Chapter 25: Wound management
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Related theory
The degree of skin reaction depends on intrinsic (patient‐related) and extrinsic (treatment‐related) factors (NHSQIS [104]). These factors should be considered when determining the risk of a patient developing a more severe radiotherapy‐induced skin reaction (see Table 25.10).
Table 25.10 Factors that increase the risk of skin reaction severity
| Risk factor | Rationale |
|---|---|
| Intrinsic factors | |
| Increasing age | The ageing process affects the epidermal cell cycle, leading to extended healing times. Peripheral vasculature is compromised with age, leading to delayed healing |
| Ethnic origin | There is some evidence that patients with darker skin suffer more severe skin reactions (Ryan et al. [121]). |
| Poor nutritional status | Adequate nutritional status provides optimum tissue repair; undernourished patients have increased likelihood of impaired repair mechanisms |
| Obesity | Increases the likelihood of skin folds and friction. Adipose tissue heals slowly |
| Skin and connective tissue disorders, e.g. bacterial or fungal skin infection or underlying skin conditions such as eczema, psoriasis, lichen sclerosus | Many skin and connective tissue disorders can compromise normal skin repair |
| Smoking and alcohol | Decreased capillary blood flow and oxygen levels lead to increased skin reactions and impaired healing |
| Co‐morbidities, e.g. diabetes, HIV‐related disease | Certain conditions may compromise repair mechanisms due to impaired capillary blood flow or may lead to increased likelihood of wound complications |
| Genetic predisposition | Increasingly believed to influence skin sensitivity and repair mechanisms |
| Extrinsic factors | |
| Dose fractionation | High total dose/high dose per fraction |
| Bolus/build‐up, electrons or superficial X‐rays | Often used to bring the dose closer to the skin surface |
| Concurrent chemotherapy or monoclonal antibodies | Many concurrent pharmaceutical drugs are radiosensitizers (increase the effect of radiation) |
| Unmodified/less sophisticated treatment techniques | May lead to inhomogeneous doses to the skin |
| Entry/exit sites and techniques treating through skin folds or moist areas subject to friction | Friction is known to exacerbate radiotherapy skin reactions. Folds of skin and adipose tissue act as build‐up for the underlying skin |
Radiosensitizing chemotherapy drugs used concomitantly will increase all side‐effects, including the skin reaction to radiotherapy. Monoclonal antibody treatment that targets the epidermal growth factor receptors is known to produce an acne‐like rash which varies in severity (Saltz et al. [122]) but particularly affects treatment fields in head and neck areas (Bernier et al. [18]).
