How should radiation‑induced skin injury be graded and managed?

Radiation-Induced Skin Injury: Grading and Management

Radiation-induced skin injuries should be graded using the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 scale (Grades 1-4), and management centers on mechanical protection of fragile skin, maintaining cleanliness without applying topical products before radiation exposure, and avoiding skin biopsy during the healing phase. 1

Grading System

The NCI CTCAE version 3.0 provides the standardized classification framework 1:

• Grade 1: Faint erythema or dry desquamation 1
• Grade 2: Moderate to brisk erythema; patchy moist desquamation mostly confined to skin folds and creases; moderate edema 1
• Grade 3: Moist desquamation beyond skin folds and creases; bleeding induced by minor trauma or abrasion 1
• Grade 4: Skin necrosis or ulceration of full-thickness dermis; spontaneous bleeding from the involved site 1

For acute radiation syndrome from whole-body exposure, additional cutaneous findings include erythema, blistering, onycholysis, edema, desquamation, and petechiae 1.

Critical Recognition and Prevention

Early recognition is essential because the inherent delay of weeks between exposure and manifest injury often causes patients and physicians to miss the causal relationship, leading to inappropriate initial treatments. 1

Patient Counseling (Class I Recommendation)

All patients receiving air kerma at the interventional reference point >5 Gy must be counseled about skin injury possibility and instructed on recognizing earliest signs 1. The prototypical high-risk patient is an obese diabetic who has undergone one or more long-duration fluoroscopic procedures within the past several months 1.

Management Algorithm by Grade

Grade 1 Management

• Clean and dry the irradiated area gently before each treatment 1
• Apply topical moisturizers, anti-inflammatory emulsions (trolamine, hyaluronic acid cream), or zinc oxide paste—but only after radiation treatment, never before 1
• Avoid sun exposure using soft clothing coverage and/or mineral sunblocks 1
• Avoid skin irritants including perfumes, deodorants, and alcohol-based lotions 1

Grade 2-3 Management

The cornerstone of optimizing outcomes is mechanical protection while skin attempts repair—radiation-injured skin is fragile and mechanical trauma causes sloughing. 1

• Continue cleaning and drying the area, even when ulcerated 1
• Apply drying gels with antiseptics (chlorhexidine-based creams, not chlorhexidine in alcohol) 1
• Use hydrophilic dressings over cleaned, dried wounds to absorb exudate 1
• Consider silver sulfadiazine or beta-glucan cream applied after radiotherapy in the evening 1
• Avoid greasy topical products—they inhibit wound exudate absorption and promote superinfection 1
• Limit corticosteroid treatment duration if used 1
• Assess skin reactions at least weekly with integrated team (radiation oncologist, nurse, dermatologist) 1

Infection Management

When infection is suspected 1:

• Swab the affected area for pathogen identification
• Check blood granulocyte count, especially with concomitant chemotherapy
• Obtain blood cultures if fever or sepsis signs present
• Reserve topical antibiotics for documented superinfection only—never use prophylactically 1

Grade 4 Management

Grade 4 injuries require specialized wound care on a case-by-case basis, managed primarily by wound specialists with assistance from radiation oncologists, dermatologists, and nurses 1.

Critical Pitfalls to Avoid

Never perform skin biopsy on radiation-injured skin—the healing process is impaired and biopsy causes additional trauma. 1

Never apply topical moisturizers, gels, emulsions, or dressings shortly before radiation treatment—they create a bolus effect that artificially increases radiation dose to the epidermis. 1

Patients must clean and dry the radiation field before each irradiation session 1.

Dose Thresholds

Transient erythema occurs at 2-5 Gy, while permanent epilation, ulceration, and desquamation occur above this level 2. Skin injuries from absorbed doses less than complete tissue necrosis can be managed successfully with good supportive dermatological care if properly protected 1.

Documentation

Digital photographic documentation should be adopted as standard practice to enable subsequent independent confirmation of gradings and minimize subjective interpretation discrepancies between clinical studies 1.