Acute Skin Effects

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Acute skin reactions associated with radiation include erythema, dry desquamation, hyperpigmentation, and moist desquamation (Table 1).14 All patients do not experience all acute skin reactions. However, there may be a combination of reactions occurring

Table 1. Acute effects of radiation on skin

Tissue response

Onset/Duration

Clinical presentation

Erythema

Dry desquamation

Hyperpigmentation

Moist desquamation

Onset within 4—14 days of first treatment (dose 10—30 Gy), peaks at 4—5 weeks. Resolves 2—6 weeks after last treatment As early as 3rd—4th week (40 Gy), but typically by 5th—6th; earlier with accelerated RT or chemotherapy. Resolves 3—4 weeks after completion of treatment As early as 2—3 weeks of standard fractionated radiation therapy, depending on baseline skin pigmentation. Usually resolves 3 months—1 year following completion of treatment; occasionally chronic Following 40—50 Gy or with trauma/excess friction, bolus material, or chemotherapy. Recovery usually 2—6 weeks after completion of treatment

Faint to brisk redness that outlines treatment field. Intensifies as treatment continues. Increased skin temperature. Slight edema Dryness, flaking, and peeling often accompanied by itching, a layer of dry, dead, dark skin can accumulate over part or all of the treatment field and will eventually slough off. Mild pain Tanned appearance

Bright erythema, sloughing skin, exposed dermis, serous exudates and mucus oozing from skin surface. Moderate pain simultaneously in the radiation treatment field. There are a number of factors influencing the onset, duration, and intensity of acute skin reactions. These include

• Skin folds in the neck, or behind ear lobe. Skin folds provide a warm, moist environment, and friction with movement, all of which contribute to increased risk for acute reactions and skin breakdown.

• Some types of skin tolerate radiation better than others. The scalp has the greatest tolerance followed in decreasing order by the face, neck, trunk, ears, groin, and

extremities.

• Beam type: electrons generally increase skin reactions and photons are generally deposited below the skin resulting in fewer acute skin reactions.

• The use of tissue equivalent materials, e.g., bolus, in close proximity to the skin will increase the severity of the skin reaction.

• Age, skin integrity at initiation of treatment, nutritional status, and comorbidities also influence skin response.

• Previous radiation therapy to the same field, prior or concurrent chemotherapy increase skin reactions.

• Patient compliance with daily skin care recommendations may diminish severity of skin response.

Acute skin reactions can cause discomfort and varying degrees of somatic pain. If the reaction progresses to moist desquamation, pain may increase and the risk of superficial skin infection increases. Regular routine skin assessment is essential in minimizing and managing skin reactions.

B1. Assessment of Acute Skin Effects

An evaluation of the skin should be performed before initiation of treatment to identify factors that may increase the skin reaction. The purpose of a skin assessment is to establish a baseline assessment for future comparison and to determine the severity of skin alteration. The frequency of assessments vary with the patient's condition and needs; however, a visual examination of the skin within the treatment fields (including exit sites) should be conducted once a week during treatment and at all regular follow-up examinations. Skin should be assessed for color, drainage, odor, dryness, and the presence of sloughing, necrosis, or infection. Patients should be questioned about the r -22

presence of pain or pruritus.

There are several grading systems for acute radiation skin reactions. The most recent is the 2003 version of the Common Terminology Criteria for Adverse Events version 3.0 (CTCAE).11 Table 2 summarizes grading of acute skin reactions using this evaluation scale. The Oncology Nursing Society's Radiation Oncology Documentation tool5 is another instrument to assist health professionals to objectively monitor patients and accurately document skin reactions (Table 3).

B2. Management of Acute Skin Reactions

Patient education regarding anticipated skin reactions (acute and late), time frame for occurrence, onset and duration, as well as self care guidelines, promotes optimal

Table 2. Acute radiation scoring criteria (CTCAE v3.0)

Grade

Table 2. Acute radiation scoring criteria (CTCAE v3.0)

Grade

Adverse event

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