What are the treatment options for skin irritation after radiotherapy due to cancer?

Management of Radiation-Induced Skin Irritation

The cornerstone of managing radiation dermatitis is maintaining skin hygiene by gently cleaning and drying the irradiated area before each treatment session, with treatment intensity escalating based on severity grade—from optional moisturizers for mild reactions to specialized wound care for severe cases. 1

General Principles for All Grades

Critical timing consideration: Never apply topical products (moisturizers, gels, emulsions, or dressings) shortly before radiation treatment, as they create a bolus effect that artificially increases radiation dose to the epidermis. 1

Essential Skin Care Practices

• Gently clean and dry the radiation field before each treatment session using pH-neutral synthetic detergents rather than soap 1, 2
• Avoid sun exposure by covering the area with soft clothing or using mineral-based sunblocks 1
• Eliminate all skin irritants including perfumes, deodorants, and alcohol-based lotions 1
• Never scratch the affected area 1

Grade-Specific Treatment Algorithm

Grade 1 (Faint Erythema or Dry Desquamation)

Minimal intervention is appropriate—the most important step is keeping the area clean between treatments. 1

• Moisturizer use is optional and should be non-perfumed 1
• If anti-infective measures are desired, use antibacterial moisturizers containing triclosan or chlorhexidine occasionally 1
• Avoid overtreatment, as excessive use of antiseptic creams can irritate the skin 1
• Nursing staff can manage these reactions primarily 1

Grade 2 (Moderate to Brisk Erythema; Patchy Moist Desquamation in Skin Folds)

Keep the irradiated area clean even when ulcerated, and apply topical treatments after radiation sessions. 1

Topical Treatment Options (choose based on location):

• Drying pastes for skin folds where reactions remain moist 1
• Gels for seborrhoeic areas 1
• Creams for areas outside skin folds 1, 2
• Hydrophilic dressings applied after radiotherapy to cleaned areas for symptomatic relief 1
• Anti-inflammatory emulsions such as trolamine 1
• Hyaluronic acid cream 1
• Zinc oxide paste if easily removable before radiotherapy 1
• Silver sulfadiazine or beta glucan cream applied after radiotherapy (possibly in the evening) after cleaning 1

Important caveat: Avoid greasy topical products as they inhibit wound exudate absorption and promote superinfection. 1

When Infection is Suspected:

• Swab the affected area to identify the infectious agent 1
• Reserve topical antibiotics for documented superinfection—never use prophylactically 1
• Check blood granulocyte counts, especially if receiving concomitant chemotherapy 1
• Obtain blood cultures if signs of sepsis or fever are present 1

Management team: Integrated approach with radiation oncologist, nurse, medical oncologist, and dermatologist as needed 1

Grade 3 (Moist Desquamation Beyond Skin Folds; Bleeding from Minor Trauma)

Verify that radiation dose and distribution are correct before proceeding with treatment. 1

• Follow the same topical treatment approaches as Grade 2 1
• Wound specialist should manage primarily, with assistance from radiation oncologist, dermatologist, and nurse 1
• Assess skin reactions at least weekly 1

Grade 4 (Skin Necrosis or Full-Thickness Ulceration)

Requires specialized wound care on a case-by-case basis with multidisciplinary team involvement. 1

Role of Corticosteroids

While topical corticosteroids are not contraindicated and can reduce severity of radiation dermatitis, limit the overall treatment duration to minimize risk of skin atrophy and telangiectasias. 1, 2

Recent evidence supports corticosteroid efficacy:

• Prophylactic betamethasone-17-valerate cream significantly reduces skin reactions regardless of radiation schedule 3
• Topical betamethasone 0.1% delays onset and progression of radiation dermatitis in head and neck cancer 4
• Methylprednisolone 0.1% ameliorates but does not prevent radiation dermatitis 5

For neck and facial areas, use cream formulations rather than ointments as they are less greasy and more cosmetically acceptable. 2

Prophylaxis

No evidence supports prophylactic treatments beyond keeping the irradiated area clean and dry for reducing incidence or severity of radiation dermatitis. 1

However, the strongest recent evidence suggests prophylactic potent corticosteroids initiated at radiation start may be beneficial 3, though this contradicts older consensus guidelines 1.

Pain Management

Consider pain relief in the context of any existing pain medications the patient may be receiving for other treatment-related effects like mucositis. 1