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
2
Q
Severe Skin Reactions
A
• May have a dose limiting impact on treatment or treatment breaks may be required
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
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
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)
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
7
Q
Other Changes in the Skin
A
• Changes in pigmentation, interrupted hair growth, changes to the sweat and sebaceous glands
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
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)
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
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
12
Q
Desquamation
A
Sloughing of the epithelium with potential exposure of the dermal layer of skin
13
Q
Factors increasing Risk of Moist Desquamation
A
- Friction
- Skinfolds
- Use of bolus material (as it increases skin dose)
- Addition of chemotherapy
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
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
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
