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CSB025 > Radiation Induced Skin Reactions > Flashcards

Radiation Induced Skin Reactions Flashcards

1
Q

Effects of Acute Radiation Skin Reactions

A
  • Physical discomfort and pain
  • Itching
  • Difficulty with movement of a limb or ambulation
  • Sleep impairment
  • Difficulty with wearing clothing
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2
Q

Severe Skin Reactions

A

• May have a dose limiting impact on treatment or treatment breaks may be required

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3
Q

Late Skin Reactions

A
  • May occur months to years after treatment

* Can result from extracellular matric alterations and the deposition of collagen during the healing phases

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4
Q

Reactions Directly From Radiation

A
  • Occur most frequently within the first four weeks of treatment
  • Epidermal regeneration, healing and resolution occurring within three to five weeks following treatment
  • Complete healing can take up to three months
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5
Q

Physiology of a Reaction

A
  • Radiation accelerates the destruction of basal cells
  • End result is inflammation, epidermal cell apoptosis and a reduction and alteration in normal epithelial stem cells
  • Collagen formed is immature or insufficient (doesn’t meet demands of normal wound healing)
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6
Q

Transient Erythema

A
  • May occur within hours of commencing treatment within the treatment field
  • Due to capillary dilation in the dermis and oedema as a result of increased vascularity and obstruction
  • Red and warm skin surface, may have a rash-like appearance
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7
Q

Other Changes in the Skin

A

• Changes in pigmentation, interrupted hair growth, changes to the sweat and sebaceous glands

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8
Q

Hyperpigmentation

A
  • Melanin cells migrate to more superficial layers of the epidermis due to increase cellular destruction
  • May appear as a moderate tan
  • Occurs after two to four weeks of treatment
  • Normal Skin tone returns within three months following the last radiation treatment
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9
Q

Dose Relation to Reaction

A

• Total hair loss within the radiation field can occur with doses higher than 55 gray
o May take two to three months to regrow following treatment

• Sweat and sebaceous glands may be permanently destroyed after a cumulative dose of 30 Gy
o Leads to reduction in skin lubrication and increase in dryness and pruritus (itchy skin)

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10
Q

Repair Following Acute Injuries

A
  • Normal tissue repair caused by the migration of epithelial cells from the basal membrane through homeostatic stimulation, proliferation and cellular differentiation begins 10 – 14 days following treatment
  • Migration of these cells across the irradiated field is improved with a moist wound healing environment (shown to heal wounds 50% faster than a non-moist wound healing environment
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11
Q

Types and Severity of Acute Skin Reactions

A
  • Many patients don’t experience noticeable changes within first two weeks with a daily fraction of 1.8 – 2 Gy
  • When cumulative dose reaches 20Gy – patient may experience dryness, pruritus, flaking of the skin or dry desquamation
  • At doses exceeding 30Gy – extra capillary cell damage may occur, resulting in increased capillary blood flow and oedema
  • At doses 40-60 Gy – if severe, there is epilation leading to moist desquamation including arterial thrombi, fibrinous exudate, oedema and considerable pain
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12
Q

Desquamation

A

Sloughing of the epithelium with potential exposure of the dermal layer of skin

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13
Q

Factors increasing Risk of Moist Desquamation

A
  • Friction
  • Skinfolds
  • Use of bolus material (as it increases skin dose)
  • Addition of chemotherapy
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14
Q

Moist Desquamation

A
  • Dermis is exposed
  • The treatment field is moist and tender with oozing and leaking of serous fluid
  • Light or heavy exudate and crusting may be present
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15
Q

Treatment Related Risk Factors for Acute Skin Reactions

A
  • Location of the treatment field (e.g., head and neck, breast, axilla, perineum, skinfolds)
  • Large volume of tissue being treated
  • Total dose of radiation
  • Larger fraction size (>2Gy / fraction)
  • Accelerated fractionation treatments
  • A longer treatment duration
  • The type of energy resulting in a higher skin dose
  • Use of tangential fields
  • Use of tissue equivalent or bolus material
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16
Q

Patient Related Risk Factors for Increased Skin Reaction

A
  • Areas of thin o smooth epidermis
  • Areas of skin-to-skin contact
  • Previous lymphocele aspiration
  • Areas of compromised skin integrity within the treatment field (burns, lesions, existing surgical incisions, scars, planned postoperative radiation)
  • Presence of comorbidities (e.g., diabetes, renal failure)
  • Poor Nutritional Status
  • Older Age
  • Inclusion of drug therapy (e.g., chemotherapy)
  • Patient race and skin routine
17
Q

Radiation Recall Dermatitis

A
  • An acute inflammatory response in a previously irradiated treatment field following the administration of an inciting systemic drug
  • Most frequently associated with MV radiation
  • Can also occur within the mucosa, muscles and organs
  • Appears as dermatitis but can range from a mild erythema or a pruritic rash to a severe exfoliative dermatitis
18
Q

Late Effects

A
  • May be identified as persistent, non-healing skin reactions
  • True late radiation-induced changes may take months or years to develop, become progressive and vary in severity
  • May appear as transient oedematous changes, hyperpigmentation, hypopigmentation resulting from the destruction of melanocytes and telangiectasia
19
Q

Telangiectasia

A
  • Appears as reddened spider like veins close to the skin surface within the treatment fields
  • Caused by damage to and stretching of the small vessels
20
Q

Late Effects are Associated with:

A
  • Larger total treatment dose and volume of irradiated tissue
  • A dose per fraction > 2 Gy and higher daily dose
  • Other therapies including chemo
  • Patients age and general medical condition
  • Comorbidities (e.g., diabetes, collage vascular disorders)
  • Individual genetic factors
  • Radiation fibrosis
  • Atrophy
21
Q

Advantages of Preoperative Radiation

A
  • Smaller treatment volumes and radiation fields, lower radiation doses (less tumour cell hypoxia), surgery being performed on more normal blood vessels (fewer hypoxic and radioresistant cells
  • Been shown to reduce risk of recurrence in soft tissue sarcoma and improve survival rates in rectal cancer
22
Q

Disadvantages with Preoperative Radiation

A
  • Increased wound complications

* Difficulties associated with interpreting postsurgical pathology specimens

23
Q

Advantages of Postoperative Radiation

A
  • Lower risk and fewer short term wound complications

* Access to a full pathology report

24
Q

Disadvantages of Postoperative Radiation

A
  • Needs for a larger radiation treatment field and volume (need to encompass the original tumour volume prior to surgery)
  • Concern that treatment may be compromised if there is a wide surgical disruption of tissues
  • Risk of enhanced late toxicity
  • Higher risk of fractures (in patients with sarcoma)
25
Q

Phototherapy

A
  • Involves the use of a cellular photosensitising agent and artificial light to cause a cytotoxic reaction within cells
  • Has been used in treatment for nonmelanoma skin cancers, lupus, management of refractory internal tumours
  • Palliative management of obstructive symptoms caused by oesophageal and lung cancers
  • Following administration, most of the drug is excreted in approx. 48 hours with the remaining drug retained within the malignant tumours -> waiting period of 40-50 hours between administration and light activation
26
Q

Total Body Irradiation

A
  • Used in conjunction with chemotherapy as part of a the conditioning protocol in preparation for bone marrow transplantation
  • Used to treat Leukaemias, non-Hodgkin lymphoma, aplastic anaemia and other haematological cancers
  • Uniform dose of radiation is delivered to the entire body – including the skin, underlying tissue and organs
  • Has the ability to shield or protect specific organs such as the lung, liver, kidneys and eyes
  • May be delivered in either a single fraction of 8-10 Gy or as a fractionated treatment over three to six days
27
Q

Skin Reactions from Total Body Irradiation

A
  • Begin to appear within hours or days following the radiation and have duration of 3-21 days
  • Typically, generalised erythema, alopecia, tanning, hyperpigmentation of the entire skin
  • Moist desquamation of the skin may occur after treatment
  • Patients may also experience chronic dry skin as a result of radiation effects on sebaceous or sweat glands
  • Nails become dystrophic
  • Hyperpigmentation typically fades within about a year of transplantation unless complicated by conditions
28
Q

Total Skin Irradiation

A
  • Also referred to as total skin electron beam therapy
  • Used in the treatment of cutaneous T-cell lymphomas, including mycosis fungoides and Sezary syndrome (immature T-lymphocytes invade the epidermis and dermis causing patchy plaques that can occur across large areas of the skin)
  • Delivered to the entire skin surface using electrons and is the most effective treatment for CTCL
  • Delivered using a lower-energy linear accelerators with a six field technique
  • Typical doses for treatment of the skin are 30-60 Gy with 18-20 Gy for the hands and feet
  • Treatment ranging from 30-45 minutes per day
  • Shielding of the hands and feet and eye shields to protect the cornea and lens are used during the treatment
29
Q

Skin Reactions from TSI

A
  • May include erythema, pruritus, dry desquamation, and moist desquamation
  • Wrinkling of the skin, uneven pigmentation, alopecia, and hypohidrosis (abnormal decrease in sweating) can occur following treatment
30
Q

Scleroderma

A
  • Connective tissue disease that can affect the skin and internal organs
  • Diagnosis generally has been a contraindication to radiation therapy because of the perceived increased risks of acute and late effects
31
Q

Soap and Water

A
  • Current literature supports washing irradiated skin with lukewarm water and a mild soap
  • Washing with soap and water had a statistically significant reduction in itching, erythema and desquamation scores
  • Studies found significantly increased incidence of moist desquamation in patients who didn’t was their hands, as well as a greater incidence of pain, itching, and burning
32
Q

Deodorant

A
  • Studies found no variation in surface dose due to the use of deodorant
  • Reactions found were determined to be caused by an irritating chemical ingredient
33
Q

Calendula Cream

A
  • Medicinal herb with antimicrobial activity developed from the marigold plant
  • Statistically significant benefit in reducing grade 2 skin reaction, pain reduction and reducing the number of treatment interruptions
34
Q

Occlusive Dressings

A
  • Have been shown to reduce pain in skin reaction wounds, reduce the development of eschar and improve epidermal regeneration and overall wound healing
  • Dressings with low water transmission rates retain moisture and support a moist wound healing environment without increasing the incidence of infection
35
Q

Cavilon No-Sting Barrier Film

A
  • Statistically reduced the frequency and duration of moist desquamation and pruritus
  • Available in a cream or a saturated foam wipe and is easily applied to intact skin acting as a protective film or across a radiation skin reaction
  • Provides both protection from further trauma and a moisture-retaining barrier, thereby creating a healing environment
36
Q

Silver Leaf Nylon Dressing

A
  • Nonadherent rayon and polyester dressings have been used to manage a variety of acute and chronic wounds
  • Benefits – moisture retention, exudate management, improved comfort, less disruption of the wound bed because of less frequent dressing changes

CSB025 (14 decks)

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