How should pain from a radiation‑induced skin burn be managed?

Management of Radiation Burn Pain

Pain relief for radiation-induced skin burns should be considered in the context of any existing pain medications the patient is already receiving (such as for mucositis), with topical treatments providing symptomatic relief while maintaining proper wound care. 1

Grade-Specific Pain Management Approach

Grade 1 Radiation Dermatitis (Faint Erythema/Dry Desquamation)

• Keep the area clean and dry between treatments using a pH-neutral synthetic detergent rather than soap, which can irritate the skin 1
• Apply a non-perfumed moisturizer after cleaning if desired, though this is optional 1
• Moisturizers containing antibacterials (chlorhexidine or triclosan) may be used occasionally if anti-infective measures are appropriate 1
• Avoid overtreatment, including overuse of antiseptic creams, as this can irritate the skin and worsen pain 1

Grade 2-3 Radiation Dermatitis (Moderate to Severe)

For more significant burns with moist desquamation, erythema, and pain:

Topical Applications for Pain Relief:

• Anti-inflammatory emulsions (trolamine or hyaluronic acid cream) can provide symptomatic relief 1
• Hydrophilic dressings placed over cleaned, dried wounds can be soothing for the patient and help skin healing by absorbing wound exudate 1
• Drying gels with antiseptics (chlorhexidine-based creams, not chlorhexidine in alcohol) for appropriate areas 1
• Zinc oxide paste if sufficiently easy to remove before radiotherapy 1
• Silver sulfadiazine or beta glucan cream applied after radiotherapy (possibly in the evening after cleaning) 1

Corticosteroid Use:

• While topical corticosteroids are not contraindicated for radiation dermatitis, limit the overall treatment time of any corticosteroid-containing treatment 1
• Corticosteroids can help reduce inflammation and associated pain but should be used judiciously 1

Grade 4 Radiation Dermatitis (Skin Necrosis/Full-Thickness Ulceration)

• Requires specialized wound care managed primarily by a wound specialist with assistance from radiation oncology, medical oncology, dermatology, and nursing 1
• Treatment should be individualized on a case-by-case basis given the severity 1

Critical Timing Considerations

Before Each Radiation Treatment:

• Gently clean and dry the skin in the radiation field shortly before each irradiation session 1
• Do not apply topical moisturizers, gels, emulsions, or dressings shortly before radiation treatment as they cause a bolus effect, artificially increasing the radiation dose to the epidermis and potentially worsening burns 1

Product Selection by Skin Area

Different areas require different formulations for optimal pain relief and healing 1:

• Drying pastes for skin folds where reactions remain moist
• Gels for seborrhoeic areas
• Creams for areas outside skin folds and seborrhoeic areas
• Avoid greasy topical products as they inhibit wound exudate absorption and promote superinfection 1

Essential Supportive Measures to Reduce Pain

What to Avoid:

• Sun exposure wherever possible—use soft clothing to cover the area and/or mineral sunblocks 1
• Skin irritants including perfumes, deodorants, or alcohol-based lotions 1
• Scratching of the affected area 1

Hygiene Practices:

• Wash the area with a gentle cleanser and dry with a soft, clean towel 1
• Maintain good standards of hygiene to minimize infection risk, which can worsen pain 1

Monitoring for Complications That Worsen Pain

Watch for infection, which significantly increases pain 1:

• Consider swabbing the affected area if infection is suspected 1
• Check blood granulocyte count, especially if receiving concomitant chemotherapy 1
• Perform blood cultures if signs of sepsis and/or fever are present 1
• Reserve topical antibiotics for documented superinfection—do not use prophylactically 1

Common Pitfalls

• Applying products before radiation therapy creates a bolus effect and worsens skin damage 1
• Using soap instead of pH-neutral cleansers increases irritation and pain 1
• Overusing antiseptic creams can irritate the skin rather than help 1
• Prolonged corticosteroid use should be avoided to prevent complications 1

Team-Based Management

• Grade 1: Can be managed primarily by nursing staff 1
• Grades 2-3: Managed by an integrated team comprising radiation oncologist, nurse, medical oncologist (where appropriate), and dermatologist, with weekly assessments 1
• Grade 4: Requires wound specialist as primary manager 1