A review of radiation induced skin reactions and their management.

1. May 28 – 30, 2015, Montréal, Québec
Standards for Skin Care in
Radiation Therapy
Amanda Bolderston, MRT(T), MSc, FCAMRT
Radiation Therapy Provincial Professional Practice
& Academic Leader, BCCA
@AmandaBoldersto

2. Disclosure Statement: No Conflict of Interest
May 28 – 30, 2015, Montréal, Québec
I do not have an affiliation, financial or otherwise, with a pharmaceutical
company, medical device or communications organization.
I have no conflicts of interest to disclose (i.e. no industry funding received
or other commercial relationships).
I have no financial relationship or advisory role with pharmaceutical or
device-making companies, or CME provider.
I will not discuss or describe in my presentation at the meeting the
investigational or unlabeled ("off-label") use of a medical device, product,
or pharmaceutical that is classified by Health Canada as investigational for
the intended use.

3. Today’s objectives
• To examine the significance of radiation
induced skin reactions (RISR) in external
beam radiotherapy
• To identify current practice trends in the
prevention and management of RISR
• To review available evidence in the prevention
and management of RISR using the recent
Society and College of Radiographers
guidelines

4. Acknowledgements
Dr Heidi Probst, Reader in Radiotherapy, Sheffield Hallam University
Dr Rachel Harris, Professional & Education Manager, Society & College of Radiographers
Charlotte Beardmore, Director of Professional Policy, Society & College of Radiographers
Gemma Burke, Senior Lecturer & Prof. Development Facilitator, Sheffield Hallam University
Sarah James, Prof. Officer for Radiotherapy, Society & College of Radiographers
Claire Bennett, Program Lead for Radiotherapy & Oncology, University of the West of England
Samantha Bostock, Superintendent Radiographer, Gloucestershire Oncology Centre
Carole Downs, Breast Cancer Specialist Radiographer, Northern Centre for Cancer Care
Professor Sara Faithfull, Strategic Lead for Innovation & Enterprise, University of Surrey
Sonja Hoy, Nurse Specialist for Head & Neck, The Royal Marsden NHS Foundation Trust
Audrey Scott, Macmillan Head & Neck CNS, Mount Vernon Cancer Centre
Dr Diana Tait, Consultant Clinical Oncologist, The Royal Marsden NHS Foundation Trust
Ellen Trueman, Senior Radiotherapy Sister, St James's Institute of Oncology
Professor Mary Wells, Professor of Cancer Nursing Research & Practice, University of Stirling
Angela Cashell, Clinical Educator, Princess Margaret Cancer Centre, Toronto, Ontario

5. Radiation Induced Skin Reaction
• One of the most
common side effects
• Can limit treatment in
severe cases
• Source of patient
discomfort/distress
Brown and Rzucidlo, 2011; Ryan, 2012
Image: UICC “Radiotherapy in Cancer Care”

6. Radiation Induced Skin Reaction
•Frequency < with IMRT,
hypofractionation
•RISR is genetically related
to the individual’s DNA
repair capacity
•But other clinical factors
can > RISR
Chang-Claude et al., 2005; Pinar et al., 2007; Andreassen
and Alsner, 2009 and Russell et al., 1994; Russell 2010

8. Blausen gallery 2014. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762.

9. RTOG 0: No visible skin reaction.
RTOG 1: Faint or dull erythema, heat, pain
sometimes with itching and edema.
RTOG 2a: Tender or bright erythema with or
without dry desquamation
RTOG 2b: Patchy, moist desquamation,
moderate erythema.
RTOG 3: Confluent, moist desquamation
and pitting edema
Radiotherapy Oncology Group Stages

10. Stages: Erythema
Image: SCoR guidelines PPT (Appendix 10)

11. Stages: Dry desquamation
Image: SCoR guidelines PPT (Appendix 10)

12. Stages: Moist desquamation
Image: SCoR guidelines PPT (Appendix 10)

13. Goals of care
• Delay RISR onset
• Minimise severity
• Reduce symptom-
related discomfort
• Prevent further
complications
“Radiation treatment techniques are
the most promising intervention in
reducing the degree of skin reaction”
(McQuestion et al., 2012)

14. Two problems!
1. There is a considerable evidence-
practice gap in many departments
2. The evidence available is limited and
it’s often hard to compare data across
studies

15. 2013 provincial skin care survey (n=14)
•Skin care guidelines (12/14):
– BC Cancer Agency
– CCO guidelines “to some extent”
– NCIC RISR assessment tool
– In-house by interprofessional group
– “We have department guidelines but
physicians are not consistent”
Ontario practice
Used with permission: Ontario Provincial Radiation Therapy
Skin Care Working Group

16. •All (14/14) allowed gentle washing
•All recommended “unscented mild soap”
•Half (7/14) said “no deodorant”
•Most (10/14) asked patients to avoid creams
2 hours prior to treatment
Ontario practice
Used with permission: Ontario Provincial Radiation Therapy
Skin Care Working Group

17. • Topical prevention, erythema and dry
desquamation recommendations:
– Glaxal
– Calendula cream
– Aloe Vera
– Lubriderm
– Cavillon barrier spray
– Hydrocortisone
– Flamazine
– Proshield
– Baby powder/cornstarch
Ontario practice
Used with permission: Ontario Provincial Radiation Therapy
Skin Care Working Group

18. • Recommendations for moist desquamation:
– Hydrogels
– Tefla/non adherent dressings
– Hydrocolloids
– Saline or burosol soaks
– Flamazine
– Polysporin (may be mixed with xylocaine)
– Mepilex/Mepitel dressings
– Proshield
– Hydrofibres
Ontario practice
Used with permission: Ontario Provincial Radiation Therapy
Skin Care Working Group

19. World Wide Radiation Therapist FB group

20. General recommendations
To reduce friction and irritation:
•Loose clothing
•Avoid extremes of heat and cold
•Gentle washing, pat dry
•Use electric razor for shaving
•Minimise sun exposure, high SPF
sunblock
•Avoid adhesive tape
•No make up, perfume or aftershave in
treated area

21. Current evidence: SCoR
Phase 1: Extensive literature review of > 300
articles from 1980 to 2010
– Included 2 systematic reviews of skin care literature
(Bolderston et al., 2006; Kedge 2009)
Phase 2: 2014 systematic review to uncover
latest evidence.
– Included 3 systematic reviews of skin care literature
(Butcher and Williamson, 2012; Schnur et al., 2013;
Chan et al., 2014)

22. • Topical antibiotics unless proven infection.
(Sitton, 1992; Campbell and Lane, 1996; Korinko
and Yurick, 1997)
• Topical steroids on broken skin due to the
adverse effect on wound healing. (Blackmar,
1997; Rice, 1997; Jones, 1998)
• Gentian Violet due to potential carcinogenesis.
(Campbell and Lane, 1996; Rice,1997; Boot-
Vickers and Eaton, 1999)
Contraindicated

23. Washing:
“Gentle skin and hair washing should be unrestricted
for patients with no restriction to a particular type of
soap.”
SCoR Review summary
Campbell and Illingworth, 1992; Burch et al.,
1997; Westbury et al., 2000; Roy et al., 2001;
Rudd and Dempsey, 2002; Aistars, 2006;
Bolderston et al., 2006; Aistars and Vehlow,
2007; Butcher and Williamson 2012.

24. Deodorant:
•Normal deodorant – discontinue if irritation
occurs
SCoR Review summary
Bennett, 2009; Butcher and Williamson, 2012;
Watson et al., 2012; Wong et al., 2013; Lewis et
“Breast cancer patients who are
advised not to use a deodorant often
cite this as one less area of control
they have in their life and they note
concern regarding body odour.”
(Komarnicki, 2010)

25. Topical products:
“Overall, the evidence base is not strong enough to
either support or refute the use of any particular product
for topical application.”
•Use a product that is sodium lauryl sulphate free. (Tsang and Guy,
2013; Patel et al., 2013)
SCoR Review summary
Wells et al., 2004; Richardson et al., 2005;
Russell, 2010; Gosselin, 2010

26. Steroids:
•MASCC guidelines recommend steroids to < itching
and discomfort (Wong et al., 2013)
•However – past studies are mixed pro and con for
steroid use (Sitton, 1992; Dunne-Daly,1995;
Sperduti et al., 2006; Bostrom et al., 2001; Miller et
al., 2011; El Madani et al., 2012; Hindley and Dunn,
2013)
SCoR Review summary

27. Films:
•Promising work on the use of Mepitel film to < friction
(Herst et al., 2014; Diggelmann et al., 2010; MacBride et al.,
2008)
– Not included in SCoR guidelines as a recommendation
due to limited evidence/methodological issues
Restrictions on cream/lotion application:
•“Bolus effect” minimal for normal application – no need to
remove/restrict application (Morley et al., 2014)
Editorial comments!

28. Moist desquamation:
•Use appropriate dressing/product on broken skin to <
further trauma and infection.
– non-adhesive, silicone low adhesion
– non or low paraffin/petroleum jelly based.
•Avoid prophylactic antibiotics unless proven infection
SCoR Review summary
Image: SCoR guidelines PPT (Appendix 10)

29. Other practice recommendations:
•Importance of assessments (Richardson et al., 2005; Fisher
et al., 2006; NHS Scotland, 2010)
– Baseline assessment of patient’s current skin condition and care
– Baseline should include what skin products are used currently
– Assessment/review of the skin should continue throughout
treatment
•Health promotion strategies/interventions pre-treatment
(e.g. nutritional advice and smoking cessation) are beneficial
(Wells et al., 2004; Wan et al., 2012; Sharp et al., 2013)
SCoR Review summary

30. Further research:
– Dept audits assessing numbers of patients that develop
different RTOG graded reactions across different sites
– New high quality trials with assessor blinding and
comparators should include ‘current best evidence practice'
or 'no intervention'
– Evaluation into wet vs dry shaving, perfume and make-up
– Patient preferences and compliance
– Evaluation of aftercare to ensure local continuity and
consistency of care across the patient pathway
SCoR Review summary

31. What’s next?
Dr Rachel Harris, RTT, Professional & Education Manager, Society and College of
Radiographers, London, UK
Angela Cashell, RTT, Clinical Educator, Radiation Medicine Program, Princess Margaret
Cancer Centre, Ontario
Maurene McQuestion, RN, Clinical Nurse Specialist / Advanced Practice Nurse
H&N Site Group, Princess Margaret Hospital, University Health Network, Ontario
Clare Summers, RTT, Nova Scotia Cancer Centre, Halifax
Michele Cardoso, RTT, Clinical Specialist RT, Juravinski Cancer Centre, Ontario
• E-survey examining Canadian practice
• Collecting responses from RTTs, RNs
• Using SCoR survey tool for comparison

32. www.sor.org