Radiation Dermatitis #524

Abstract

Background

Radiation dermatitis is a common side effect of radiation therapy. While significant dermatitis rarely results from lower dose radiotherapy (e.g., single fraction palliative radiotherapy), it is common with higher dose radiation typically used in the definitive or adjuvant treatment of cancer. It results from skin damage due to ionizing radiation and typically develops within 1–4 weeks of starting therapy. This Fast Fact will discuss the clinical presentation and management of radiation dermatitis.

Natural History

Radiation dermatitis is characterized by acute and late skin effects. The first dose of radiation damages basal keratinocytes of the epidermis, leading to an inflammatory response in the epidermis and dermis. It also disrupts the barrier function and self-renewing property of the epidermis, damages epidermal DNA, and alters the dermis. Subsequent treatments do not allow time for cells to repair or proliferate, thus significant skin reactions occur.^1,2 Use of sensitizing chemotherapy and intrinsic factors such as chronic sun exposure, smoking, obesity, or diabetes can worsen its severity.³

Clinical Presentation

Severe radiation dermatitis is painful and markedly worsens quality of life. It can lead to hospitalization, interruption of radiotherapy, and is occasionally life-threatening³ (Table 1).

Table 1.

Clinical Characteristics of Radiation-Induced Skin Changes Over Time.

Skin changes	Timeline, radiation dose	Clinical characteristics
Acute	First 24 hours after first treatment	Primary transient erythema
	Weeks 2–4 of treatment	Sustained generalized erythema, dryness, hair loss, hyperpigmentation
	Weeks 3–6 of treatment
	Doses ≥ 20 Gy	Dry desquamation: Pruritic, scaling, flaking
	Doses ≥ 40 Gy	Moist desquamation: Painful, tender, oozing, bullae, ulceration, dermal exposure; very susceptible to sun damage and infection
Chronic	>90 days after completion	Epidermal thinning, dermal atrophy, vascular injury, fibrosis, dermal thickening, progressive induration, edema, dyspigmentation, telangiectasias, dermal necrosis with ulceration
Future risks	Months to years after completion	Subcutaneous dystrophic calcification, non-melanotic cutaneous malignancies

Grading

This table is adapted from NCI Common Terminology Criteria for Adverse Effects⁴ (Table 2).

Table 2. Grading of Radiation-Induced Skin Changes, adapted from NCI Common Terminology Criteria for Adverse Effects v5.0.

Normal	Grade 1 (mild)	Grade 2 (moderate)	Grade 3 (severe)	Grade 4 (life-threatening)
No skin changes	Faint erythema or dry desquamation	Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases, moderate edema	Moist desquamation in areas other than skin folds and creases; bleeding induced by minor trauma or abrasion	Life-threatening consequences; skin necrosis or ulceration of full-thickness dermis; spontaneous bleeding; skin graft indicated

Management

Data are very heterogeneous; however, broad consensus exists in some areas. The Oncodermatology Study Group of the Multinational Association of Supportive Care in Cancer published guidelines for the prevention and management of radiation dermatitis.⁵

Prevention: there is broad consensus on recommending daily washing of irradiated skin with mild soap and water, moisturizing irradiated skin with non-fragranced lotions such as Aquaphor, and the use of topical mometasone, betamethasone, or silver sulfadiazine to prevent dermatitis.^3,6

Treatment: ◦

Grades 1 and 2: Apply a saline-soaked gauze to the affected area for 10 minutes, followed by an occlusive emollient application such as Aquaphor, one to three times daily.

◦

Grade 3: Use hydrogel dressings and silver sulfadiazine for moist desquamation. Topical steroids can be used for inflammation or itching in surrounding dry and intact skin. Systemic analgesia is indicated to manage moderate-to-severe pain, usually with acetaminophen, non-steroidal anti-inflammatories, and/or opioids. Provide patient education on the avoidance of friction, trauma, and irritants such as perfume or alcohol-based products, and watch for signs of infection such as purulence or malodor.

◦

Grade 4: Hospitalize and involve specialists (wound care, plastic surgery, etc.) as necessary.

Summary

Although radiation oncologists are usually the primary specialists addressing dermatitis, it is essential for all clinicians involved in a patient’s care to actively assess radiation dermatitis, recognize its presentation, and deliver effective management while maintaining clear, coordinated communication with specialty teams. Wound care, pain management or palliative care, and surgeons may need to be consulted for optimal management.

Footnotes

Author Disclosure Statement

The authors have no relevant conflicts of interest to disclose.

Funding Information

The authors have no funding to report.

References

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Finkelstein

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, et al. Comparison of clinical practice guidelines on radiation dermatitis: a narrative review. Supportive Care Cancer, 2022; 30:4663–4674.

US Department of Health and Human Services. Common Terminology Criteria for Adverse Events, Injury, poisoning and procedural complications. National Institutes of Health, National Cancer Institute. 2017.

Behroozian

, Caini

, van den Hurk

, et al. Systematic review and meta-analysis on interventions for radiation dermatitis prevention and management: An overview of the methods. Supportive Care Cancer, 2023; 31(261):1–7.

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. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm. J Am Acad Dermatol, 2019; 81(2):558–567.