Dermatologists may have frequent interactions with cancer survivors navigating radiation-induced skin injury as a result of their treatment. Nearly 50% of patients with cancer will receive radiation therapy as at some point as a component of their treatment program.1,2 In many cases, initial radiation-induced dermatitis (RID) leads to permanent skin impairment that is both physically painful and significantly disturbing to the patient’s quality of life.

Prevalence

The prevalence of RID is unusually high. An estimated 95% of cancer patients receiving radiation therapy will experience at least mild to moderate dermatitis as a result, and many have much more severe reactions that can affect their ability to continue their treatments.1,2 Severe RID can require reduced doses of radiation or interruption of treatment, with significant potential influence on treatment efficacy against the primary cancer; both prevention and treatment of RID are major concerns of a cancer treatment program.1


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The severity of the reaction is largely related to the dose and the location of the cancer. Although current radiation technologies are designed to minimize the dosage around the targeted area, in some cases the skin is too near the target to be well protected from receiving damaging radiologic doses.1 Patients treated for head and neck cancers, as well as those of the vulva and anus, are at particular risk for severe and/or chronic RID, as the skin around the treatment site is difficult to isolate from the target area and so receives higher than desired doses of radiation throughout the treatment course.1-3  In breast cancer treatment, in which  an estimated 45% of patients will receive radiation, the rate of RID is 74% to 100% and is often moderate to severe.4

Acute vs Chronic RID

Radiation dermatitis can manifest as acute erythema and desquamation or as a chronic syndrome with unresolved symptoms.1,2 According to Jonathan Leventhal, MD, director of the Onco-Dermatology Program at Smilow Cancer Hospital, Yale-New Haven in HavenYale University ,Connecticut, an important distinction is that, “acute RID resolves after completion of radiation whereas chronic RID tends to persist. In severe cases radiation induced fibrosis can occur of the breast which is unfortunately challenging to treat and often permanent.”

The acute signs of RID are those that occur within a few days to weeks following radiation treatments; however, the diagnosis more broadly accepts symptoms that develop up to 90 days from the start of therapy. The most common signs, Dr Leventhal said, are localized redness and dry scaly skin developing at the radiation site, starting hours to days after treatment initiation. “Acute RID presents with sunburn like redness, then over several treatments dry scale typically occurs. In severe cases moist blistering of involved skin can develop, and pain, stinging, or burning and blistering can occur in severe cases which are disturbing to patients’ QOL. “

Chronic RID develops more slowly, starting90 days post-treatment and generally has more serious chronic effects including skin atrophy, telangiectasias, and fibrosis.1 Dr Leventhal, a coauthor of multiple reviews of RID, explained that “chronic RID presents as pigmentary and textural change of skin, often with fibrosis/contracture of involved skin (often the breast)…telangiectasias can develop.” 

Pathophysiology

RID occurs when free radicals and reactive oxygen species develop after application of radiation to healthy skin, causing changes to the local endothelial cells within hours of exposure. The skin becomes inflamed by the generation of cytokines and chemokines, which over the next few weeks produces erythema. The affected skin then becomes dry and scaly with peeling. Repeated insult to the epithelial layer over subsequent radiation courses remodel the vasculature and connective tissue, causing telangiectasis.1,2

The main factors influencing the likelihood of RID are the proximity of the radiation target to the skin and the energy of the radiation used. The severity is determined by things like radiation dose and scheduling, the size of the skin surface area exposed, and a residual radiosensitizing effect from chemotherapy. 1,2 Certain patient factors may also contribute to increasing the severity of RID include being a current smoker, a high BMI and poor nutritional status, preexisting skin disease, genetic susceptibility and older age, as well as concomitant treatment with chemotherapy.1-3

Topical Treatments

 “Topical emollients and topical steroids can be highly effective as well as gentle skin care, which includes use of nonfragrance gentle soaps, moisturizers, and avoidance of skin irritation and sunburn,” Dr Leventhal said. “Also using an electric razor and gentle deodorant can be helpful. In cases where blistering occurs, topical or oral antiseptics or antibiotics may be used as well as meds for pain relief. Sitz baths can be soothing for patients with radiation to the buttocks.”

Preventive Measures

Patients are often given preventive recommendations, including wearing loose-fitting clothing with high ultraviolet protective factor–rated materials to help minimize friction and added sun exposure to the skin.1 They are counseled to avoid sun exposure, shaving of skin, or the use of cosmetics or any nonphysician recommended topical agents, and encouraged to use specific topical emollients to keep skin hydrated, although reactions can occur to other ingredients in the formula. Gentle daily washing with soap and water is generally supported in the literature.1,2

“While gentle skin care and avoidance of irritation/trauma/sunburn can help alleviate dermatitis and prevent worsening of RID, there are few things which can actually prevent RID,” Dr Leventhal said. “Some studies have shown that topical steroids can reduce the incidence and severity of acute RID.” He noted that further high-quality clinical trials are needed to find new measures to reduce incidence and severity. “For now, topical steroids and gentle skin care are the most commonly employed measures,” he concluded.

References

1. Radiation Dermatitis: Recognition, Prevention, and Management. Leventhal J, Young MR. Oncology (Williston Park). 2017 Dec 15;31(12):885-7, 894-9. Available at: https://www.cancernetwork.com/view/radiation-dermatitis-recognition-prevention-and-management

2. Iacovelli NA, Galaverni M, Cavallo A, et al. Prevention and treatment of radiation-induced acute dermatitis in head and neck cancer patients: a systematic review. Future Oncol. 2018;14(3):291–305.

3. Russi EG, Moretto F, Rampino M, et al. Acute skin toxicity management in head and neck cancer patients treated with radiotherapy and chemotherapy or EGFR inhibitors: literature review and consensus. Crit Rev Oncol Hematol. 2015;96(1):167–182.

4. Ramseier JY, Ferreira MN, Leventhal JS. Dermatologic toxicities associated with radiation therapy in women with breast cancer. Int J Womens Dermatol. 2020 Sep 30;6(5):349-356.