Management of Radiation-Induced Skin Reactions Up to Individual Practices

Although cancer patients who undergo radiation therapy frequently have acute and chronic skin reactions, there are no hard and fast guidelines on management of radiation-induced skin reactions or the best products to use. Each center or practice should develop its own clinical guide about how patients should manage skin reactions and which products are recommended for patient use, said Maureen McQuestion, RN, Princess Margaret Hospital, Toronto, Ontario, Canada. She spoke at a symposium called “New Perspectives in Oncology Practice” held in conjunction with The Chemotherapy Foundation Symposium.

“Your practice should be consistent regarding recommendations for products, so that the oncologist, nurses, and nurse practitioner are all telling patients the same thing,” she said. Pharmacists should also be included in the discussion about product recommendations.

Radiation techniques have evolved over the past few decades, and now most patients receive targeted therapy with conformal radiation delivered to the tumor cells, sparing more normal tissue than in the past. Nevertheless, skin reactions do occur, and some are quite severe and painful.

“Acute reactions are worse at the end of radiation, but they will improve 2 to 3 weeks later,” said Ms McQuestion.

Acute reactions can include mild erythema, dry desquamation, moist desquamation, alopecia, pruritus, altered pigmentation, and fibrosis. She said that reactions can be mixed, with both wet and moist desquamation in the radiated area.

Patient factors that affect skin reaction include older age, nutritional status, comorbidities, hygiene, and chronic sun exposure. Treatment-related factors include the area radiated and the total dose and fraction size. Hyperfractionated treatment twice a day increases the chances of more severe skin reaction.

Patients can experience pain, difficulty ambulating and sitting, discomfort wearing clothes, impaired body image, increased urination and bowel movements, loss of independence with decreased ability for self-care, and they have to bear the cost of products to take care of skin reactions.

“Dressings and creams are typically not covered by drug plans,” Ms McQuestion told the audience.  

The goal of management of radiation-induced skin reaction is healing, and the principles are similar to general ones for wound healing. Promoting moisture is important, “but some patients think they should dry the affected area,” she noted.

Patients should be instructed to gently wash the affected area with a mild soap such as Dove and not to rub or abrade the skin. They should not use cornstarch or talc, but they can use deodorants that do not contain aluminum. Although a multitude of creams and lotions can be purchased over the counter, Ms McQuestion said that at her center they have found that hyaluronic acid cream and calendula cream can be helpful. Cavilon No Sting Barrier Film prevents moisture loss. Antimicrobials are not needed if the patient is practicing good hygiene.

“Corticosteroids are not recommended unless the patient has pruritus or documented folliculitis,” she stated.

Other recommendations for patients include avoiding swimming in chlorinated water or hot tubs and keeping the skin area well moisturized, especially if the patient has moist desquamation.