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Anatomy and physiology

Radiation impairs stem cell division within the basal layer of the epidermis, disrupting or sometimes halting the normal process of skin regeneration (Archambeau et al. [9]). Skin damage occurs when the rate of repopulation of the basal layer cannot match the rate of cell destruction caused by the treatment. Radiotherapy‐induced skin damage is usually noted around 10–14 days from the start of treatment. There are a number of stages of acute radiotherapy skin reactions:
Erythema is the first stage of an acute radiotherapy reaction caused by exposure of the skin to ionizing radiation. Erythema is characterized by reddening of Caucasian skin or darkening of more pigmented skin types. The change is caused by dilation of superficial capillaries as an inflammatory response to basal cell damage (McQuestion [94]). Erythematous skin can feel hot and itchy.
Continued exposure to radiation can promote increased mitotic activity, leading to a thickening of the stratum corneum. The reaction is exacerbated by a reduction in sweat and sebum production. At this point the reaction is described as dry desquamation and is characterized by itchy, blotchy and flaky skin. Deepening of the pigmentation will continue due to stimulation of melanocytes, and epilation may start due to hair follicle damage.
The next stage of skin reaction seen in some patients is moist desquamation. This occurs when the basal layer produces insufficient cells to replace those lost, resulting in the epidermis becoming denuded and the dermis exposed. The skin will become inflamed with areas of blistering or ulceration. At this point there is a risk of infection. There is usually associated pain requiring pain medication. The reaction can be distressing and uncomfortable with an exudate of serum causing added discomfort.
The final stage of the acute skin reaction is necrosis, tissue death, and should rarely occur using modern radiotherapy techniques.
The severity of the skin reaction can increase for up to 2 weeks following completion of the course of radiotherapy. After this peak reaction, the skin will start to repair although it may take between 4 and 10 + weeks for full healing to take place if the skin reaction has been severe.
A formal grading tool, the Radiation Therapy Oncology Group (RTOG) schema, grades radiation skin reactions, based on the appearance of the skin (see Table 25.9).
Table 25.9  RTOG radiation skin reaction scores
Assessment/observationEffect on skinIntervention
RTOG 0
No visible change to skin
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Gently wash skin with warm water and pat skin dry. Continue with regular skin care products including soaps and moisturizers. Moisturizing creams provide symptomatic relief. (Avoid moisturizers containing sodium lauryl sulphate)
Assess weekly
RTOG 1
Faint or dull erythema. Mild tightness of skin and itching may occur
image
Increase application of moisturizing cream as required for comfort. Consider prophylactic use of Cavilon No Sting barrier spray, Mepitel film or Mepilex Lite to reduce friction. Hydrogel sheets can soothe hot or irritated skin unless there is skin breakdown. Antihistamines or 1% corticosteroids can be considered for pruritus; use sparingly
Assess weekly
RTOG 2a
Bright erythema/dry desquamation. Sore, itchy and tight skin
image
Increase application of moisturizing cream as required for comfort. Polymem can be used for dry desquamation. Dampen for better skin contact. It contains a cleansing agent and maintains a moist healing environment. Continue with RTOG 1 interventions
Assess daily
RTOG 2b
Patchy moist desquamation. Yellow/pale green exudate. Soreness with oedema
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Continue using moisturizing cream on unbroken skin. Refer to radiotherapy nurse for specialist advice and wound dressing. Saline soaks can be used to remove slough and are soothing. Amorphous hydrogels are particularly useful behind ears, in skin folds or on perineum. Cavilon No Sting Barrier spray acts as a second skin which prevents infection and reduces pain. Mepitel and Polymem as before
Assess daily
RTOG 3
Confluent moist desquamation. Yellow/pale green exudate. Soreness with oedema
image
Stop moisturizing cream on broken skin. Continue with RTOG 2b interventions. Refer to radiotherapy nurse for specialist advice and wound dressing
Assess daily
RTOG 4
Ulceration, bleeding, necrosis (rarely seen)
 Seek specialist advice from tissue viability team. Debride any eschar/slough
Sources: Intervention data adapted from The Royal Marsden Handbook (2016). Other text and images from The Princess Royal Radiotherapy Review Team (2011). Reproduced with permission of Ellen Trueman. RN. Former Senior Sister. Princess Royal Radiotherapy Review Team, Bexley Wing, St James's Institute of Oncology, Leeds Teaching Hospitals NHS Trust. [Table created by Punita Shah, Practice Facilitator Radiotherapy Pre‐treatment, from information contained in The Royal Marsden Handbook (2016), Radiotherapy Side Effects; text and images adapted from The Princess Royal Radiotherapy Review Team (2011), Managing Radiotherapy Induced Skin Reactions; A Toolkit for Health Professionals]
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