Radiation therapy (RT) is a method often used as a treatment for cancer. Acute and / or chronic skin changes may occur during radiotherapy, which may affect the quality of life of the cancer patient. Radiation reactions can lead to delayed oncology treatment and functional disorders.
What is Radiation induced dermatitis
Radiation induced dermatitis or Radiation Dermatitisis a common side effect of radical ionizing radiation treatment. The pathophysiology of a radiation skin reaction is a combination of radiation injury and the subsequent inflammatory response and can occur at both the entrance and exit site of the irradiation. Ionizing radiation damages the mitotic ability of stem cells within the basal layer preventing the healing and therefore skin’s health. Reactions are evident one to four weeks after beginning of treatment and can persist for several weeks post treatment.
The high-intensity radiation used in modern radiotherapy produces results of direct and indirect ionization leading not only to injury of cancer cells, but also to the risk of injury to normal tissues. This can lead to desquamation, peeling and shedding of the skin, depending on the total radiation dose provided. Impaired skin barrier function carries the risks of wound formation, loss of immune function and infection.
Types of Radiation Dermatitis
Radiation Dermatitis is divided into acute and chronic.
Acute radiation dermatitis occurs within 90 days of exposure to radiation. The patient may have skin changes ranging from faint erythema (reddening) and desquamation (peeling skin) to skin necrosis (death of skin cells) and ulceration, depending on the severity of the reaction.
The National Cancer Institute (USA) has developed 4 stage criteria for the classification of acute radiation dermatitis:
Grade 1 – Faint erythema or desquamation. Grade 2 – Moderate to brisk erythema or patchy, moist desquamation confined to skin folds and creases. Moderate swelling. Grade 3 – Confluent, moist desquamation greater than 1.5 cm diameter, which is not confined to the skin folds. Pitting oedema (severe swelling). Grade 4 – Skin necrosis or ulceration of full thickness dermis (middle layer of skin).
Onset of chronic radiation dermatitis may occur in a period of time, from 15 days to 10 years or more after the beginning of radiation therapy. It is an extension of the acute process and involves further inflammatory changes in the skin.
Chronic radiation-induced changes in the skin are characterized by:
- disappearance of epidermal (skin) structures (pores)
- increase in collagen and damage to elastic fibers in the dermis
- fragile skin surface (epidermis)
- telangiectasia (prominent blood vessels)
Secondary skin cancers may also result from repeated exposure to radiation therapy, with basal cell carcinoma mostly occurred.
Factors Contributing to the Severity of Radiation Dermatitis
Factors contributing to the severity of Radiation Dermatitis include among others, type of Radiation, treatment technique and the volume of Treated Tissue and Dose, the Chemotherapeutic Agents, Co-existing Chronic llnesses, smoking, age, nutritional status, application of topical skin products to the affected area prior to radiation and prolonged exposure to radiation.
General Management of Radiation Dermatitis
Important parameters that contribute to the management of Radiation Dermatitis are check of radiation dose and distribution, the discontinuing concomitant medication that may have contributed to the reaction, monitoring for possible skin changes during radiation therapy, but also proper cleansing and skin care. Moisturizing, emollient products, topical corticosteroids and healing bandages are used to care for the affected skin.
What to avoid
Patients should avoid sun exposure keeping the irradiated area covered with clothing or using sunscreen with SPF 50+. They are also discouraged from using skin irritants, like perfumed products, deodorants which may possess chemical irritants and alcohol as well as they should take care of the irradiated area from rubbing and scratching.
Specially designed medical devices have been developed to prevent and treat the symptoms of radiation-induced dermatitis.
Focus on quality of life of oncological patients
Chemotherapy treatment-related side effects have a detrimental outcome on normal daily activity of patients with cancer. Administration of supportive care treatment controls frequency and intensity of these adverse events and its use is very important because: “It is crucial for cancer patients not only to survive but to live a better life”.
Nausea and vomiting
Nausea and vomiting induced by chemo-treatment have been recognized by most of the cancer patients as adverse events with high frequency that cause fear1. Sufficient prevention of nausea and vomiting is necessary for the administration of indicated chemotherapy and it is associated with clinical response and survival benefits in patients with malignancies.
The evolution in antiemetic prophylaxis has been recognized as one of the top 5 Advances in 50 Years of Modern Oncology 1,2.
Target of therapy
Focusing on the most innovative and efficacious therapies of supportive care in cancer, the therapeutic goal of antiemetic prevention targets to control: acute and delay nausea and vomiting following high emetogenic chemotherapy, acute and delay nausea and vomiting following moderately emetogenic chemotherapy, terms associated with the number of patients with emesis symptoms (90% for high emetogenic chemotherapy και 31-90% for moderately respectively). Recent clinical research has led to reliable therapeutical approaches in antiemetic prophylaxis giving access to novel treatments for cancer patients improving the quality of their life.
1. N Engl J Med 2016;374:1356-67
2. ASCO, 2014 (https://www.asco.org/about-asco/press-center/news-releases/asco-50th-anniversary-poll-names-top-5-advances-past-50-years)
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