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Patient Education - Radiation-induced cutaneous damage - Late Effects

Patient Education - Radiation-induced cutaneous damage - Late Effects

Patient Education - Radiation-induced cutaneous damage - Late Effects

SUMMARY

Radiation-induced cutaneous damage (RICD) is a common side effect of radiation therapy that affects your skin. As much as 95 percent of all patients receiving radiation therapy will experience some form of RICD.[1] The initial skin changes (acute effects) caused by radiation usually heal after radiotherapy is completed, but late skin changes (chronic effects) can develop months or years later. Up to 15% of patients receiving radiation therapy will develop chronic effects of radiation (chronic RICD).[2]

  • The skin of the affected area may present:
    • Wounds that are difficult to heal (ulceration) 
    • Stiffening and scarring (fibrosis), 
    • Changes in skin color (morphea) 
    • Swelling (edema) 
    • Blackening of the skin (necrosis)  
    • Fine, weblike veins (telangiectasias)
  • Factors that increase your chances of developing chronic RICD include:
    • Higher total radiation dose [3].
    • Larger treatment area [4].
    • Radiotherapy after surgery [5].
    • Radiotherapy while receiving chemotherapy [6].
    • Existing skin disorders, such as acne, psoriasis, and eczema [7].
    • Smoking [8]
    • Treatment
      • For minor ulcers, your healthcare team will keep your wounds clean, moist, and apply bandages. If these treatment measures don’t improve your wound, you may need surgery to help with healing [9].
      • Deep ulcers that damage blood vessels and bone will require surgery [10].
      • Treating fibrosis requires multiple approaches, including massage and physical therapy, medications, laser therapy, and surgery [11][12][11][13].
      • Telangiectasias can be treated with laser therapy [14].
      • Mild swelling can be treated with compression garments and weight loss. Severe cases are treated with surgery [15][16][17].
      • Skin discoloration can be treated with light therapy, steroids, and medication [18].
    • Additional Therapies
      • Ulcers that do not show signs of improvement after the treatment listed above may be treated with adjunctive therapies and/or surgery.

        When to contact your healthcare provider

        Contact your doctor if you begin experiencing any signs of chronic RICD, or if you develop a fever, increasing pain, redness or swelling, skin changes, breaks, or drainage

          WHAT is radiation-induced cutaneous damage?

          • Radiation-induced cutaneous damage (RICD) is a common side effect of radiation therapy that affects your skin. It is also known as radiation dermatitis, radiodermatitis, cutaneous radiation injury, and radiation-induced skin injury.
          • As much as 95 percent of all patients receiving radiation therapy will experience some form of RICD. [1]. The initial skin changes (acute effects) caused by radiation usually heal after radiotherapy is completed, but the late skin changes (chronic effects) can develop months or years later. Up to 15% of patients receiving radiation therapy will develop chronic RICD [2]

          WHAT are the symptoms of chronic RICD?

          Chronic effects can occur months to years after treatment and after acute effects have healed. At this point, your treatment area may show [11]:

          • Wounds that are difficult to heal (ulceration)
          • Stiffening and scarring (fibrosis)
          • Changes in skin color (morphea)
          • Swelling (edema)
          • Blackening of the skin (necrosis)
          • Fine, weblike veins (telangiectasias)

          Keep in mind that these symptoms may not occur in any particular order.

          AM I at risk for developing RICD? 

            Your risk for developing chronic RICD depends on many factors, including:

            • Higher total radiation dose [3].
            • Larger treatment area [4].
            • Radiotherapy after surgery [5] .
            • Radiotherapy while receiving chemotherapy [6].
            • Existing skin disorders, such as acne, psoriasis, and eczema [7].
            • Smoking [8].

            WHEN does chronic RICD usually occur?

            The skin changes you experience after radiotherapy depend on the total amount of radiation you receive. If you receive a higher dose of radiation, you are at increased risk for chronic RICD, even years after finishing radiation therapy 

            [7]

            Radiation dosage is measured in units called Gray (Gy). Ask your treatment team what your total radiation dose is. If your total dose is greater than 45 Gy, there is a higher chance of developing chronic RICD. Review table 1 below to see possible signs of chronic RICD.

            Table 1. Late effects of radiation after radiation therapy, depending on total dosage in Gray (Gy) [1][19][4][11][20][19]

            If your total radiation dose in Gray (Gy) is...then in the irradiated area you may experience......after treatment
            >45Skin blackening (necrosis) and skin breakdown (ulcer)
            months
            >45Stiffening and scarring of the skin (fibrosis)
            months to years
            10-25Dilated blood vessels (telangiectasias)
            months to years

            HOW can chronic effects of radiation be treated? 

              The goals of treating chronic effects are to limit and repair your skin damage so that you can have the best possible quality of life. Thus, your treatment depends on what kind of chronic effects you have.

                Ulcers

                • For minor ulcers, the main goals are to keep your wounds clean and moist. Your wound will be cleaned and debris will be removed, then a dressing will be applied. If your wound is infected, you will receive an antibiotic. If these treatment measures don’t improve your wound, you may need surgery or other therapies to help with healing [9].
                • Some ulcers can extend deep under your skin and damage structures such as blood vessels and bone. For this kind of damage, surgery will be necessary [10].

                Fibrosis

                • Fibrosis can be difficult to treat. Currently, the best outcomes require multiple different therapies:
                  • Rehabilitation: massage and physical therapy can help with keeping your treatment area mobile [11].
                  • Medications: Some studies have shown that pentoxifylline and vitamin E may help reduce fibrosis [12].
                  • Laser therapy: laser therapy in combination with skin grafts may help treat fibrosis [13].
                  • Surgery: In cases where fibrosis threatens vital structures, surgery will be needed [11]

                Teleangectasias

                  • Teleangectasias can be disfiguring and cause distress. They are effectively treated with laser therapy [14].

                Adjunctive Therapies

                If your wound does not improve within 4-6 weeks after starting first-line treatments, your provider may opt to treat you with adjunctive therapies, which are treatments added on to your original regimen to maximize your healing. You may receive adjunctive therapies such as:

                • Negative pressure wound therapy.[21] This therapy requires a special vacuum pump and increases blood flow, causes new cells to grow, and decreases the amount of bacteria in the wound [22].
                • Hyperbaric oxygen therapy. This means large amounts of oxygen will be delivered to your wound to encourage new blood vessels to form [20]
                • Advanced dressings called cellular and/or tissue based products to cover the wound. 

                WHAT happens if chronic RICD is left untreated?

                  If left untreated, chronic RICD wounds may become infected, uncomfortable, or painful, and limit your quality of life. Ulceration may progress to damage deeper structures such as muscle, blood vessels, and nerves. In the most severe cases, these wounds can become life-threatening.

                  WHEN should I call my healthcare provider? 

                    Contact your doctor if you begin experiencing any signs of chronic RICD. If possible, keep track of your wound by noting its size and appearance. Continue to follow-up with your doctor because chronic RICD is progressive and irreversible.

                    • Call your healthcare provider if you have a fever, increasing pain, redness, or swelling, skin changes, breaks, or drainage, and any new symptoms.

                    FAQs

                      Q: What do I do if my skin tears?

                        A: Do not apply moisturizing cream to broken skin. Do not peel the skin. Contact your doctor.


                        Q: Is there a cure for chronic RICD?

                        A: Skin affected by the late effects of radiation can show RICD that is chronic, progressive, and unlikely to be self-repairing. However, chronic RICD can be managed with the interventions described above.


                        Q: How do I know if I am at risk of chronic RICD?

                        A: If you received radiotherapy in the past, then you are at risk of chronic RICD. Unfortunately, it is not yet possible to determine who will get chronic RICD and who will not.


                        Q: I am finished with radiotherapy. Can I resume my usual skincare routine?

                        A: This will depend on the condition of your skin. Your doctor will be able to tell you if you can resume your usual skincare routine.

                        For more information

                          For more information about radiation-induced cutaneous damage, contact your healthcare team or cancer treatment center.

                          Online resources include:

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                          NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

                          REFERENCES

                          1. Bray FN, Simmons BJ, Wolfson AH, Nouri K et al. Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy. Dermatology and therapy. 2016;volume 6(2):185-206.
                          2. Borab Z, Mirmanesh MD, Gantz M, Cusano A, Pu LL et al. Systematic review of hyperbaric oxygen therapy for the treatment of radiation-induced skin necrosis. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2017;volume 70(4):529-538.
                          3. Collette S, Collette L, Budiharto T, Horiot JC, Poortmans PM, Struikmans H, Van den Bogaert W, Fourquet A, Jager JJ, Hoogenraad W, Mueller RP, Kurtz J, Morgan DA, Dubois JB, Salamon E, Mirimanoff R, Bolla M, Van der Hulst M, Wárlám-Rodenhuis CC, Bartelink H, EORTC Radiation Oncology Group. et al. Predictors of the risk of fibrosis at 10 years after breast conserving therapy for early breast cancer: a study based on the EORTC Trial 22881-10882 'boost versus no boost'. European journal of cancer (Oxford, England : 1990). 2008;volume 44(17):2587-99.
                          4. Singh M, Alavi A, Wong R, Akita S et al. Radiodermatitis: A Review of Our Current Understanding. American journal of clinical dermatology. 2016;volume 17(3):277-92.
                          5. Davis AM, O'Sullivan B, Turcotte R, Bell R, Catton C, Chabot P, Wunder J, Hammond A, Benk V, Kandel R, Goddard K, Freeman C, Sadura A, Zee B, Day A, Tu D, Pater J, Canadian Sarcoma Group., NCI Canada Clinical Trial Group Randomized Trial. et al. Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncol.... 2005;volume 75(1):48-53.
                          6. Toledano A, Garaud P, Serin D, Fourquet A, Bosset JF, Breteau N, Body G, Azria D, Le Floch O, Calais G et al. Concurrent administration of adjuvant chemotherapy and radiotherapy after breast-conserving surgery enhances late toxicities: long-term results of the ARCOSEIN multicenter randomized study. International journal of radiation oncology, biology, physics. 2006;volume 65(2):324-32.
                          7. Hymes SR, Strom EA, Fife C et al. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. Journal of the American Academy of Dermatology. 2006;volume 54(1):28-46.
                          8. De Langhe S, Mulliez T, Veldeman L, Remouchamps V, van Greveling A, Gilsoul M, De Schepper E, De Ruyck K, De Neve W, Thierens H et al. Factors modifying the risk for developing acute skin toxicity after whole-breast intensity modulated radiotherapy. BMC cancer. 2014;volume 14():711.
                          9. Hegedus F, Mathew LM, Schwartz RA et al. Radiation dermatitis: an overview. International journal of dermatology. 2017;volume 56(9):909-914.
                          10. Waghmare CM. Radiation burn--from mechanism to management. Burns : journal of the International Society for Burn Injuries. 2013;volume 39(2):212-9.
                          11. Spałek M. Chronic radiation-induced dermatitis: challenges and solutions. Clinical, cosmetic and investigational dermatology. 2016;volume 9():473-482.
                          12. Wong RK, Bensadoun RJ, Boers-Doets CB, Bryce J, Chan A, Epstein JB, Eaby-Sandy B, Lacouture ME et al. Clinical practice guidelines for the prevention and treatment of acute and late radiation reactions from the MASCC Skin Toxicity Study Group. Supportive care in cancer : official journal of the Multinational Association of Supportive Car.... 2013;volume 21(10):2933-48.
                          13. Tran TN, Hoang MV, Phan QA, Phung TL, Purschke M, Ferinelli WA, Sabir S, Ziegler A, Nelson S, Anderson RR et al. Fractional epidermal grafting in combination with laser therapy as a novel approach in treating radiation dermatitis. Seminars in cutaneous medicine and surgery. 2015;volume 34(1):42-7.
                          14. Seité S, Bensadoun RJ, Mazer JM et al. Prevention and treatment of acute and chronic radiodermatitis. Breast cancer (Dove Medical Press). 2017;volume 9():551-557.
                          15. Iyer S, Balasubramanian D et al. Management of radiation wounds. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons.... 2012;volume 45(2):325-31.
                          16. Warren LE, Miller CL, Horick N, Skolny MN, Jammallo LS, Sadek BT, Shenouda MN, O'Toole JA, MacDonald SM, Specht MC, Taghian AG et al. The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study. International journal of radiation oncology, biology, physics. 2014;volume 88(3):565-71.
                          17. Zou L, Liu FH, Shen PP, Hu Y, Liu XQ, Xu YY, Pen QL, Wang B, Zhu YQ, Tian Y et al. The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast cancer (Tokyo, Japan). 2018;volume 25(3):309-314.
                          18. Fruchter R, Kurtzman DJB, Mazori DR, Wright NA, Patel M, Vleugels RA, Femia AN et al. Characteristics and treatment of postirradiation morphea: A retrospective multicenter analysis. Journal of the American Academy of Dermatology. 2017;volume 76(1):19-21.
                          19. Ryan JL. Ionizing radiation: the good, the bad, and the ugly. The Journal of investigative dermatology. 2012;volume 132(3 Pt 2):985-93.
                          20. Jacobson LK, Johnson MB, Dedhia RD, Niknam-Bienia S, Wong AK. et al. Impaired wound healing after radiation therapy: A systematic review of pathogenesis and treatment JPRAS Open. 2017;volume 13():92–105.
                          21. Nagata T, Fujiwara M, Fukamizu H et al. Treatment of a radiation ulcer combining negative pressure wound therapy with flap reconstruction. The Journal of dermatology. 2013;volume 40(9):766-7.
                          22. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS et al. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) Device: a review. American journal of clinical dermatology. 2005;volume 6(3):185-94.
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