region. Strahlenther Onkol 6:321–329

    Article  Google Scholar 

  40. 40.

    Shell JA, Stanutz F, Grimm J (1986) Comparison of moisture vapor permeable (MVP) dressings to conventional dressings for management of radiation skin reactions. Oncol Nurs Forum 13:11–16

    PubMed  CAS  Google Scholar 

  41. 41.

    Simonen P, Hamilton C, Ferguson S et al (1998) Do inflammatory processes contribute to radiation induced erythema observed in the skin of humans? Radiother Oncol 46:73–82

    PubMed  Article  CAS  Google Scholar 

  42. 42.

    Snyder CC (1986) Oncology nursing. Little, Brown and Company, Boston, MA

    Google Scholar 

  43. 43.

    Snyder DS, Greenberg RA (1977) Radiographic measurement of topical corticosteriod-induced atrophy. J Invest Dermatol 279–281

  44. 44.

    Szumacher E, Wighton A, Franssen E et al (2001) Phase II study assessing the effectiveness of biafine cream as a prophylactic agent for radiation-induced acute skin toxicity to the breast in women undergoing radiotherapy with concomitant CMF chemotherapy. Int J Radiat Oncol Biol Phys 51:81–86

    PubMed  CAS  Google Scholar 

  45. 45.

    Westbury C, Hines F, Hawkes E et al (2000) Advice on hair and scalp care during cranial radiotherapy: a prospective randomized trial. Radiother Oncol 54:109–116

    PubMed  Article  CAS  Google Scholar 

  46. 46.

    Williams MS, Burk M, Loprinzi CL et al (1996) Phase III double-blind evaluation of an aloe vera gel as a prophylactic agent for radiation-induced skin toxicity. Int J Radiat Oncol Biol Phys 36:345–349

    PubMed  CAS  Google Scholar 

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Acknowledgements

The PEBC is sponsored by, but editorially independent of, Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

The SCGG would like to thank Ms. Karima Velji for her contribution during the initial stages of the development of the guideline and Ms. Julie Wilson for assisting in the preparation of this manuscript.

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Correspondence to Rebecca K. S. Wong.

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A complete list of Supportive Care Guidelines Group members is available at: http://www.cancercare.on.ca/.

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Bolderston, A., Lloyd, N.S., Wong, R.K.S. et al. The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline. Support Care Cancer 14, 802 (2006). https://doi.org/10.1007/s00520-006-0063-4

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Keywords

  • Practice guideline
  • Systematic review
  • Acute skin reactions
  • Radiation therapy