Clinical ReviewRadiation dermatitis: Clinical presentation, pathophysiology, and treatment 2006
Section snippets
Acute radiation dermatitis
After RT or accidental exposures, the acute changes usually occur within 90 days. The National Cancer Institute common toxicity criteria version 3.0 has become the standard for evaluation (Table I). Generalized erythema, sometimes undetectable without special instrumentation, may occur hours after radiation exposure, and fade within hours to days.6, 7 A second phase of more sustained erythema is apparent 10 to 14 days after dosing, and is characterized by a blanchable reactive pink hue, without
Chronic radiation dermatitis
The skin may appear relatively normal for a varying duration after RT, and chronic changes may not develop for months to years after exposure. These changes are sometimes transient, like the edematous peau d'orange appearance that appears in the postirradiated breast and that often resolves in the first year. Postinflammatory hypopigmentation and hyperpigmentation are commonly seen after any disruption of the dermoepidermal junction and, depending on the severity of the initial reaction and
Pathophysiology
The skin is a continuously renewing organ, and radiotherapy not only interferes with normal maturation, reproduction and repopulation of germinative epidermal and hair matrix cells, but also targets fibroblasts and the cutaneous vasculature.30 The radiation-induced injury has been termed a ācomplex wound,ā in which structural tissue damage occurs instantaneously, mediated by a burst of free radicals resulting in DNA damage and alteration of proteins, lipids, and carbohydrates. Each additional
Dose fractionation schedules
The total dose, dose/fractionation, type and quality of the beam, volume, and surface area exposed influence the degree of damage to the epidermis, dermis, adnexal structures, and microvasculature.2, 32, 34, 57, 58, 59 When photons are absorbed, single- and double-strand DNA breakage may occur. In addition, ionized water molecules form free radicals, which then have the potential to diffuse and further damage DNA. In the case of acute radiation dermatitis, the clinical consequences of this
Differential diagnosis
Common cutaneous problems, including dermatitis or infection, may become manifest during or after treatment. Fig 11 demonstrates a contact dermatitis to the marking pens used to draw fiducials, or field lines. Even after the immediate effects of radiation have subsided, the treated skin may manifest a host of physical and functional changes. Compromised integrity and impaired barrier function may produce a ālocus minoris resistentiae,ā a Latin phrase meaning āa place of less resistance,ā
Treatment of acute radiation dermatitis
Early changes (grade 1) characterized by erythema and dry desquamation are best treated symptomatically. The affected area is washed gently with plain water alone or combined with a mild, low pHācleansing agent that does not exacerbate the existing dermatitis. This has proven to be both physically and psychologically more beneficial than older practices of not washing at all.108, 109, 110 Washing may also reduce the bacterial load and thereby reduce potential superantigen-induced inflammation.
Topical therapy and wound care
Many of the recommendations for skin care are derived from the wound care literature.111, 112 The goal of treating the erythema and dry desquamation is to avoid a bolus effect, minimize transepidermal water loss, decrease pain, and prevent progression to moist desquamation. Petrolatum-based emollients are commonly used, with or without hydrogel dressings. Radioemulsions containing trolamine were hoped to be āradioprotectiveā because they are macrophage cell stimulators that remove necrotic
Future directions
The treatment of radiation-induced skin injury continues to be a multidisciplinary effort that focuses on identifying patients at risk, new skin-sparing technology, and wound care of established disease. Technological advances in radiation delivery include conformal RT, which targets the tumor while minimizing exposure of normal tissue. Intensity-modulated radiotherapy utilizes collimators that focus multiple beams on the intended target. This results in a smaller high-dose target, but at the
References (185)
- et al.
Do inflammatory processes contribute to radiation-induced erythema observed in the skin of humans?
Radiother Oncol
(1998) - et al.
Pathophysiology of irradiated skin and breast
Int J Radiat Oncol Biol Phys
(1995) - et al.
Consequential late effects in normal tissues
Radiother Oncol
(2001) - et al.
The radiotherapeutic injuryāa complex 'wound'
Radiother Oncol
(2002) - et al.
Ionizing radiation therapy in dermatology
J Am Acad Dermatol
(1994) - et al.
Reactions to ionizing radiation
J Am Acad Dermatol
(1980) - et al.
Radiobiology of the skin: review of some effects on epidermis and hair
J Invest Dermatol
(1981) - et al.
Prognostic factors for acute and late skin reactions in radiotherapy patients
Int J Radiat Oncol Biol Phys
(1996) - et al.
Patient-to-patient variability in the expression of radiation-induced normal tissue injury
Semin Radiat Oncol
(1994) - et al.
Relationship between early and late normal-tissue injury after postmastectomy radiotherapy
Radiother Oncol
(1991)
Delayed effects of accidental cutaneous radiation exposure: fifteen years of follow-up after the Chernobyl accident
J Am Acad Dermatol
Modulation of IL-6 production and IL-1 activity by keratinocyte-fibroblast interaction
J Invest Dermatol
Ionizing radiation induces human intercellular adhesion molecule-1 in vitro
J Invest Dermatol
TGF-beta1 and radiation fibrosis: a master switch and a specific therapeutic target?
Int J Radiat Oncol Biol Phys
[Radiation-induced skin toxicities: prevention, treatment]
Cancer Radiother
Striking regression of subcutaneous fibrosis induced by high doses of gamma rays using a combination of pentoxifylline and alpha-tocopherol: an experimental study
Int J Radiat Oncol Biol Phys
Interference with transforming growth factor-beta/Smad3 signaling results in accelerated healing of wounds in previously irradiated skin
Am J Pathol
Wound healing following radiation therapy: a review
Radiother Oncol
Effect of therapeutic radiation on wound healing
Clin Dermatol
Microarray analysis to identify molecular mechanisms of radiation-induced microvascular damage in normal tissues
Int J Radiat Oncol Biol Phys
Factors affecting acute skin toxicity in patients having breast irradiation after conservative surgery: a prospective study of treatment practice at the Royal Marsden Hospital
Clin Oncol (R Coll Radiol)
Tolerance of normal tissue to therapeutic irradiation
Int J Radiat Oncol Biol Phys
Skin toxicity due to intensity-modulated radiotherapy for head-and-neck carcinoma
Int J Radiat Oncol Biol Phys
Deterministic rather than stochastic factors explain most of the variation in the expression of skin telangiectasia after radiotherapy
Int J Radiat Oncol Biol Phys
Personal characteristics, therapy modalities and individual DNA repair capacity as predictive factors of acute skin toxicity in an unselected cohort of breast cancer patients receiving radiotherapy
Radiother Oncol
ATM mutations in female breast cancer patients predict for an increase in radiation-induced late effects
Int J Radiat Oncol Biol Phys
Clinical radiosensitivity in breast cancer patients carrying pathogenic ATM gene mutations: no observation of increased radiation-induced acute or late effects
Radiother Oncol
Mutations of the human homolog of Drosophila patched in the nevoid basal cell carcinoma syndrome
Cell
Increase in nucleoli after x-radiation of fibroblasts of patients with Gorlin syndrome
J Lab Clin Med
Hypersensitivity to G2 chromatid radiation damage in familial dysplastic naevus syndrome
Lancet
Radiation-induced chromatid breaks and DNA repair in blood lymphocytes of patients with dysplastic nevi and/or cutaneous melanoma
J Invest Dermatol
Evidence for individual differences in the radiosensitivity of human skin
Eur J Cancer
Individual radiosensitivity measured with lymphocytes may be used to predict the risk of fibrosis after radiotherapy for breast cancer
Radiother Oncol
Collagen vascular diseases and radiation therapy: a critical review
Int J Radiat Oncol Biol Phys
Enhanced mucosal reactions in AIDS patients receiving oropharyngeal irradiation
Int J Radiat Oncol Biol Phys
Radiation and chemotherapy sensitizers and protectors
Crit Rev Oncol Hematol
Localization of Sweet's syndrome in radiation-induced locus minoris resistentiae
J Am Acad Dermatol
Lichen planus confined to a radiation therapy site
J Am Acad Dermatol
Stevens-Johnson syndrome limited to multiple sites of radiation therapy in a patient receiving phenobarbital
J Am Acad Dermatol
Delayed breast cellulitis following breast conserving operation
Eur J Surg Oncol
Characterizing the phenomenon of radiation recall dermatitis
Radiother Oncol
The skin
Physical and biological basis of radiation therapy
Demonstration eines Cancroid des rechten Handruckens, das sich nach langdauernder Einwirkung von Rontgenstrahlen entwickelt hatte
Fortschr Rontgenstr
Chronic radiodermatitis following cardiac catheterisation: a report of two cases and a brief review of the literature
Heart
Radiation-induced temporary epilation after a neuroradiologically guided embolization procedure
Radiology
Permeability barrier function of skin exposed to ionizing radiation
Arch Dermatol
The activated keratinocyte: a model for inducible cytokine production by non-bone marrow-derived cells in cutaneous inflammatory and immune responses
J Invest Dermatol
Wound care after radiation therapy
Adv Skin Wound Care
Increased expression of the epidermal growth factor receptor in human epidermal keratinocytes after exposure to ionizing radiation
Radiat Res
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Conflicts of interest: None identified.
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