Clinical Review
Radiation dermatitis: Clinical presentation, pathophysiology, and treatment 2006

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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 ā€œcomplex 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 ā€œlocus minoris resistentiae,ā€ a Latin phrase meaning ā€œa 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 pHā€“cleansing 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 ā€œradioprotectiveā€ 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

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