Radiotherapy Skin Care Guidelines

Publication: 01/09/2003  --
Last review: 22/12/2021  
Next review: 22/12/2024  
Clinical Guideline
CURRENT 
ID: 235 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Radiotherapy Skin Care Guidelines

  1. Key Recommendations
  2. Introduction
  3. Aims and Objectives
  4. Staff Education and Training
  5. Assessment and Management

Tables

Table 1: Intrinsic factors affecting the radiotherapy skin reaction
Table 2: Extrinsic factors affecting the radiotherapy skin reaction
Table 3: Management of radiotherapy induced skin reactions
Table 4: Suitable dressings for use in the management of radiotherapy induced skin reactions
Table 5: Additional interventions for use in the management of radiotherapy induced skin reactions

Appendices

  1. Appendix 1: RTOG Assessment and Grading Tool (Adapted from RTOG/EORTC assessment tool cited in Harris, 2011)
  2. Appendix 2: Patient Information Leaflets
  3. Appendix 3: Cycle of radiotherapy induced skin reaction
  4. Appendix 4: Pain management adapted from World Health Organisation (WHO) analgesic ladder
  5. Appendix 5: MOSAIQ Skin Assessment Tool
  6. Appendix 6: Contact details

Glossary

References

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1. Key recommendations

The RTOG grading scale is used to assess skin. (Appendix 1)

  1. Skin assessment done at initial scan (where possible) to include RTOG, patient compliance, current products used and any interventions needed. Patient to be referred to review clinic nursing staff if any pre-existing skin conditions are present.
  2. Assessment to be documented electronically at the start of treatment and then weekly throughout the course of Radiotherapy and until any reaction has settled. (Appendix 5)
  3. Those assessing skin should be able to demonstrate knowledge and competence in the management of radiotherapy skin reactions.
  4. Prior to commencing radiotherapy, all patients will receive verbal and written information about skin care. (Appendix 2)
  5. All radical and adjuvant patients will receive further verbal information and advice about skin care in their last few days of treatment.
  6. All patients to be advised to wash at least once a day with the products they already use.
  7. Patients receiving radiotherapy to lower GI, H&N and Gynae will receive a specific skin care product if they are not already using a moisturiser in the treatment area at commencement of radiotherapy to maintain optimum skin condition whilst the skin is intact. (See Table 3)
  8. If the skin becomes broken in the treated area, patients are to discontinue the use of all topical products on the broken skin and an appropriate dressing should be applied. Continue to wash as normal any intact skin within the treatment area not covered by a dressing. (See Table 4)
  9. Refer patients to the review clinic nursing team if:
  • Skin in the treated area breaks (RTOG 2.5 and above) or dressings are required.
  • Skin in the treated area becomes irritated by the skin care product used.
  • Current skin care product does not relieve the discomfort caused by the skin reaction.
  1. If the skin reaction is greater than the anticipated RTOG grade for fractionation and dose delivered so far, inform clinician, treatment planning, and check patient is following skin care guidelines before any further radiotherapy is given.
  2. Upon completion of the radiotherapy course, a referral should be made to an appropriate health care professional for either follow up in review clinic in their first week post and/or referral to district nurse, if:
  • A skin reaction requires ongoing assessment and management post completion of radiotherapy.
  • It is anticipated that the grade of skin reaction will progress to RTOG 2.5 or above.
  • There are specific concerns relating to the patient’s skin reaction
  1. After treatment patients are advised to use an SPF of 50+ with a UVA rating with a minimum of 4 stars.

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2. Introduction

Radiotherapy is a primary cancer treatment along with surgery and chemotherapy. Radiotherapy causes biochemical changes within cells, as the DNA molecules are susceptible to radiation damage during mitosis. Radiobiological damage affects regeneration of the skin by the process of repair, redistribution, repopulation and reoxygenation. Damaged cells are replaced by cells moving from the resting phase (G0) into the active cycle (Repopulation). Skin damage occurs when the rate or repopulation of the basal cell layer (Stratinium Germinativum) cannot match the rate of cell destruction by treatment (Gutierrez et al, 2012 and Sitton 1992). The inflammatory response activated is a normal physiological reaction to radiotherapy.

For radical and adjuvant doses of radiotherapy, the skin reaction develops approximately 10-14 days following the first fraction of radiotherapy, corresponding with the time it takes for the damaged basal cells to migrate to the skin surface. For elderly patients this can be much later. Initially the skin will become warm, itchy and inflamed (erythema). As the skin reaction develops through further exposure to radiation, it tries to compensate by increasing mitotic activity in order to replace the damaged cells. If the new cells reproduce faster than the old cells are shed then the skin will become dry and flaky (dry desquamation). As radiotherapy continues, the basal layer cannot produce enough new cells to replace the old ones and therefore the outer layer of the epidermis will become broken and oedematous with exudate (moist desquamation). This exudate is an expected part of the radiotherapy reaction and is rich in nutrients, which help the growth of new skin cells as part of the healing process. Skin necrosis is rarely seen, primarily due to the advanced techniques used in the planning and delivery of radiotherapy.

The severity of skin reactions may increase for an average of seven to ten days after the course of radiotherapy has finished. Sometimes the reaction may take up to a month to appear. It can take this amount of time for the cells that have been affected by radiotherapy to reach the outer epidermis. Four to six weeks after treatment is completed, the skin should be healing well and may even be fully healed. The area may still look darker (hyperpigmented) as the basal cells of the epidermis recover and the new skin starts to grow and heal (Appendix 3) (Noble – Adams 1999, and Aistars, 2006). Extrinsic and intrinsic factors may significantly increase the severity of radiotherapy skin reactions and can delay the healing process (Wells et al 2004). Table 1 and 2 provide a summary of the factors affecting the severity of radiotherapy skin reactions.

All patients receiving external beam radiotherapy are at potential risk of developing a skin reaction (Olsen et al 2001). It is essential that any reaction is minimised as far as possible by ensuring that interventions are based upon best practice and supported by evidence-based guidelines (Harris, 2011a, D’haese et al, 2010 & Cumming and Routsis, 2009). There are a lack of randomised controlled trials to evaluate prophylactic skin care interventions and treatment of radiotherapy skin reactions (Harris, 2011b and Feight et al, 2011). This guidance has drawn on the available published evidence, which includes ‘Radiation Dermatitis Guidelines for Radiotherapy Healthcare Professionals’, published by the SOR in 2020 and expert opinion from specialists with the Leeds Cancer Centre.

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3. Aim and Objectives

These guidelines are for the use of all health care professionals involved in the management of radiotherapy induced skin reactions of adults and children receiving external beam radiotherapy.

These guidelines aim to ensure radiotherapy patients receive consistent, evidence based, best practice advice and care through:

  • Consistent assessment and documentation of skin reactions using the RTOG assessment and grading tool.
  • Implementation and ongoing evaluation of recommended interventions which aim to:
         1. Delay onset of the reactions
         2. Minimise severity of reaction where possible
         3. Prevent exacerbation of reaction
         4. Optimise patient comfort
  • Increasing multidisciplinary knowledge and awareness across the cancer centre, cancer units and primary care teams.

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4. Staff Education and Training

It is mandatory that all health care professionals who are responsible for assessing, managing and documenting a patient’s skin condition pre, during and post radiotherapy, have the following knowledge and skills, which are renewable on a yearly basis:

  • Ability to provide patient information and advice
  • Knowledge or predisposing factors
  • Ability to assess and grade skin reactions according to the RTOG scale (Appendix 1)
  • Attended mandatory annual skincare update sessions
  • Recognise the limitations of their scope of practice and know when to contact the radiotherapy specialist team for further advice and support

The radiotherapy specialist team for skin care includes:

  • Review clinic nursing staff (See appendix 6 for contact details)

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5. Assessment and Management

Assessment of the skin forms an integral part of a patient’s holistic care. Predicting the severity of skin reactions can be difficult due to the varying radio-sensitivity of skin and a number of contributing extrinsic risk factors (Harris, 2011a, Wells and MacBride, 2003). Predisposing factors that can affect the severity of an individual’s skin reaction are summarised in Table 1 and 2. This information should be considered when assessing a patient’s skin and when providing skin care advice. The frequency of skin assessments should be influenced by the patient’s individual risk factors.

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Dermatological conditions

If a patient wishes to use any preparations on the treated area other than those recommended in these guidelines consult the specialist pharmacist about the ingredients to ensure there are no contraindications with radiotherapy.

For patients with chronic skin problems or pre-existing conditions, their Dermatology specialist/Clinical Oncologist may also need to be consulted for further advice before making changes to their skin care regimen.

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Assessment of skin

A consistent approach to skin assessment is necessary. Skin status should be graded and recorded by an appropriately trained member of the multidisciplinary team (Harris, 2011a). This Trust uses a modified version of the acute radiation scoring criteria developed by the Radiation Therapy Oncology Group (RTOG) in 1985 (Appendix 1). The RTOG scoring criteria does not account for the subjective aspects of the skin reaction such as pain and discomfort. If the skin reaction is causing pain or discomfort, refer to the adapted WHO analgesic ladder (Appendix 4).

Assessment of the skin should take place at the following points of the patient’s radiotherapy treatment pathway:

  • At radiotherapy scan; skin integrity in the treatment field should be assessed and recorded using assessment tool in MOSAIQ (Appendix 5)
  • At the first fraction; skin integrity in the treatment field to be reassessed and documented electronically in MOSAIQ.
  • On a daily basis, radiographers will observe skin integrity within the treatment field and monitor changes. At weekly intervals, or when there is a significant change in the skin reaction, radiographers will document any skin reaction using the MOSAIQ skin assessment tool. If skin reaction requires any additional interventions, advise the patient according to the Management of Radiotherapy Induced Skin Reactions (see below). If beyond the scope of the radiographer, contact the radiotherapy nursing team or skin care specialists for advice/intervention
  • At any point during radiotherapy treatment if the management of a patient’s skin reaction goes beyond the clinical scope of practice of the radiotherapy nursing team, contact clinical oncologist for further expert advice and support.
  • If at any point the radiotherapy reaction of a patient is above the expected level of reaction for the dose and fractionation received, DO NOT TREAT until:
    Informed treatment planning, who can check the dose distribution of the plan
    Discussed with the clinical oncologist or one of their team
    Check that the patient is following the skin care guidelines and not using any irritant products
  • Upon completion of treatment, if ongoing assessment and management of a skin reaction is required, the nursing team in review clinic will review the patient a week post treatment and/or refer to community nursing team (eg, District Nurse), if patient is unable to self-care.

As part of any assessment for skin reactions, the health professional should be mindful of any potential radiotherapy side effects developing in the underlying structures. If assessment and/or management of such effects are beyond the score of the practitioner, an appropriate referral should be made (Appendix 6).

Mosaiq assessment tool should always be used to document RTOG

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Management of Radiotherapy Induced Skin Reactions

The evidence supporting the rationale for interventions has been compiled from a review of relevant, current literature, best practice recommendations and consensus expert opinion from specialists within the Leeds Cancer Centre.

Radiotherapy skin reaction management aims to:

  • Maintain skin integrity and hydration,
  • Reduce the potential for further exacerbation of the reaction (i.e. prevention of trauma caused by friction, inappropriate dressings etc.)
  • Promote comfort and treatment compliance
  • Minimise pain and discomfort
  • Prevent infection
  • Promote a moist wound healing environment where the skin is broken
  • Control bleeding, odour and excessive exudate where radiotherapy is being given for symptom management of a fungating tumour

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General Advice for all patients receiving radiotherapy treatment

  • To continue daily washing of the treatment area using own current products, advise not to use highly perfumed products.
    Rationale: Patient more likely to adhere to own skin care routine and less likelihood of reactions to product.
  • Pat dry skin with a clean, soft towel to avoid friction.
  • Continue to use preferred deodorant products even if axilla is in or near the treatment area. Patients are able to use either roll on or spray deodorants if they wish, but may be advised to cease using deodorant if irritation occurs.
    Rationale: There is little evidence to support using a particular brand or type of deodorant and patients have reported a loss of control and concerns regarding body odour when advised not to use deodorant (Society of Radiographers, 2020).
  • Do NOT use cosmetics (anything that changes skin appearance) in the treated area (e.g. make-up, self-tan, gradual tanning creams, anything containing glitter or sparkles).
  • Do NOT use toiletries in the treatment area (i.e. perfume, aftershave, talcum powder).
    Rationale: These products may cause irritation and increase the skin reaction (Haas & Moore-Higgs, 2010)
  • Hydrocortisone 1% cream can be prescribed and used for a limited time (five to seven days) to relieve skin itching (pruritus).
    Rationale: Hydrocortisone cream can reduce itching caused by inflammation but should not be used indiscriminately (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2013)
  • Wear loose fitting clothing over the treated area unless a dressing is in place. Breast patients should avoid wearing underwired bras, preferably not wearing a bra when at home.
    N.B. Any dressings used to cover a skin reaction must be in direct contact with the broken skin to optimise effectiveness.
    Rationale: To avoid friction, which can exacerbate the skin reaction.
  • Avoid direct exposure to the sun of treated area until skin has healed. Once the radiotherapy course is completed and any broken skin is healed, a high factor sun cream of SPF 50 or above should be used (British association of Dermatologists, 2009) with minimum four starts for UVA protection. It is advisable to follow sun protection precautions.
    Rationale: Irritated skin will always be more sensitive to and at increased risk of sun damage.
  • Swimming is allowed provided the skin is not broken. Shower immediately afterwards to wash off the chlorine and apply moisturiser to alleviate dry skin. (Society of Radiographers, 2020).
  • Do not apply hot water bottles, heat packs or ice packs to the treatment area.
    Rationale: Extremes of temperature can exacerbate the skin reaction.
  • Do not shave or use hair removal products in the treatment area.
    Rationale: To avoid further trauma to the skin.

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Post-radiotherapy management

The rationale for interventions is the same as during radiotherapy: promotion of healing, patient comfort, reduction of the risk of infection and minimising further trauma. The interventions detailed in Table 3, for the management of radiotherapy induced skin reactions, should continue after treatment has completed until the skin reaction settles. Seek specialist advice from the radiotherapy review clinic team or clinician if interventions are no longer effective or if problems arise which are outside of your scope of practice.

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Table 1: Intrinsic factors affecting the radiotherapy skin reaction

Age:

The natural ageing process affects the epidermal cell cycle, which can result in delayed onset of the reaction and extended healing times.

Nutrition:

Adequate nutritional intake is necessary for optimum repair of tissue damage. The skin of undernourished patients may be at increased risk of damage (Sitton, 1992, Nayel et al (1992), Porrock, 2002 and Ginot et al, 2010)

Smoking and Alcohol:

Can decrease capillary blood flow and oxygen levels thus increasing the severity of the skin reaction and impairing the body’s ability to heal damaged tissues and fight infection.

Co-morbidities:

Other illnesses and some medications can increase the risk and intensity of skin reaction and impact upon the healing process. Eg diabetes or steroids (McNees, 2006))

UV exposure:

There is a suggestion that patients with long term UV exposure will experience a more severe radiotherapy induced skin reaction and impaired healing. Patients from Black or Minority Ethnic (BME) groups have reported more severe post treatment skin reactions compared to those of white ethnic origin (Ryan et al, 2007))

Obesity:

Extra adipose tissue can affect healing and exacerbate skin toxicity due to the extra skin folds or areas where there is a natural skin fold e.g. natal cleft and inframammary fold.

Infection:

The presence of bacterial and/or fungal infection can damage the cells in the basal layer resulting in delayed healing. (Krishnasamy, 2008)
NB: Not to be confused with the exudate produced in radiotherapy induced skin reaction RTOG 2.5 and above (Table 3).

Irritants

Irritants can exacerbate the skin reaction and may delay the healing process. Examples include:
Chemical - cosmetics and toiletries with metallic ingredients e.g. perfume, talcum powder, aftershave, self tan, gradual tanning creams
Thermal - extremes in temperature e.g. hot water bottles, ice packs.
Mechanical - friction by rubbing skin or wearing tight fitting clothing ie: bras (underwired)

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Table 2: Extrinsic factors affecting the radiotherapy skin reaction

Radiotherapy

  • Dose
  • Volume
  • Bolus
  • Modality
  • Energy
  • Delivery techniques

Higher doses, increased volume, electron therapy and the presence of bolus can all lead to an increase in the severity of the skin reaction.
The higher the energy of the x-ray beam, the lesser the skin reaction. Megavoltage x-ray therapy delivers the maximum dose below the skin surface. Electron therapy, used to treat skin cancers, delivers the maximum dose to the skin surface.
VMAT delivery techniques will reduce the severity of the skin reaction.

Radiosensitisers:

Some chemotherapy agents are radiosensitisers (e.g. 5-Fluorouracil, Mitomycin C, Cisplatin,) and can increase the severity of skin reaction.
Cetuximab can cause an acne-like rash to the face, neck and body. If this is occurs within the treatment field, seek specialist advice (Appendix 6).

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Table 3: Management of radiotherapy induced skin reactions

Assessment

Intervention (action)

Rationale

RTOG 0

No visible change to skin

-Normal skin care regime.
-Highlight to patient gentle washing, not soaking in bath, nothing too hot or cold on skin
-Emollients can be used if this is already included in daily routine
-Discourage the use of Sudocrem
-Ensure patient has received appropriate ‘skin care during and after radiotherapy’ leaflet.

To maintain clean, hydrated skin and support skin integrity
To support skin integrity.
To promote comfort by soothing and softening the skin.
To promote participation in self-care
To inform patient of potential skin reaction

RTOG 1

Faint or dull erythema.
Mild tightness of skin.

-Normal skin care regime
-Alternative or additional specialist creams may be indicated (Table 5)
-Consider analgesia as guided by WHO analgesic ladder (Appendix 4)

To maintain clean, hydrated skin and support skin integrity
To promote comfort by soothing and softening the skin.
To relieve irritation
To relieve pain/soreness

RTOG 2

Brisk erythema and/or
Dry desquamation.
Moderate oedema may develop.
Skin may feel sore, itchy and tight.
Itching (pruritus)

-Normal skin care regime
-Alternative or additional specialist creams may be indicated (Table 5)
-Dressings may be indicated if topical agents are no longer effective in providing comfort (Table 4)
-Commence analgesia as guided by WHO analgesic ladder (Appendix 4)

To maintain clean, hydrated skin.
To promote comfort.
To relieve irritation
To delay skin breakdown
To relieve pain/soreness

RTOG 2.5

Patchy moist desquamation Yellow/pale green exudate. Slight bleeding may be evident.
Sore with oedema

-Stop application of all creams/products on broken skin.
-Continue daily washing/showering with normal skin care regime on unbroken skin. Areas of broken skin to be washed gently with luke warm water only.
-Apply an appropriate dressing to broken skin (Table 4)
-Continue analgesia as guided by modified WHO analgesic ladder (Appendix 4)

To reduce risk of complications of further trauma & infection.
To maintain clean skin
To promote comfort.
To maintain clean, hydrated skin
To reduce risk of complications of further trauma & infection
To promote comfort.
To relieve pain/soreness

RTOG 3

Confluent moist desquamation. Yellow/pale green exudate.
Bleeding may be evident.
Sore with oedema

-It is acceptable for luke-warm water to come into contact with the broken skin during daily showers.
-Do not remove exudate from reaction site unless excessive
-Apply an appropriate dressing to broken skin (Table 4)
-Consider increasing analgesia as guided by WHO analgesic ladder (Appendix 4)

To reduce risk of complications of further trauma & infections
The exudate bathes the exposed nerve endings, providing pain relief.
To promote recovery of the skin by maintaining a moist wound healing environment.
Reduce risk of complications of further trauma & infection
To promote comfort
To relieve pain/soreness

RTOG 4 (rarely seen)
Ulceration, necrosis

Seek specialist advice i.e.; clinical oncologist, nurse specialist, at the St James, Institute of Oncology

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IF ABOVE INTERVENTIONS ARE NOT EFFECTIVE SEEK SPECIALIST ADVICE FROM RADIOTHERAPY REVIEW CLINIC, NURSE SPECIALIST OR CLINICIAN (See Appendix 6 for contact details).

Table 4: Suitable dressings for use in the management of radiotherapy induced skin reactions

NB: These dressings MUST be removed during the delivery of radiotherapy unless directed otherwise by prescribing oncologist*.

Name of Dressing/Product

When to use

How to apply

Frequency of change/application

Size

Where to order

MEPILEX LITE is a self-adhesive soft silicone faced polyurethane foam dressing

Minimises trauma to wound and pain during dressing changes

Non - low exuding wounds.

 

 

Dressing to overlap wound by 2 - 3 cm.

Can be cut to shape.

Secondary dressing not required.

Daily during radiotherapy*

As required once treatment is complete, dependent on amount of exudate produced by the wound.

6 x 8.5cm (5)

10 x 10cm (5)

15 x 15cm (5)

 

Supplies Dept

MEPILEX is a soft silicone faced polyurethane foam dressing

Minimises trauma to wound and pain during dressing changes

 

Moderate to heavy exuding wounds

 

Dressing to overlap wound by 2 – 3 cm

Can be cut to shape

Secondary dressing not required

Daily during radiotherapy*

As required once treatment is complete, dependent on amount of exudate produced by the wound.

10 x 10cm(5)

10 x 20cm (5)

15 x 15cm (5)

20 x 20cm (5)

Supplies Dept

MEPILEX BORDER LITE is a self adhesive soft silicone faced polyurethane foam island dressing

Minimises trauma to wound and pain during dressing changes

Light exuding wounds where a self adherent dressing is required

Can be used in combination with Mepitel One which helps prevent dressings sticking to skin in treatment area

Apply directly to wound ensuring adhesive border is onto intact, non-friable skin

Daily during radiotherapy*

As required once treatment is complete, dependent on amount of exudate produced by the wound.

4 x 5cm (10)

5 x 12.5cm (5)

7.5 x 7.5cm (5)

10 x 10cm (5)

15 x 15cm (5)

Supplies Dept

MEPILEX BORDER a self adhesive soft silicone faced polyurethane foam island dressing

Minimises trauma to wound and pain during dressing changes

Moderate – high exuding wounds where self adherent dressing is required

 Can be used in combination with Mepitel One which helps prevent dressings sticking to skin in treatment area

Apply directly to wound ensuring adhesive border is onto intact, non-friable skin, outside the treated area

Daily during radiotherapy *

As required once treatment is complete, dependent on amount of exudate produced by the wound.

 

10 x 10cm (5)

15 x 15cm (5)

15 x 20cm (5)

Supplies Dept

MEPILEX TRANSFER is a thin highly conformable soft silicone foam that absorbs and transfers exudate away from the wound.

Minimises trauma to wound and pain during dressing changes

 

Low - high exuding and difficult-to-dress wounds

As a protective layer on:
- fragile skin,
- skin folds (to reduce skin on skin friction) and
- fungating wounds

Dressing to overlap onto dry, surrounding skin by approx 2 - 3 cm

Secure with secondary absorbent dressing

Can be cut to shape

Daily during radiotherapy*

 

As required once treatment is complete, dependent on amount of exudate produced by the wound.

15 x 20cm (5)

Supplies Dept

MEPITEL ONE is a porous, soft silicone wound contact layer that allows exudate to transfer into a secondary absorbent dressing

Minimises trauma to wound and pain during dressing changes

As a protective layer on fragile skin and fungating wounds

Dressing to overlap onto dry, surrounding skin by approx 2 - 3 cm

Secure with secondary absorbent dressing

Can be cut to shape

Daily during radiotherapy *

 

As required once treatment is complete.

6 x 7 cm
9 x 10cm
13 x 15cm

Supplies Dept

MEPITAC is a conformable self adhesive tape

Minimises trauma and pain during dressing changes

In difficult -to-dress wounds where non-adhesive dressings require fixation to maintain contact with wound bed

Self adhesive tape

As required

 

2 x 300cm

Supplies
Dept

POLYMEM (POLYMEM, POLYMEM MAX & POLYMEM ROLL) is a foam dressing that contains a cleanser, moisturiser and absorbing agent all held within a polyurethane matrix

Low - moderate exuding wounds (Polymem and Polymem Roll)

Moderate - high exuding wounds (Polymem Max)

Apply directly onto wound with overlap margin 1 - 2 cm

Apply with ‘printed’ side facing outwards

Can be cut to size

Daily during radiotherapy * or dependant on amount of exudate produced by the wound

Change when strikethrough
within 1 - 2 cm of dressing edges

8cm x 8cm

10cm x 10cm

13cm x13cm

17cm x 19cm

10cm x 61cm

Supplies
Dept

ALLEVYN LITE is a non adhesive hyrdocellular flexible dressing

To be used in cases of allergy to other suggested dressings

Low to moderate exuding wounds

 

Apply perforated
( white ) side to skin

Can be cut to shape

Do not secure with tape

Daily during radiotherapy * or dependant on amount of exudate produced by the wound

Change when strikethrough
within 1 - 2 cm of dressing edges

If sticking occurs soak off with n/saline

10 x10cm (20)

15 x 20cm (10)

10 x 20cm (10)

Supplies Dept

ALLEVYN is a non adhesive polyurethane foam, hydrophilic dressing

To be used in cases of allergy to other suggested dressings

Moderate to high exuding wounds

 

Apply perforated (white) side to skin

Can be cut to shape
Secure with net knickers/mepitac tape

 

Daily during radiotherapy * or dependant on amount of exudate produced by the wound

Change when strikethrough
within 1 - 2 cm of dressing edges

 

If sticking occurs soak off with Normal Saline

10 x 20cm (10)

20 x 20cm ( 10)

 

Supplies Dept

ACTIFORM COOL is a non-adhesive high water content hydrogel sheet 

Topical relief of itching/burning sensation

Apply direct to wound
When a dressing becomes warm, remove, allow to cool and then reapply.

For short-term relief circa. 5-10 mins

5cm x 6.5cm (5)
10 x 10cm (5)

10 x 15cm (3)

Supplies Dept

POLYMEM WIC is a foam dressing that contains a cleanser,
moisturiser and absorbing agent
all held within a polyurethane matrix

Low - moderate exuding wounds

Both sides are active, for use in skin folds, ie. Groin, natal cleft.

As with polymem above:
Can be left in place but due to positioning,
will need to be removed when using the toilet.

8cmx8cm (10)

Supplies Dept

EXU-DRY
Bio cellulose Dressing Full Absorbency

For high exudating wounds

Place over the top of dressing, to absorb excess exudate.

Every day while on treatment as dressing will likely be removed due to bolusing effect

10cmx5cm

Supplies Dept

TIELLE/TIELLE XTRA Non adhesive hydropolymer dressing

For use if allergy to previously mentioned dressings

Can be cut to shape or used for cavity dressing

Everyday whilst on treatment (as above)

9.5cmx9.5cm

11cmx11cm

15cmx15cm

Supplies Dept.

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All dressings mentioned above are now available on formulary for all patients in the Leeds Area for primary and secondary
Health care professionals.

Table 5: Additional interventions for use in the management of radiotherapy induced skin reactions

(Seek advice from Radiotherapy Review Clinic or Nurse Specialist)

Name of Dressing/Product

When to use

How to apply

Frequency of change/application

Size

Where to order/Price

Preferably continue with own skin care regime
or
A non-perfumed, sodium-lauryl-sulphate-free* moisturising agent, eg:

  • Diprobase Cream
  • Cetroban

If the skin becomes itchy or uncomfortable, apply to intact skin to soothe and soften.

Cream must not be too thick to avoid excessive friction when rubbing into skin.

Apply sparingly twice per day. Number of applications can be increased if irritation persists but care must be taken not to allow a build-up of cream as this can have a bolus effect.

Various, please refer to BNF

 

Antihistamines

Can be obtained over the counter

If skin becomes itchy during or after treatment.

Take as instructed on box or by your pharmisist/GP

Ensure you get a non-drowsy version of the Antihistamine

N/A

 

Dependant on antihistamine used

Can be bought over the counter (You may want to ask your pharmacist  for advice) Or on Prescription via GP

HYDROCORTISONE CREAM 1%

 (Steroid Cream)

Only to be used for severe pruritus

 

Apply to unbroken skin sparingly.

Stop using when skin is broken

Apply as instructed on prescription.

Do not use more than twice daily or for 7 days

15g tube

30g tube

Pharmacy dept on prescription only

PROCTOSEDYL ointment

 

Apply after painful defecation

 

Apply directly externally around anus to clean skin.

Use sparingly as contains 0.5% hydrocortisone

Apply after each bowel motion.

Do not use for more than 7 days.

30g tube

Pharmacy dept on prescription only

Barrier cream (cream or foam applicator)

A non-sting barrier film which is alcohol free. Forms a breathable transparent coating on skin

 

Also provides moisture to dry skin.

Apply directly onto skin in a very thin layer.

Make sure product is dry before applying clothing/dressings.

Apply daily although can be left for up to 72 hours.

1- 3 ml foam applicator

28g tube

Supplies Dept

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Appendix 1: RTOG Assessment and Grading Tool (Adapted from RTOG/EORTC assessment tool cited in Harris, 2011)

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Appendix 2: Patient Information Leaflets

https://www.leedsth.nhs.uk/patients-visitors/patient-and-visitor-information/patient-information-leaflets/cancer-radiotherapy-treatment

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Appendix 3: Cycle of radiotherapy induced skin reaction

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Appendix 4: Pain management adapted from World Health Organisation (WHO) analgesic ladder

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Appendix 5: MOSAIQ Skin Assessment Tool

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Appendix 6: Contact details

Princess Royal Suite (Radiotherapy Nursing Team)

Monday - Friday 8.00am to 6:30 pm

Tel: 0113 206 7587 /0113 206 7667

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Glossary

Bolus: A tissue equivalent material occasionally used to increase skin dose in the treated area.
Cetuximab: A monoclonal antibody used as a radiosensitor for bowel and head and neck cancers.
Dry Desquamation: Inflammatory reaction characterised by dry, flaky or scaly skin and can be itchy.
Electron therapy: Radiotherapy using an electron beam to deliver a dose to superficial structures while minimising dose to underlying tissues
EORTC: European Organisation for Research and Treatment of Cancer
Erythema: Inflammatory reaction characterised by reddened skin that may be oedematous and accompanied by warmth and itching (pruritis)
Fraction: The term for a single dose of radiotherapy. Radiotherapy can be delivered either as a single treatment (i.e. one fraction), or over several smaller, equal fractions if a larger overall dose of radiation is needed.
IMRT: Intensity Modulated Radiation Therapy, a radiotherapy treatment technique designed to deliver a precise dose to the treatment area with minimal dose to the surrounding tissues.
Kilo-voltage X-ray therapy: Kilo voltage xray therapy used to treat small superficial (skin) lesions
Mega-voltage X-ray therapy: Mega voltage xray therapy used for treatment at depth whilst minimising the dose to the superficial structures (skin sparing).
Moist Desquamation: Inflammatory reaction characterised by blistering, peeling and sloughing of the skin. Can have a shiny or wet appearance.
Necrosis: Cell death, the skin will darken and turn black.
Radiosensitisors: An additional agent such as chemotherapy which increases the toxicity of radiotherapy.
RTOG: Radiation Therapy Oncology Group
Treatment field: The area of tissue covered by the radiation beam.
VMAT: Volumetric Arc Therapy, a radiotherapy treatment technique designed to deliver a precise dose to the treatment area with minimal dose to the surrounding tissues, using a continuously moving arc of radiation.

Provenance

Record: 235
Objective:

To ensure radiotherapy patients receive consistent, evidence based/best practice advice and care in the management of skin reactions through:-

  1. Consistent assessment and documentation of skin reactions. 
  2. Implementation and ongoing evaluation of recommended interventions.
  3. Increasing multidisciplinary knowledge and awareness across the cancer centre, cancer units and primary care teams.
Clinical condition:
Target patient group: Radiotherapy Patients
Target professional group(s): Secondary Care Nurses
Primary Care Nurses
Adapted from:

N/A


Evidence base

Aistars J (2006) Validity of skin care protocols for external radiotherapy. Clinical Journal of Oncology Nursing 10(4)
And II Breast Cancer. International Journal of Radiation Oncology Biology and Physics 83(1).
British Association of Dermatologists (2009) Sunscreen factsheet. Sun Awareness.
British Medical Association, Royal Pharmaceutical Society of Great Britain. (2013) British national formulary. London: BMA, RPS, 65
Cork MJ and Danby S (2011) Aqueous cream damages the skin barrier. British Journal of Dermatology 164(6):1179-1180.
Cox J Stetz J and Pajak T (1995) Toxicity criteria of the radiation therapy oncology group (RTOG) and the European Organisation for Research and Treatment of Cancer (EORTC), International Journal of Oncology, Biology and Physics. 31, 5, 1341 - 1346.
Cumming J & Routsis D (2009) Are improvements needed in the management of severe acute skin reactions following completion of breast radiotherapy? A discussion of some possible service options. Journal of Radiotherapy Practice 8.
D’haese S Van roy Bate T Bijdekerke P and Vinh-Hung V (2010) Management of skin reactions during radiotherapy in Flanders (Belgium): A study of nursing practice before and after the introduction of a skin care protocol journal of Oncology Nursing 14 pp 367-372
Danby SG Al-Enezi T and Sultan A (2011) The effect of aqueous cream BP on the skin barrier in volunteers with a previous
history of atopic dermatitis. British Journal of Dermatology 165 pp329-334
Feight D Baney T Bruce S and McQuestion M (2011)Evidence based interventions for radiation dermatitis Clinical Journal of Oncology Nursing 15(5) pp 481-492 last accessed 16/01/2014 at URL: www.medscape.com
Ginot A Doyen J Hannoun-Levi JM Courdi A (2010). Normal Tissue Tolerance to External Beam Radiation Therapy: Skin] Cancer Radiotherapy 14(4-5): 379-85.
Gutierrez LC Khosravi-Shahi p and Alvarez YE (2012) Management of dermatitis in patients with locally advanced squamous cell carcinoma of the head and neck receiving cetuximab and radiotherapy Oral oncology 48 pp 293-297.
Harris R (2011a) Summary of Interventions for Acute Radiotherapy-Induced Skin Reactions in Cancer Patients: A Clinical Guideline recommended for use by The Society and; College of Radiographers Society of Radiographers (https://www.sor.org)
Harris R, et al (2011b), Radiotherapy skin care: A survey of practice in the UK, Radiography 18 pp 21-27
Haas MA, Moore-Higgs GJ, eds. (2010) Principles of skin care and the oncology patient. Pittsburg, PA: Oncology Nursing
Society cited in: McQuestion M (2011) Evidence-based skin care management in radiation therapy: clinical update Seminars in Oncology Nursing 27(2) pp 1-17.
Kedge E (2008) A systematic review to investigate the effectiveness and acceptability of interventions for moist desquamation in radiotherapy patients
Krishnasamy M (2008) Wound Management. In: Corner J, Bailey CD, editors. Cancer Nursing: care in context. 2nd ed. Oxford: Blackwell; p.488-9.
McNees P (2006) Skin and wound assessment and care in Oncology. Seminars in Oncology Nursing 22 (3) pp 130-4.
MHRA (2013) Aqueous cream: contains sodium lauryl sulfate which may cause skin reactions, particularly in children with eczema.
MHRA UK Public Assessment Report.
Nayel H el-Ghoneimy E el-Haddad S (1992). Impact of Nutritional Supplementation on Treatment Delay and Morbidity in Patients with Head and Neck Tumors Treated with Irradiation. Nutrition 8(1): 13-8.
NHS (2010) Best practice statement – Skin care of patients receiving radiotherapy. Quality Improvement Scotland.
Noble –Adams R (1999) Radiation Induced Reactions. 1. An examination of the phenomenon in British Journal of Nursing Sept 23 - Oct 13th 8 - 17.
Olson D, Raub, W Bradley C, Johnson, M. Machias. JL, Love, V and Markoe A (2001). The effect of Aloe Vera gel/mild soap alone in preventing skin reactions in patients undergoing radiation. Oncology Nursing forum. No 3. 2001.
Patel AN, Varma S, Batchelor JM & Lawton PA (2013) Why aqueous cream should not be used in radiotherapy induced skin reactions. Clinical Oncology 25.
Porrock D (2002) Factors Influencing the Severity of Radiation Skin and Oral Mucosal Reactions: Development of a Conceptual Framework. European Journal of Cancer Care (Engl) 11(1): 33-43
Porrock, D & Kristjanson, L (1999). Skin reactions during radiotherapy for Breast Cancer: the use and impact of topical agents and dressing. European journal of Cancer.
Roy I Fortin A and Larochelle (2001) The impact of skin washing with water and soap during breast irradiation: a randomized study Radiotherapy and Oncology 58(3) pp333-339
Ryan JL Bole C Hickok JT Figueroa-Moseley C Colman L Khanna RC Pentland AP and Morrow GR (2007) Post-treatment skin reactions reported by cancer patients differ by race, not by treatment or expectations. British Journal of Cancer. 97 pp14-21.
Sharp L Finnila K Johansson H Abrahamsson M Hatschek T and Bergenmar M (2013) No differences between Calendula cream and aqueous cream in the prevention of acute radiation skin reactions: Results from a randomised blinded trial. European Journal of Oncology Nursing 17 pp429-435.
Sitton E (1992) Early and late radiation - induced skin alterations. Part 1: Mechanisms of skin changes Oncology Nursing forum 19(5)
Therberge V Harel F and Dagnault A (2009) Use of axillary deodorant and effect on acute skin toxicity during Radiotherapy for breast cancer: a prospective randomized Noninferiority trial. International Journal of Radiation Oncology Biology and Physics 75(4).
Watson LC Gies D Thompson E & Thomas B (2012) 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,
Wells M Macmillan M, Raab G MacBride S Bell N, MacKinnon K MacDougall H Samuel L and Munro A ( 2004) Does Aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomised control trial. Radiotherapy and Oncology 73. 153-162.
Wells, M and MacBride S. (2003) Radiation Skin Reactions. Chapter 8 in: Faithfull S & Wells M (Eds) Supportive Care in Radiotherapy. Elsevier Science Ltd.

Document history

LHP version 2.0

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