Abstract
Radiodermatitis (radiation dermatitis, radiation-induced skin reactions, or radiation injury) is a significant side effect of ionizing radiation delivered to the skin during cancer treatment as well as a result of nuclear attacks and disasters, such as that which occurred in Fukushima in 2011. More specifically, 95 % of cancer patients receiving radiation therapy will develop some form of radiodermatitis, including erythema, dry desquamation, and moist desquamation. These radiation skin reactions result in a myriad of complications, including delays in treatment, diminished aesthetic appeal, and reduced quality of life. Recent technological advancements and novel treatment regimens have only been successful in partly ameliorating these adverse side effects. This article examines the current knowledge surrounding the pathogenesis, clinical manifestations, differential diagnoses, prevention, and management of radiodermatitis. Future research should examine therapies that incorporate the current understanding of the pathophysiology of radiodermatitis while measuring effectiveness using objective and universal outcome measures.
Similar content being viewed by others
References
Siegel R, Desantis C, Virgo K, et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin. 2012;62(4):220–41.
McQuestion M. Evidence-based skin care management in radiation therapy: clinical update. Semin Oncol Nurs. 2011;27(2):e1–17.
Ryan JL. Ionizing radiation: the good, the bad, and the ugly. J Invest Dermatol. 2012;132(3 Pt 2):985–93.
Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol. 2006;54(1):28–46.
Feight D, Baney T, Bruce S, McQuestion M. Putting evidence into practice: evidence-based interventions for radiation dermatitis. Clin J Oncol Nurs. 2011;15(5):481–92.
Dendaas N. Toward evidence and theory-based skin care in radiation oncology. Clin J Oncol Nurs. 2012;16(5):520–5.
Salvo N, Barnes E, van Draanen J, Stacey E, Mitera G, Breen D, et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Curr Oncol. 2010;17(4):94–112.
Hindley A, Zain Z, Wood L, Whitehead A, Sanneh A, Barber D, et al. Mometasone furoate cream reduces acute radiation dermatitis in patients receiving breast radiation therapy: results of a randomized trial. Int J Radiat Oncol Biol Phys. 2014;90(4):748–55.
Radvansky LJ, Pace MB, Siddiqui A. Prevention and management of radiation-induced dermatitis, mucositis, and xerostomia. Am J Health Syst Pharm. 2013;70(12):1025–32.
Chan RJ, Larsen E, Chan P. Re-examining the evidence in radiation dermatitis management literature: an overview and a critical appraisal of systematic reviews. Int J Radiat Oncol Biol Phys. 2012;84(3):e357–62.
Chan RJ, Webster J, Chung B, Marquart L, Ahmed M, Garantziotis S. Prevention and treatment of acute radiation-induced skin reactions: a systematic review and meta-analysis of randomized controlled trials. BMC Cancer. 2014;14:53.
Morgan K. Radiotherapy-induced skin reactions: prevention and cure. Br J Nurs. 2014;23(16):S24, S26–32.
Freedman GM, Anderson PR, Li J, Eisenberg DF, Hanlon AL, Wang L, et al. Intensity modulated radiation therapy (IMRT) decreases acute skin toxicity for women receiving radiation for breast cancer. Am J Clin Oncol. 2006;29(1):66–70.
Pignol J-P, Olivotto I, Rakovitch E, Gardner S, Sixel K, Beckham W, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26(13):2085–92.
Freedman GM, Li T, Nicolaou N, Chen Y, Ma CCM, Anderson PR. Breast intensity-modulated radiation therapy reduces time spent with acute dermatitis for women of all breast sizes during radiation. Int J Radiat Oncol Biol Phys. 2009;74(3):689–94.
Vano-Galvan S, Fernandez-Lizarbe E, Truchuelo M, Diaz-Ley B, Grillo E, Sanchez V, et al. Dynamic skin changes of acute radiation dermatitis revealed by in vivo reflectance confocal microscopy. J Eur Acad Dermatol Venereol. 2013;27(9):1143–50.
Glover D, Harmer V. Radiotherapy-induced skin reactions: assessment and management. Br J Nurs. 2014;23(4):S28, S30–5.
Hu SC-S, Hou M-F, Luo K-H, Chuang H-Y, Wei S-Y, Chen G-S. Changes in biophysical properties of the skin following radiotherapy for breast cancer. J Dermatol. 2014;41(12):1087–94.
Trueman E, Taylor L. Using a soft-silicone dressing to treat moist desquamation. Br J Nurs. 2014;23(10):S32, S34–7.
Amber KT, Shiman MI, Badiavas EV. The use of antioxidants in radiotherapy-induced skin toxicity. Integr Cancer Ther. 2014;13(1):38–45.
Kim JH, Kolozsvary AJJ, Jenrow KA, Brown SL. Mechanisms of radiation-induced skin injury and implications for future clinical trials. Int J Radiat Biol. 2013;89(5):311–8.
Müller K, Meineke V. Radiation-induced mast cell mediators differentially modulate chemokine release from dermal fibroblasts. J Dermatol Sci. 2011;61(3):199–205.
Akita S, Yoshimoto H, Akino K, Ohtsuru A, Hayashida K, Hirano A, et al. Early experiences with stem cells in treating chronic wounds. Clin Plast Surg. 2012;39(3):281–92.
Akita S. Treatment of radiation injury. Adv Wound Care. 2014;3(1):1–11.
Akita S, Yoshimoto H, Ohtsuru A, Hirano A, Yamashita S. Autologous adipose-derived regenerative cells are effective for chronic intractable radiation injuries. Radiat Prot Dosimetry. 2012;151(4):656–60.
Roche S, Delorme B, Oostendorp RAJ, Barbet R, Caton D, Noel D, et al. Comparative proteomic analysis of human mesenchymal and embryonic stem cells: Towards the definition of a mesenchymal stem cell proteomic signature. Proteomics. 2009;9(2):223–32.
Strem BM, Hicok KC, Zhu M, Wulur I, Alfonso Z, Schreiber RE, et al. Multipotential differentiation of adipose tissue-derived stem cells. Keio J Med. 2005;54(3):132–41.
Meyer F, Fortin A, Wang CS, Liu G, Bairati I. Predictors of severe acute and late toxicities in patients with localized head-and-neck cancer treated with radiation therapy. Int J Radiat Oncol Biol Phys. 2012;82(4):1454–62.
De Langhe S, Mulliez T, Veldeman L, Remouchamps V, van Greveling A, Gilsoul M, et al. Factors modifying the risk for developing acute skin toxicity after whole-breast intensity modulated radiotherapy. BMC Cancer. 2014;14:711.
Spalek M, Jonska-Gmyrek J, Gałecki J. Radiation-induced morphea: a literature review. J Eur Acad Dermatol Venereol. 2015;29(2):197–202.
Piérard GE, Piérard-Franchimont C, Paquet P, Quatresooz P. Emerging therapies for ionizing radiation-associated skin field carcinogenesis. Expert Opin Pharmacother. 2009;10(5):813–21.
Wong RKS, Bensadoun RJ, Boers-Doets CB, Bryce J, Chan A, Epstein JB, et al. Clinical practice guidelines for the prevention and treatment of acute and late radiation reactions from the MASCC Skin Toxicity Study Group. Support Care Cancer. 2013;21(10):2933–48.
Yoshida EJ, Chen H, Torres M, Andic F, Liu H, Chen Z, et al. Reliability of quantitative ultrasonic assessment of normal-tissue toxicity in breast cancer radiotherapy. Int J Radiat Oncol Biol Phys. 2012;82(2):724–31.
Rizza L, D’Agostino A, Girlando A, Puglia C. Evaluation of the effect of topical agents on radiation-induced skin disease by reflectance spectrophotometry. J Pharm Pharmacol. 2010;62(6):779–85.
Simonen P, Hamilton C, Ferguson S, Ostwald P, O’Brien M, O’Brien P, et al. Do inflammatory processes contribute to radiation induced erythema observed in the skin of humans? Radiother Oncol. 1998;46(1):73–82.
Piérard GE. EEMCO guidance for the assessment of skin colour. J Eur Acad Dermatol Venereol. 1998;10(1):1–11.
Wengström Y, Forsberg C, Näslund I, Bergh J. Quantitative assessment of skin erythema due to radiotherapy—evaluation of different measurements. Radiother Oncol. 2004;72(2):191–7.
Coleman CN, Turrisi AT. Radiation and chemotherapy sensitizers and protectors. Crit Rev Oncol Hematol. 1990;10(3):225–52.
Azria D, Gourgou S, Sozzi WJ, Zouhair A, Mirimanoff RO, Kramar A, et al. Concomitant use of tamoxifen with radiotherapy enhances subcutaneous breast fibrosis in hypersensitive patients. Br J Cancer. 2004;91(7):1251–60.
Clark SC, Zirwas MJ. Management of occupational dermatitis. Dermatol Clin. 2009;27(3):365–83.
Casamiquela KM, Cohen PR. Radiation port dermatophytosis: Tinea corporis occurring at the site of irradiated skin. Dermatol Online J. 2012;18(1):5.
Urosevic-Maiwald M, Harr T, French L, Dummer R. Stevens–Johnson syndrome and toxic epidermal necrolysis overlap in a patient receiving cetuximab and radiotherapy for head and neck cancer. Int J Dermatol. 2012;51:864–7.
Haas RLM, de Klerk G. An illustrated case of doxorubicin-induced radiation recall dermatitis and a review of the literature. Neth J Med. 2011;69(2):72–5.
Levy A, Hollebecque A, Bourgier C, Loriot Y, Guigay J, Robert C, et al. Targeted therapy-induced radiation recall. Eur J Cancer. 2013;49(7):1662–8.
Azad A, Maddison C, Stewart J. Radiation recall dermatitis induced by pazopanib. Onkologie. 2013;36(11):674–6.
Shukla PN, Gairola M, Mohanti BKRG. Prophylactic beclomethasone spray to the skin during postoperative radiotherapy of carcinoma breast: a prospective randomized study. Indian J Cancer. 2006;43:180–4.
Schmuth M, Wimmer MA, Hofer S, Sztankay A, Weinlich G, Linder DM, et al. Topical corticosteroid therapy for acute radiation dermatitis: a prospective, randomized, double-blind study. Br J Dermatol. 2002;146(6):983–91.
Miller RC, Schwartz DJ, Sloan JA, Griffin PC, Deming RL, Anders JC, et al. Mometasone furoate effect on acute skin toxicity in breast cancer patients receiving radiotherapy: a phase III double-blind, randomized trial from the North Central Cancer Treatment Group N06C4. Int J Radiat Oncol Biol Phys. 2011;79(5):1460–6.
Hemati S, Asnaashari O, Sarvizadeh M, Motlagh BN, Akbari M, Tajvidi M, et al. Topical silver sulfadiazine for the prevention of acute dermatitis during irradiation for breast cancer. Support Care Cancer. 2012;20(8):1613–8.
Elliott EA, Wright JR, Swann RS, Nguyen-Tân FTC, et al. Phase III trial of an emulsion containing trolamine for the prevention of radiation dermatitis in patients with advanced squamous cell carcinoma of the head and neck: results of Radiation Therapy Oncology Group Trial 99-13. J Clin Oncol. 2006;24:2092–7.
Pommier P, Gomez F, Sunyach MP, D’Hombres A, Carrie C, Montbarbon X. Phase III randomized trial of Calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. J Clin Oncol. 2004;22(8):1447–53.
Fenig E, Brenner B, Katz A, Sulkes J, Lapidot M, Schachter J, et al. Topical Biafine and Lipiderm for the prevention of radiation dermatitis: a randomized prospective trial. Oncol Rep. 2001;8(2):305–9.
Fisher J, Scott C, Stevens R, Marconi B, Champion L, Freedman GM, et al. 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. 2000;48(5):1307–10.
Abbas H, Bensadoun RJ. Trolamine emulsion for the prevention of radiation dermatitis in patients with squamous cell carcinoma of the head and neck. Support Care Cancer. 2012;20(1):185–90.
Nymann P, Hedelund L, Hædersdal M. Intense pulsed light vs. long-pulsed dye laser treatment of telangiectasia after radiotherapy for breast cancer: a randomized split-lesion trial of two different treatments. Br J Dermatol. 2009;160(6):1237–41.
Delanian S, Balla-Mekias S, Lefaix JL. Striking regression of chronic radiotherapy damage in a clinical trial of combined pentoxifylline and tocopherol. J Clin Oncol. 1999;17(10):3283–90.
Kouvaris JR, Kouloulias VE, Plataniotis GA, Balafouta EJ, Vlahos LJ. Dermatitis during radiation for vulvar carcinoma: prevention and treatment with granulocyte-macrophage colony-stimulating factor impregnated gauze. Wound Repair Regen. 2001;9(3):187–93.
Ajani JA, Winter KA, Gunderson LL, Pedersen J, Benson AB, Thomas CR, et al. Fluorouracil, mitomycin, and radiotherapy vs fluorouracil, cisplatin, and radiotherapy for carcinoma of the anal canal: a randomized controlled trial. JAMA. 2008;299(16):1914–21.
Roy I, Fortin A, Larochelle M. The impact of skin washing with water and soap during breast irradiation: a randomized study. Radiother Oncol. 2001;58(3):333–9.
Westbury C, Hines F, Hawkes E, Ashley S, Brada M. Advice on hair and scalp care during cranial radiotherapy: a prospective randomized trial. Radiother Oncol. 2000;54(2):109–16.
Campbell IR, Illingworth MH. Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial. Clin Oncol (R Coll Radiol). 1992;4(2):78–82.
Watson LC, Gies D, Thompson E, Thomas B. Randomized control trial: evaluating aluminum-based antiperspirant use, axilla skin toxicity, and reported quality of life in women receiving external beam radiotherapy for treatment of stage 0, I, and II breast cancer. Int J Radiat Oncol. 2012;83(1):e29–34.
Bennett C. An investigation into the use of a non-metallic deodorant during radiotherapy treatment: a randomised controlled trial. J Radiother Pract. 2009;8(01):3.
Théberge V, Harel F, Dagnault A. Use of Axillary deodorant and effect on acute skin toxicity during radiotherapy for breast cancer: a prospective randomized noninferiority trial. Int J Radiat Oncol Biol Phys. 2009;75(4):1048–52.
Gee A, Moffitt D, Churn M, Errington RD. A randomised controlled trial to test a non-metallic deodorant used during a course of radiotherapy. J Radiother Pract. 2000;1(04):205–12.
Omidvari S, Saboori H, Mohammadianpanah M, Mosalaei A, Ahmadloo N, et al. Topical betamethasone for prevention of radiation dermatitis. Indian J Dermatol Venereol Leprol. 2007;73(3):209.
Boström Å, Lindman H, Swartling C, Berne B, Bergh J. Potent corticosteroid cream (mometasone furoate) significantly reduces acute radiation dermatitis: results from a double-blind, randomized study. Radiother Oncol. 2001;59(3):257–65.
Kirova YM, Fromantin I, De Rycke Y, Fourquet A, Morvan E, Padiglione S, et al. Can we decrease the skin reaction in breast cancer patients using hyaluronic acid during radiation therapy? Results of phase III randomised trial. Radiother Oncol. 2011;100(2):205–9.
Primavera G, Carrera M, Berardesca E, Pinnaró P, Messina MGAG. A double-blind, vehicle-controlled clinical study to evaluate the efficacy of MAS065D (XClair), a hyaluronic acid-based formulation, in the management of radiation-induced dermatitis. Cutan Ocul Toxicol. 2006;25:165–71.
Liguori V, Guillemin C, Pesce GF, Mirimanoff RO, Bernier J. Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy. Radiother Oncol. 1997;42(2):155–61.
Heggie S, Bryant GP, Tripcony L, Keller J, Rose P, Glendenning M, et al. A Phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nurs. 2002;25(6):442–51.
Williams MS, Burk M, Loprinzi CL, Hill MSP, et al. 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. 1996;36:345–9.
Wells M, Macmillan M, Raab G, MacBride S, Bell N, MacKinnon K, et al. Does aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomised controlled trial. Radiother Oncol. 2004;73(2):153–62.
Evensen JF, Bjordal K, Jacobsen AB, Løkkevik E, Tausjø JE. Effects of Na-sucrose octasulfate on skin and mucosa reactions during radiotherapy of head and neck cancers—a randomized prospective study. Acta Oncol. 2001;40(6):751–5.
Lievens Y, Haustermans K, Van den Weyngaert D, Van den Bogaert W, Scalliet P, Hutsebaut L, et al. Does sucralfate reduce the acute side-effects in head and neck cancer treated with radiotherapy? A double-blind randomized trial. Radiother Oncol. 1998;47(2):149–53.
Maiche A, Isokangas OP, Gröhn P. Skin protection by sucralfate cream during electron beam therapy. Acta Oncol. 1994;33(2):201–3.
Dale PS, Tamhankar CP, George D, Daftary GV. Co-medication with hydrolytic enzymes in radiation therapy of uterine cervix: evidence of the reduction of acute side effects. Cancer Chemother Pharmacol. 2001;47(Suppl):S29–34.
Gujral MS, Patnaik PM, Kaul R, Parikh HK, Conradt C, Tamhankar CP, et al. Efficacy of hydrolytic enzymes in preventing radiation therapy-induced side effects in patients with head and neck cancers. Cancer Chemother Pharmacol. 2001;47(Suppl):S23–8.
Halperin EC, Gaspar L, George S, Darr DPS. A double-blind, randomized, prospective trial to evaluate topical vitamin C solution for the prevention of radiation dermatitis. Int J Radiat Oncol Biol Phys. 1993;26:413–6.
Röper B, Kaisig D, Auer F, Mergen E, Molls M. Thêta-Cream® versus Bepanthol® Lotion in breast cancer patients under radiotherapy: a new prophylactic agent in skin care? Strahlentherapie und Onkol. 2004;180(5):315–22.
Lin LC, Que J, Lin LK, Lin FC. Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: a double-blind, randomized study. Int J Radiat Oncol Biol Phys. 2006;65(3):745–50.
Aygenc E, Celikkanat S, Kaymakci M, Aksaray F, Ozdem C. Prophylactic effect of pentoxifylline on radiotherapy complications: a clinical study. Otolaryngol Head Neck Surg. 2004;130(3):351–6.
Niazi TM, Vuong T, Azoulay L, Marijnen C, Bujko K, Nasr E, et al. Silver clear nylon dressing is effective in preventing radiation-induced dermatitis in patients with lower gastrointestinal cancer: results from a phase III study. Int J Radiat Oncol Biol Phys. 2012;84(3):e305–10.
Aquino-Parsons C, Lomas S, Smith K, Hayes J, Lew S, Bates AT, et al. Phase III study of silver leaf nylon dressing vs standard care for reduction of inframammary moist desquamation in patients undergoing adjuvant whole breast radiation therapy. J Med Imaging Radiat Sci. 2010;41(4):215–21.
Diggelmann KV, Zytkovicz AE, Tuaine JM, Bennett NC, Kelly LE, Herst PM. Mepilex Lite dressings for the management of radiation-induced erythema: a systematic inpatient controlled clinical trial. Br J Radiol. 2010;83(995):971–8.
Lanigan SW, Joannides T. Pulsed dye laser treatment of telangiectasia after radiotherapy for carcinoma of the breast. Br J Dermatol. 2003;148(1):77–9.
Løkkevik E, Skovlund E, Reitan JB, Hannisdal E, Tanum G. Skin treatment with bepanthen cream versus no cream during radiotherapy: a randomized controlled trial. Acta Oncol. 1996;35(8):1021–6.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
Manni Singh, Afsaneh Alavi, Rebecca Wong, and Sadanori Akita have no conflicts of interest to disclose related to this manuscript.
Funding
No funding was received for the preparation of this review.
Rights and permissions
About this article
Cite this article
Singh, M., Alavi, A., Wong, R. et al. Radiodermatitis: A Review of Our Current Understanding. Am J Clin Dermatol 17, 277–292 (2016). https://doi.org/10.1007/s40257-016-0186-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40257-016-0186-4