Radiotherapy-induced skin reactions: prevention and cure Kàren Morgan

Key words: Friction ■ Obesity ■ Quality of life desquamation ■ Breast cancer



Skin care



Moist

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his is the final article in a three-part series on the use of silicone dressings on radiotherapy-induced skin reactions. The first article gives an overview of the assessment and management of these skin reactions (Glover and Harmer, 2014), while the second describes the use of a soft-silicone dressing, Mepilex® Lite (Mölnlycke Health Care), on skin reactions with signs of moist desquamation (Trueman and Taylor, 2014). This article concludes the series by describing how another soft-silicone dressing, Mepitel® Film (Mölnlycke Health Care), can be used to prevent dry and moist desquamation in patients with breast cancer undergoing radiotherapy.

Understanding radiotherapy Radiotherapy is the use of high-energy X-rays (photons) and other forms of ionising radiation to treat cancer. A key factor related to ionising radiation is its ability to directly or indirectly damage the structures and chemicals within cells in the target area (Faithfull and Wells, 2004). Cells in healthy tissues are much more likely to recover and repopulate than

Kàren Morgan, Macmillan Consultant Radiographer, Taunton and Somerset Foundation Trust Accepted for publication: August 2014

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Skin reactions in radiotherapy The behaviour of 6MV photons (the energy of the radiation beam normally used to treat breast cancer) usually results in the maximum radiation dose being delivered approximately 1.5 cm below the skin surface (Sibtain et al, 2012). The severity of radiotherapy-induced skin reactions relates to the biological damage done to the dermis and epidermis during treatment. Normal skin cell repopulation occurs when superficial epithelial cells are shed and replaced by new cells formed during mitosis in the basal layer below (Princess Royal Radiotherapy Review Team, 2011). In radiotherapytreated skin, due to the skin-sparing effect described above, the deeper dermis is affected rather than the upper epidermal layer. Erythema occurs as a result of an acute response to radiation. Dilation of capillary vessels within the dermis and a subsequent release of a histamine-like substance, leaves the skin inflamed, red, itchy, and warm to the touch. This erythema will become visible within 2-3 weeks of starting

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Abstract

This article describes the prophylactic use of Mepitel Film in three breast-cancer patients undergoing adjuvant radiotherapy. Each patient had significant risk factors for developing severe radiotherapy-induced skin reactions. This article details the experience encountered by these patients through their treatment courses, with observations by the review radiographers responsible for the care and support of these patients during their radiotherapy and the patients themselves. The film was found to be easy to use by the clinical team and resulted in a significant reduction in adverse side effects to the skin, with an associated improvement in patient satisfaction. There was found to be a financial benefit with the use of Mepitel Film when compared to the foam dressings often required for wound management if the patients had suffered moist desquamation.

the cancer cells in the tumour. This is the basis on which radiotherapy works. In order to gain tumour control and ultimately (in the case of radical treatment), eradication, the total dose of treatment is usually given in divided daily amounts (called fractions). This allows higher doses of radiation to be used and a certain amount of cell repopulation each day (Faithfull and Wells, 2004). The unit of measurement of absorbed radiation dose in tissue is called the Gray (Gy). Dose (Gy) and fractionation are considered on an individual basis for every patient and much depends upon the aim of treatment. Typically, palliative treatments tend to be smaller doses and fractionation (anything from 8Gy given in a single fraction, to 30Gy given in 10 fractions is common). Radical treatments tend to be much higher doses and longer fractionation (typically 60 Gy or more in 30 or more fractions). Treatments are given using megavoltage radiation, which means that they possess considerable penetrating power. Typical treatment photon beam energies are in the order of 6–10 megavolts (MV). The advantage of using megavoltage radiation is that the interaction of the radiation beam with tissue results in the maximum dose being received below the basal layer of the skin.The absorbed dose builds up in the first few centimetres of tissue. The epidermis of the skin therefore receives a relatively low dose, compared to the tissues below. This effect is known as ‘skin sparing’ (Sibtain et al, 2012) and means that high doses of radiation can be used to treat structures deep within the body, without compromising the integrity of the skin.

British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 16

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Factors affecting skin reactions in radiotherapy While all patients undergoing radiotherapy are at risk of skin reactions, there are a number of intrinsic and extrinsic risk factors that can affect the severity (Porock, 2002). Intrinsic factors include age, current or past history of smoking, malnourishment, concomitant disease/medication, obesity, the presence of skin folds, and previously irradiated areas (Wells and MacBride, 2004; NHS Quality Improvement Scotland, 2010; Rutter et al, 2013). Skin folds can be a source of friction, and ultimately skin damage in patients who are morbidly obese. This can occur in the skin folds under large breasts or an abdominal apron. Extrinsic factors relate to the treatment, and concern the energy of the radiation beam or the field size of the treated area. Several assessment tools can be used to determine the severity of radiotherapy-induced skin reactions, including Radiation Therapy Oncology Group (RTOG) grading system (Cox et al, 1995); the Radiation-Induced Skin Reaction Assessment Scale (RISRAS) (Noble-Adams, 1999) and the Skin Toxicity Assessment Tool (STAT) (Berthelet et al, 2004), although they do not appear to be widely used in clinical practice (Harris et al, 2011), despite a recommendation by NHS Quality Improvement Scotland (2010) that they should be. More detail about these assessment tools is provided in the first two articles in this series. According to Harris et al (2011), 87% of patients undergoing radical radiotherapy will experience a moderate to severe skin reaction. Unfortunately, this can lead to much discomfort, with loss of sleep, functional and social constraints, and anxiety, all impairing quality of life. In severe cases, the overall dose of radiation may need to be reduced as a result. In past decades, different approaches to skin care have been advocated, resulting in wide variations in practice between radiotherapy departments (Harris et al, 2011). The lack of evidence-based care in this field underlines the need for well-designed trials to generate rigorous data on the efficacy of the various topical interventions available, which in turn can be used to determine the content of national standards and guidelines, thereby ensuring consistency of care. Aqueous cream has been used as prophylaxis throughout the treatment process, based on the view that its hydrating properties could help minimise and delay skin damage,

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although a randomised controlled trial (RCT) found it had no prophylactic benefits when applied in the initial stages of radiotherapy (Wells et al, 2004). In addition, there is concern that one of its components, sodium lauryl sulphate (SLS), can cause irritation when left on the skin as a moisturiser (Cork and Danby, 2011). Topical corticosteroids have also been used prophylactically, with some success (Salvo et al, 2010). Some radiotherapy departments continue to use topical aloe vera gel or calendula cream yet there is no evidence to support the use of either (Richardson et al, 2005; Sharp et al, 2013). In addition, patients can help minimise skin damage through good self-care—for example, by avoiding sun exposure and the use of perfumed soaps on the treatment area, wearing loose-fitting clothes, and taking certain precautions with food and drink, depending on the radiotherapy site. Full details are given in Glover and Harmer (2014). Hydrocolloid and hydrogel dressings have been used to manage moist desquamation, although it has been suggested that pooling of excess moisture under the dressing and leakage from the edges can prolong healing times and cause skin maceration, (Mak et al, 2005; Macmillan et al, 2007).

Mepitel Film Diggleman et al (2010) suggested that silicone dressings have a role to play in both the prophylaxis and treatment of radiotherapy-induced skin reactions. Dressings made with Safetac soft silicone adhesive technology are soft and conformable, with the additional advantage that they do not cause tissue trauma during removal (White, 2008).This makes them suitable for patients with fragile skin (Meuleneire and Rügnagal, 2013). The Safetac® range by Mölnlycke Health Care includes a variety of soft silicone wound dressings. According to the manufacturer, Safetac dressings conform to the wound surface without adhering to moist tissue, thereby minimising the risk of damage to the wound bed and edges during removal (Waring et al, 2011). By gently moulding to the wound in this way, they create a seal, which minimises maceration (Meaume et al, 2003). This makes the dressings comfortable for patients to wear. The previous article in this series included case studies on the use of Mepilex Lite on patients with moist desquamation. This article explores how Mepitel Film can be used as prophylaxis in patients at risk of dry and moist desquamation. Mepitel Film is a thin, flexible, transparent film dressing with Safetac technology on the wound contact layer. It is vapour permeable, and so allows excess moisture to evaporate through the dressing. It is therefore indicated for superficial wounds, where it promotes a moist healing environment. It is also used to protect fragile and sensitive skin from microbial contamination, fluid strikethrough and other external contamination. In 2014, Herst et al undertook a randomised intra-patient controlled trail that compared the prophylactic use of Mepitel Film with aqueous cream in 78 women receiving radiotherapy for breast cancer. The patients acted as their own controls, so that one half of the treatment field (breast or chest wall) was covered with Mepitel Film at the start of the radiation therapy, while the patients applied the aqueous cream twice daily to the other half.The investigators

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treatment (Harris et al, 2011) and can change in colour from a faint to a more pronounced red as the cumulative dose of radiotherapy increases. Continued treatments (after 3–4 weeks) will result in further cellular damage, which will manifest as dry desquamation. This occurs when, in an attempt to compensate for the skin damage, new cells divide and migrate to the skin surface faster than the old ones are shed. It is characterised by scaly, thickened skin. Longer courses of radiotherapy result in greater cell death, and the basal layer is unable to recover. This state is known as moist desquamation and it often presents as an exuding skin surface, with exposed dermis, oedema and blisters. More information about dry and moist desquamation is given in the previous two articles in this series (Glover and Harmer, 2014; Trueman and Taylor, 2014).

British Journal of Nursing, 2014 (Oncology Supplement), Vol 23, No 16

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PRODUCT FOCUS compared differences in the severity of skin reactions and the incidence of moist desquamation between the two interventions. The results showed that use of Mepitel Film resulted in a 92% reduction in skin reaction severity (p

Radiotherapy-induced skin reactions: prevention and cure.

This article describes the prophylactic use of Mepitel Film in three breast-cancer patients undergoing adjuvant radiotherapy. Each patient had signifi...
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