The Journal of Emergency Medicine, Vol. 47, No. 5, pp. e117–e119, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.06.054

Visual Diagnosis in Emergency Medicine

FLUOROSCOPY-INDUCED RADIATION DERMATITIS Eric F. Reichman, PHD, MD Emergency Department, University of Texas Health Science Center at Houston Medical School, Houston, Texas Reprint Address: Eric F. Reichman, PHD, MD, Emergency Department, University of Texas Health Science Center at Houston Medical School, 6431 Fannin Street, MSB B.120, Houston, TX 77030

outpatient surgical debridement of the central necrotic and ulcerated skin followed by daily wet-to-dry dressing changes. A skin graft was considered to cover the debrided area, but this idea was later rejected. The wound consultants felt that the poor healing was due to diminished blood flow to the area from radiation damage and that a skin graft would not survive. The debrided central area healed by secondary intention approximately 8 months after the debridement. The surrounding radiation dermatitis skin changes persisted and the patient remains with a well-demarcated, erythematous, and nontender area between the scapulae.

CASE REPORT A 58-year-old male presented to our emergency department (ED) with an acute ST-segment elevation anterolateral myocardial infarction (MI). He immediately underwent cardiac catheterization, angioplasty, and stenting. He was discharged home 3 days later. Approximately 7 days after angioplasty, he developed a red, scaly, slightly weepy, nonpruritic, and nonpainful ‘‘rash’’ on his back. He was treated for contact dermatitis by his primary physician with topical and oral corticosteroids without an effect. The localized ‘‘rash’’ persisted and worsened over the following 5 months, despite several visits to his primary care physician. The patient presented again to our ED 6 months after his MI for evaluation of the ‘‘rash.’’ His vital signs were normal. The physical examination was unremarkable except for obesity and the ‘‘rash.’’ The area of his chief complaint was localized between the scapulae, rectangular, well demarcated with sharp borders, erythematous, nontender, and with a central area of necrosis and ulceration (Figures 1 and 2). Thickened, raised, and scarred skin with mild induration surrounded the area of necrosis and ulceration. There was no abscess, cellulitis, discharge, or lymphangitis. The diagnosis of radiation dermatitis due to prolonged fluoroscopy during cardiac catheterization was made in the ED. The patient was referred to the wound care clinic for further evaluation and management. The patient received

DISCUSSION Radiation dermatitis or radiation-induced skin changes have been identified soon after the discovery of radiation. It can develop after prolonged fluoroscopic procedures (eg, cardiac catheterization) and radiation therapy (1 7). Radiation dermatitis has not been documented from fluoroscopy-aided procedures in the ED. This is most likely due to the relatively short procedures performed in the ED and the minimal fluoroscopy time when it is used during ED procedures. Injury is due to endothelial cell changes, epidermal cell apoptosis and necrosis, inflammation, and stem cell impairment (1). Patients may be more predisposed to radiation dermatitis if they are malnourished, obese, smokers, or received large radiation doses (1,2) Other states, such as dermatologic conditions, connective tissue diseases,

RECEIVED: 29 November 2013; FINAL SUBMISSION RECEIVED: 19 March 2014; ACCEPTED: 30 June 2014 e117

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Figure 1. The location of the patient’s complaint.

impaired DNA repair capabilities, and immunosuppression, also predispose one to radiation injury (1,2). The location of the radiation dermatitis corresponds to the site of the radiation beam entry (1,2,6,7). Radiation dermatitis is classified according to the skin changes (1,6,7). Grade 1 is mild and consists of erythema that may be accompanied by depigmentation, dry desquamation, epilation, pruritus, and scaling. Grade 2

Figure 2. Close-up view of the rectangular-shaped dermatitis demonstrating central necrosis.

E. F. Reichman

consists of persistent erythema that is tender and edematous with possible moist desquamation. Grade 3 consists of moist desquamation and pitting edema. Grade 4 is severe, as in our patient, with full thickness ulcerations and skin necrosis. Radiation dermatitis is noted to be round, square, or rectangular-shaped in most cases (2,6,7). Collimators are metal disks in the head of the radiation device that are adjusted manually to decrease the field of view of the radiation exposure. The collimators are used to focus the radiation beam to a specific area, decrease the scatter of radiation, decrease the amount of tissue exposed to radiation, and decrease overlap of fields when multiple beam angles are used to provide the radiation. These collimators result in the delivered radiation beam, and the irradiated area is round, square, or rectangular shaped. The use of collimators results in a decrease in image brightness or decreased amount of radiation delivered to the tissues due to blockage of the radiation beam. The machine automatically increases the radiation dose to the collimated area to compensate (7). This additional radiation is partially responsible for the radiation dermatitis. Radiation dermatitis is often misdiagnosed initially (2,7). This is due to the patient not returning to the physician who performed the fluoroscopic or radiation procedure or the second physician not having a history of radiation exposure. Common misdiagnoses include bacterial infections, contact dermatitis, fixed drug eruption, morphea, spider bite, and viral infections (1,7). Our patient had numerous visits to his primary care physician due to a ‘‘rash’’ that never healed despite numerous treatments. This history of multiple physician visits, a nonhealing dermatitis, a well-demarcated and non-natural appearing shaped (ie, rectangular) dermatitis in the area between the scapulae, and the history of preceding cardiac fluoroscopy led us to the diagnosis of his radiation dermatitis. Treatment of radiation dermatitis is based on the wound care literature and not specific to this entity (1,5). Mild and acute cases can be treated with emollients, hydrogel or hydrocolloid dressings, and burn pads. The use of corticosteroids is controversial and has shown mixed results (1,8). Chronic ulcers and skin necrosis requires multidisciplinary care. These cases can be treated symptomatically similar to mild cases, with the possible addition of growth factors, hyperbaric oxygen, interferon, lasers, or selective debridement (1). Severe cases of skin necrosis and ulceration may require debridement and skin grafting. There appears to be some data that the prophylactic use of topical corticosteroids before the use of prolonged fluoroscopy or radiation therapy may prevent radiation dermatitis (8). More study is needed to determine the correct corticosteroid potency, dosing, and timing of administration.

Radiation Dermatitis

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Prevention is the key to radiation dermatitis. Knowledge of the patient’s prior procedures is important to limit the cumulative radiation dose to a specific area (1,2,6,7). Limit radiation doses to allow for sufficient diagnostic information, image quality, and image guidance for procedures (2,6,7). Radiation doses can also be limited by minimizing fluoroscopy time, keeping the x-ray tube as far as possible from the skin, and minimizing the number of fluoroscopy frames and cine series. REFERENCES 1. Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol 2006;54:28–46.

2. Cousins C, Miller DL, Bernardi G, et al. ICRP PUBLICATION 120: Radiological protection in cardiology. Ann ICRP 2013;42:1–69. 3. Srimahachota S, Udayachalerm W, Kupharang T, et al. Radiation skin injury caused by percutaneous coronary intervention, report of 3 cases. Int J Cardiol 2012;154:e31–3. 4. Glazier JJ, Dixon SR. Skin injury following prolonged fluoroscopy: early and late appearances. Q J Med 2012;105:571–3. 5. Spiker A, Zinn Z, Carter WH, et al. Fluoroscopy-induced chronic radiation dermatitis. Am J Cardiol 2012;110:1861–3. 6. Koenig TR, Wolff D, Mettler FA, et al. Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR Am J Roentgenol 2001;177:3–11. 7. Koenig TR, Wolff D, Mettler FA, et al. Skin injuries from fluoroscopically guided procedures: part 2, review of 73 cases and recommendations for minimizing dose delivered to patient. AJR Am J Roentgenol 2001;177:13–20. 8. Meghrajani CF, Co HC, Ang-Tiu CM, et al. Topical corticosteroid therapy for the prevention of acute radiation dermatitis: a systematic review of randomized controlled trials. Expert Rev Clin Pharmacol 2013;6: 641–9.

Fluoroscopy-induced radiation dermatitis.

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