Appendix 8: Summary of Interventions for Acute Radiotherapy Induced Skin Reactions in Patients
Undergoing Radical External Beam Megavoltage Radiotherapy
A clinical guideline recommended for use by the Society and College of Radiographers
INTRODUCTION
This is a summary of the main findings from the literature used in order to develop a clinical
guideline for acute radiotherapy-induced skin reactions in patients undergoing radical external beam
megavoltage radiotherapy (excluding proton therapy at this time).
Skin reactions from external beam radiotherapy are one of the most common side-effects from
treatment. They may cause distress to some patients and, in certain cases, may be a factor which
can limit radiation dose. Megavoltage linear accelerators with skin sparing capabilities have
significantly reduced the severity of reactions from radiotherapy; however accelerated radiation
dose schedules with concurrent chemotherapy/biological agents have seen an increase in certain
skin reactions. The most severe reactions tend to be seen in those patients receiving high doses to
large fields and those where folds of skin are in the treatment field as skin to skin friction can occur
(for example axilla, groin, inframammary fold). More recently the use of intensity modulated
radiotherapy (IMRT) has been shown to offer the potential to reduce skin toxicity in some cases,
especially the rates of dry and moist desquamation when treating cancers in the head and neck
region. Although it is unlikely that radiation reactions can be completely prevented, the current
driver is to delay the onset and minimise the severity of a skin reaction. Most skin reactions tend to
peak towards the end of the treatment course and are often at their worse in the first two weeks
after treatment has completed. The majority of skin reactions are acute and have significantly
improved, if not resolved, by four weeks post treatment. The extent of a skin reaction is often
dependent upon the clinical site being treated. For example, patients undergoing radiotherapy for
head and neck cancer usually require immobilisation and often receive concurrent treatment such as
chemotherapy; these factors can make patients more vulnerable to intensified skin reactions.
Interruptions in radiotherapy for these patients can have a detrimental effect on treatment
outcome.
Patients often have fears and misconceptions about radiotherapy therefore consistent, current and
relevant reinforced information can help to alleviate some of these concerns. It may not be possible
to stop or even reduce the rates of skin reaction from occurring, but skin care products may provide
comfort and enhance self care. Patients should be given information about skin reactions and self
care strategies. The aim of any skin care strategy should be to minimise symptoms and to promote
and maintain comfort for as long as possible.
PATIENT INFORMATION
Patients should be given both written and verbal information which specifies:
 how and why skin reactions occur
 when they are likely to appear
 what they will look and feel like
 how they will be treated
 where the reaction is likely to occur
 self care strategies
 risk Factors
 who to contact for support and advice
INCIDENCE
In providing patients with information, the following should be taken into account:
 the incidence of skin reactions has not been quantified, although those patients receiving
radiotherapy for a schedule of over ten days are likely to experience some reaction to the skin
 treatment areas commonly cited as having a higher incidence are those of head and neck, breast
and chest wall fields, and areas containing skin folds.
INFLUENCING FACTORS
The various factors that influence how people react to radiotherapy also need to be considered in
advice designed to be given to patients, particularly:
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intrinsic factors which include demographic or disease-related characteristics such as age,
hormonal status, infection, ethnic origin, smoking, obesity, and co-existing disease (eg
diabetes).
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extrinsic factors that are treatment-related and influence the delivery of therapy. They include
treatment dose, volume, fractionation, site of treatment, beam energy, adjuvant chemotherapy,
and targeted therapies. Combined modality treatment, in particular, may lead to an increased
risk of skin reactions.
ASSESSMENT OF RADIATION SKIN REACTIONS
The use of an effective evidence-based skin care protocol and monitoring system would assist in
delivering an evidence-based approach to radiation skin care management, aid product evaluation,
and contribute to the justification of practice.
Before radiotherapy begins, it is essential that a baseline assessment of the patient’s current skin
condition and care is documented, including what skin products are being currently used. Education
and health promotion strategies and interventions given to patients pre-treatment such as
nutritional advice and smoking cessation would be beneficial and are advised.
Assessments and review of the skin should continue for all patients on a regular basis throughout
treatment, and at least on a weekly basis.
At present, a variety of different skin assessment tools exist. Within a radiotherapy department, a
single validated assessment tool and scoring criteria, such as the Radiation Therapy Oncology Group
(RTOG) scoring criteria, should be agreed upon and adopted. Preferably, a single tool should be
agreed for use across a whole cancer network and should include assessment of patient symptoms
and comfort.
Using the agreed validated tool and scoring criteria, radiotherapy departments should standardise
the initial assessment and continued regular monitoring of skin reactions and ensure that these are
recorded.
All skin reactions must be graded and recorded by an appropriately trained member of the
multidisciplinary team.
An important aspect of skin care during radiotherapy is that of patient well being. It may not be
possible to stop skin reactions from occurring or to reduce the rates of skin reaction, but there may
be comfort and psychosocial benefits (such as reduction in pain, itching, and sleep disturbance)
associated with the use of skin care products. Recording of patient acceptability/satisfaction and
compliance with skin care advice is recommended as such information can be used to evaluate the
appropriateness of skin care products for future patients. There is also a need to evaluate the cost
effectiveness of products being used on the skin.
MANAGEMENT
The following is a brief summary of the skin care management principles to be adopted.
At the start of radiotherapy and skin maintenance throughout
(This only applies to the area being treated.)
The key recommendation to staff is to discuss with patients their existing daily skin care and lifestyle
routine to identify if there is anything an individual needs to stop or start doing.
Review the patient’s skin using a validated scoring system: prior to the start of the radiotherapy
course; at weekly skin reviews (or more frequently if required); after the final treatment and at
follow-ups.
To reduce friction to the treatment area, advise the patient to:
 wash the skin gently with soap and water and gently pat dry
 use aqueous cream instead of soap if wished. This is NOT recommended as a leave-on
moisturiser
 if the scalp is in the treatment field, wash hair gently with usual shampoo but do not dry
with a hairdryer
 wear loose fitting natural fibre clothing next to the skin, for example a cotton T-shirt
 avoid an under wired bra (patients receiving radiotherapy to the breast only)
 avoid rubbing the area
 avoid heating (for example hot water bottles and microwaveable wheat bags) and cooling
pads/ice
 avoid/reduce shaving if possible
 avoid wax for hair removal and all hair removing creams/products
 avoid adhesive tape
To reduce irritation to the treatment area, advise the patient to:
 use a moisturiser that is sodium lauryl sulphate free
 use the moisturiser sparingly and not over rub into the skin
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not wipe the area clean of the moisturiser prior to treatment as this will cause more friction
to the skin
avoid make-up, hair dye, perfumes and aftershaves, if known to contain an alcohol content
avoid topical antibiotics unless there is a proven infection
continue to use normal deodorant (unless this irritates the skin) but discontinue if the skin is
broken
reduce the number of times a week they go swimming in a pool as chlorinated water may
have a drying effect on the skin and ensure after swimming to shower the skin to remove
chlorine (ask the patient to observe how their skin reacts after swimming) and discontinue if
the skin becomes broken
avoid sun exposure and shield the area from direct sunlight and use a high SPF sunscreen or
sun-block
By adhering to this guidance throughout radiotherapy treatment, patients will aid in minimising
additional skin aggravation and will be helping with their own health and wellbeing.
During radiotherapy
RTOG 0: No visible change to skin
 Advise patient to continue with own skin care moisturising regime and use own preferred
moisturiser to promote hydrated supple skin. Check that this moisturiser is sodium lauryl
sulphate free. If not already using a moisturiser, advise to start.
 Promote oral fluids and healthy nutrition (discussed in detail to account for any other
conditions such as diabetes).
 Assess weekly.
RTOG 1: Faint or dull erythema
 Advise patient to continue with own skin care moisturising regime and use own preferred
moisturiser to promote hydrated supple skin. Check that this moisturiser is sodium lauryl
sulphate free.
 Promote oral fluids and healthy nutrition (discussed in detail to account for any other
conditions such as diabetes).
 Assess weekly.
RTOG 2a: Tender or bright erythema
 Advise patient to continue with own skin care moisturising regime and use own preferred
moisturiser to promote hydrated supple skin. Check that this moisturiser is sodium lauryl
sulphate free.
 Promote oral fluids and healthy nutrition (discussed in detail to account for any other
conditions such as diabetes).
 Steroid or cortisone creams should only be used following advice from an independent
prescriber or staff qualified to dispense medication on Patient Group Directives. These
creams should not be used on broken skin.
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If the skin breaks, patients should be advised to discontinue using any cream and further
advice should be sought from a practitioner trained in radiotherapy induced skin reactions
and wound care.
Assess daily.
RTOG 2b: Patchy moist desquamation
 Use appropriate dressing/product on broken skin to reduce further trauma and infection.
Suitable products would be non-adhesive, silicone low adhesion, non or lowparaffin/petroleum jelly based.
 Do NOT use Gentian Violet.
 Take a swab if there are any signs of infection.
 Moisturiser can still be applied to other parts of the field if the skin is intact. Check that this
moisturiser is sodium lauryl sulphate free.
 Promote oral fluids and healthy nutrition (discussed in detail to account for any other
conditions such as diabetes).
 Assess daily.
RTOG 3: Confluent moist desquamation
 Use appropriate dressing/product for the amount of exudate. Suitable products would be
non-adhesive, silicone low adhesion, non or low-paraffin/petroleum jelly based.
 Do NOT use Gentian Violet.
 Take a swab if there are any signs of infection.
 Seek advice from a practitioner trained in radiotherapy induced skin reactions and wound
care.
 Promote oral fluids and healthy nutrition (discussed in detail to account for any other
conditions such as diabetes).
 Assess daily.
Symptom management
At each assessment, ask about any symptoms experienced, including pain, itching, sleep disturbance.
Provide advice and support to promote comfort and consider over-the-counter or prescription
medicines such as analgesics, anti-histamines as appropriate to individual needs.
Post radiotherapy
 For all patients at the end of their courses of radiotherapy, assess and record the skin
condition, any reaction and its grade, and the care or treatment advised.
 Advise patients of the potential for skin reactions to worsen and ‘peak’ around 7 – 10 days
after the last treatment.
 Remind and advise patients of any permanent radiotherapy related side-effects to the skin,
eg increased skin sensitivity, hyper or hypo-pigmentation, and what precautions to take.
 Establish effective, on-going liaison with community care/G.P services on post treatment
skin (and other) care.
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Ensure all members of the healthcare team are alerted to any radiotherapy skin reaction
issues that occur after treatment has competed so that the patient can be assessed by a
member of the oncology team.
MAIN RECOMMENDATIONS AND SUMMARY
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Standardised skin care education of all staff caring for patients receiving radiotherapy. All
radiotherapy departments should implement pre-treatment skin assessment with baseline
observations and pre-radiotherapy review and health promotion strategies. This should be
followed with regular reviews (at least weekly, and more often depending on individual
needs).
This can be undertaken by members of the radiotherapy team who have been trained to use
the tools, and inter-observer variability between clinicians, radiographers, and radiotherapy
nurses should be assessed periodically.
Agreement on standardisation of assessment tools across departments in the United
Kingdom would aid in gathering information nationally.
The NHS England Radiotherapy Clinical Reference Group (and equivalent groups where in
existence in the UK countries) with input from the UK-wide Radiotherapy Board and the
United Kingdom Oncology Nursing Society (UKONS) should aim to provide national
guidance, based on expert consensus of the evidence base.
New high quality trials to investigate interventions for dry or moist desquamation are
urgently required enabling a more consistent approach for patients receiving radiotherapy
and to inform guidelines. Funding bodies supporting radiotherapy research studies should
prioritise these trials as the results would have wide impact across all cancer patients
referred for radiotherapy as part of their treatment pathway.
There is a need for further research of new products before they are introduced on an adhoc basis, without evidence, into radiotherapy skin care regimens.
Future research should include designs that allow assessor blinding and comparators should
include ‘current best evidence practice' or 'no intervention'.
Assessment and quantification of the extent of radiation induced skin reactions is needed as
currently it is unknown how many patients are affected and to what level. Departments
need to audit radiation induced skin reactions locally to monitor proportions of patients that
develop different RTOG graded reactions across different treatment sites:
a) to increase the quality of information that can be given to patients and
b) to allow departments to monitor their own practice and compare across centres.
Evaluation into wet versus dry shaving and perfume and make-up use is needed.
Evaluation of treatment aftercare requires review to ensure local continuity and consistency
of care across the patient pathway.
Research into patient preferences and compliance would inform future national guidelines.
Decision tools would help patients make informed choices about radiotherapy skin care
information.
Further investigations into the skin care reactions caused by superficial, orthovotlage, and
proton beam radiotherapy are required.
Published 2015 by The Society and College of Radiographers - Review date 2018