Putting Evidence Into Practice: Evidence-Based Interventions for Radiation Dermatitis

Deborah Feight

Tara Baney

Susan D. Bruce

Maurene McQuestion

radiation therapy, evidence-based practice, evidence-based nursing, summary of evidence, literature review
CJON 2011, 15(5), 481-492. DOI: 10.1188/11.CJON.481-492

Radiation dermatitis, or radiodermatitis, is a significant symptom caused by radiation therapy for the treatment of cancerous and noncancerous conditions. Radiodermatitis can negatively affect patients' physical functioning and quality of life. The Oncology Nursing Society coordinated a Putting Evidence Into Practice (PEP) project team to develop a PEP resource summarizing current evidence for the management of patients with radiodermatitis. Oncology nurses play an important role in educating, assessing, and monitoring patients for this symptom. Many common nursing interventions for radiodermatitis are based on tradition or opinion and have not been researched thoroughly. In addition, evidence to support some current interventions in practice is lacking. This article presents information concerning radiodermatitis, summarizes the evidence-based review for its prevention and management, and identifies gaps in the literature, as well as opportunities for research, education, and practice.

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    Aistars, J. (2006). The validity of skin care protocols followed by women with breast cancer receiving external radiation. Clinical Journal of Oncology Nursing, 10, 487-492. doi:10.1188/06.CJON.487-492
    Baney, T., McQuestion, M., Bell, K., Bruck, S., Feight, D., Weis-Smith, L., & Haas, M. (2011). Radiodermatitis. In L. H. Eaton, J. M. Tipton, & M. Irwin (Eds.), Putting evidence into practice: Improving oncology patient outcomes (vol. 2, 49-76). Pittsburgh, PA: Oncology Nursing Society.
    Bentzen, S. M. (2006). Preventing or reducing late side effects of radiation therapy: Radiobiology meets molecular pathology. Nature Reviews. Cancer, 6, 702-713. doi:10.1038/nrc1950
    Bernier, J., Bonner, J., Vermorken, J. B., Bensadoun, R. J., Dummer, R., Giralt, J., … Ang, K. K. (2008). Consensus guidelines for the management of radiation dermatitis and coexisting acne-like rash in patients receiving radiotherapy plus EGFR inhibitors for the treatment of squamous cell carcinoma of the head and neck. Annals of Oncology, 19, 142-149. doi:10.1093/annonc/mdm400
    Berthelet, E., Truong, P. T., Musso, K., Grant, V., Kwan, W., Moravan, V., … Olivotto, I. A. (2004). Preliminary reliability and validity testing of a new Skin Toxicity Assessment Tool (STAT) in breast cancer patients undergoing radiotherapy. American Journal of Clinical Oncology, 27, 626-631. doi:10.1097/01.coc.0000138965.97476.0f
    Bolderson, A., Lloyd, N. S., Wong, R. K. Holden, L., & Robb-Blenderman, L. (2005). The prevention and management of acute skin reactions related to radiation therapy: A clinical practice guideline (evidence-based series #13-7). Toronto, Canada: Cancer Care Ontario.
    Bostrom, A., Lindman, H., Swartling, C., Berne, B., & Bergh, J. (2001). Potent corticosteroid cream (mometasone furoate) significantly reduces acute radiation dermatitis: Results from a double-blind, randomized study. Radiotherapy and Oncology, 59, 257-265.
    Bourgeois, J. F., Gourgou, S., Kramar, A., Lagarde, J. M., & Guillot, B. (2008). A randomized, prospective study using the LPG technique in treating radiation-induced skin fibrosis: Clinical and profilometric analysis. Skin Research and Technology, 14, 71-76.
    Burch, S. E., Parker, S. A., Vann, A. M., & Arazie, J. C. (1997). Measurement of 6-MV x-ray surface dose when topical agents are applied prior to external beam irradiation. International Journal of Radiation Oncology, Biology, Physics, 38, 447-451. doi:10.1016/S0360-3016(97)00095-3
    Campbell, I. R., & Illingworth, M. H. (1992). Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial. Clinical Oncology, 4, 78-82.
    Catlin-Huth, C., Haas, M. L., & Pollock, V. (Eds). (2002). Radiation therapy patient care record: A tool for documenting nursing care. Pittsburgh, PA: Oncology Nursing Society.
    Cox, J. D., Stetz, J., & Pajak, T. F. (1995). Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). International Journal of Radiation Oncology, Biology, Physics, 31, 1341-1346.
    De Conno, F., Ventafridda, V., & Saita, L. (1991). Skin problems in advanced and terminal cancer patients. Journal of Pain and Symptom Management, 6, 247-256.
    Elliott, E. A., Wright, J. R., Swann, R. S., Nguyen-Tan, F., Takita, C., Bucci, M. K., … Berk, L. (2006). Phase III trial of an emulsion containing trolamine for the prevention of radiation dermatitis in patients with advanced squamous cell carcinoma of the head and neck: Results of Radiation Therapy Oncology Group Trial 99-13. Journal of Clinical Oncology, 24, 2092-2096. doi:10.1200/JCO.2005.04.9148
    Enomoto, T. M., Johnson, T., Peterson, N., Homer, L., Walts, D., & Johnson, N. (2005). Combination gluthathione and anthocyanins as an alternative for skin care during external-beam radiation. American Journal of Surgery, 189, 627-631.
    Eriksson, E., & Mobacken, H. (1977). Microvascular effect of a topically applied cationic triphenylmethane dye (crystal violet). Acta Dermato-Venereologica, 57, 45-49.
    Evensen, J. F., Bjordal, K., Jacobsen, A. B., Lokkevik, E., & Tausjo, J. E. (2001). Effects of Na-sucrose octasulfate on skin and mucosa reactions during radiotherapy of head and neck cancers—A randomized prospective study. Acta Oncologica, 40, 751-755.
    Falkowski, S., Trouillas, P., Duroux, J. L., Bonnetlanc, J. M., & Clavere, P. (2011). Radiodermatitis prevention with sucralfate in breast cancer: Fundamental and clinical studies. Supportive Care in Cancer, 19, 57-65. doi:10.1007/s00520-009-0788-y
    Fenig, E., Brenner, B., Katz, A., Sulkes, J., Lapidot, M., Schachter, J., … Gutman, H. (2001). Topical Biafine and Lipiderm for the prevention of radiation dermatitis: A randomized prospective trial. Oncology Reports, 8, 305-309.
    Fisher, J., Scott, C., Stevens, R., Marconi, B., Champion, L., Freedman, G. M., … Wong, G. (2000). Randomized phase III study comparing best supportive care to Biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation Therapy Oncology Group (RTOG) 97-13. International Journal of Radiation Oncology, Biology, Physics, 48, 1307-1310.
    Freedman, G. M., Anderson, P. R., Li, J., Eisenberg, D. F., Hanlon, A. L., Wang, L., & Nicolaou, N. (2006). Intensity modulated radiation therapy (IMRT) decreases acute skin toxicity for women receiving radiation for breast cancer. American Journal of Clinical Oncology, 29, 66-70. doi:10.1097/01.coc.0000197661.09628.03
    Freedman, G. M., Li, T., Nicolaou, N., Chen, Y., Ma, C. C., & Anderson, P. R. (2009). Breast intensity-modulated radiation therapy reduces time spent with acute dermatitis for women of all breast sizes during radiation. International Journal of Radiation Oncology, Biology, Physics, 74, 689-694. doi:10.1016/j.ijrobp.2008.08.071
    Gollins, S., Gaffney, C., Slade, S., & Swindell, R. (2008). RCT on gentian violet versus a hydrogel dressing for radiotherapy-induced moist skin desquamation. Journal of Wound Care, 17, 268-275.
    Graham, P., Browne, L., Capp, A., Fox, C., Graham, J., Hollis, J., & Nasser, E. (2004). Randomized, paired comparison of no-sting barrier film versus sorbolene cream (10% glycerine) skin care during post mastectomy irradiation. International Journal of Radiation Oncology, Biology, Physics, 58, 241-246. doi:10.1016/S0360-3016(03)01431-7
    Gujral, M. S., Patnaik, P. M., Kaul, R., Parikh, H. K., Conradt, C., Tamhankar, C. P., & Daftary, G. V. (2001). Efficacy of hydrolytic enzymes in preventing radiation therapy-induced side effects in patients with head and neck cancers. Cancer Chemotherapy Pharmacology, 47(Suppl.), S23-S28. doi:10.1007/s002800170005
    Halperin, E. C., Gaspar, L., George, S., Darr, D., & Pinnell, S. (1993). A double-blind, randomized, prospective trial to evaluate topical vitamin C solution for the prevention of radiation dermatitis. International Journal of Radiation Oncology, Biology, Physics, 26, 413-416.
    Heggie, S., Bryant, G. P., Tripcony, L., Keller, J., Rose, P., Glendenning, M., & Heath, J. (2002). A phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nursing, 25, 442-451. doi:10.1097/00002820-200212000-00007
    Hymes, S. R., Strom, E. A., & Fife, C. (2006). Radiation dermatitis: Clinical presentation, pathophysiology, and treatment. Journal of the American Academy of Dermatology, 54, 28-46. doi:10.1016/j.jaad.2005.08.054
    Kedge, E. M. (2009). A systematic review to investigate the effectiveness and acceptability of interventions for moist desquamation in radiotherapy patients. Radiography, 15, 247-257.
    King, K. B., Nail, L. M., Kreamer, K., Strohl, R. A., & Johnson, J. E. (1985). Patients' descriptions of the experience of receiving radiation therapy. Oncology Nursing Forum, 12, 55-61.
    Kouvaris, J. R., Kouloulias, V. E., Plataniotis, G. A., Balafouta, E. J., & Vlahos, L. J. (2001). Dermatitis during radiation for vulvar carcinoma: Prevention and treatment with granulocyte-macrophage colony-stimulating factor impregnated gauze. Wound Repair and Regeneration, 9, 187-193. doi:10.1046/j.1524-475x.2001.00187.x
    Leonardi, M. C., Gariboldi, S., Ivaldi, G. B., Ferrari, A., Serafini, F., Didier, F., … Orecchia, R. (2008). A double-blind, randomized, vehicle-controlled clinical study to evaluate the efficacy of MAS065D in limiting the effects of radiation on the skin: Interim analysis. European Journal of Dermatology, 18, 317-321.
    Lievens, Y., Haustermans, K., Van den Weyngaert, D., Van den Bogaert, W., Scalliet, P., Hutsebaut, L., … Lambin, P. (1998). Does sucralfate reduce the acute side-effects in head and neck cancer treated with radiotherapy? A double-blind randomized trial. Radiotherapy and Oncology, 47, 149-153.
    Liguori, V., Guillemin, C., Pesce, G. F., Mirimanoff, R. O., & Bernier, J. (1997). Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy. Radiotherapy and Oncology, 42, 155-161.
    Lin, L. C., Que, J., Lin, L. K., & Lin, F. C. (2006). Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: A double-blind, randomized study. International Journal of Radiation Oncology, Biology, Physics, 65, 745-750. doi:10.1016/j.ijrobp.2006.01.015
    Lokkevik, E., Skovlund, E., Reitan, J. B., Hannisdal, E., & Tanum, G. (1996). Skin treatment with bepanthen cream versus no cream during radiotherapy—A randomized controlled trial. Acta Oncologica, 35, 1021-1026.
    MacMillan, M. S., Wells, M., MacBride, S., Raab, G. M., Munro, A., & MacDougall, H. (2007). Randomized comparison of dry dressings versus hydrogel in management of radiation-induced moist desquamation. International Journal of Radiation Oncology, Biology, Physics, 68, 864-872. doi:10.1016/j.ijrobp.2006.12.049
    Maiche, A., Isokangas, O. P., & Grohn, P. (1994). Skin protection by sucralfate cream during electron beam therapy. Acta Oncologica, 33, 201-203.
    Maiche, A. G., Grohn, P., & Maki-Hokkonen, H. (1991). Effect of chamomile cream and almond ointment on acute radiation skin reaction. Acta Oncologica, 30, 395-396.
    Mak, S. S., Molassiotis, A., Wan, W. M., Lee, I. Y., & Chan, E. S. (2000). The effects of hydrocolloid dressing and gentian violet on radiation-induced moist desquamation wound healing. Cancer Nursing, 23, 220-229. doi:10.1097/00002820-200006000-00010
    Mak, S. S., Zee, C. Y., Molassiotis, A., Chan, S. J., Leung, S. F., Mo, K. F., & Johnson, P. J. (2005). A comparison of wound treatments in nasopharyngeal cancer patients receiving radiation therapy. Cancer Nursing, 28, 436-445. doi:10.1097/00002820-200511000-00005
    McQuestion, M. (2010). Radiation-induced skin reactions. In M. L. Haas & G. J. Moore-Higgs (Eds.), Principles of skin care and the oncology patient (pp. 115-140). Pittsburgh, PA: Oncology Nursing Society.
    Meegan, M. A., & Haycocks, T. R. (1997). An investigation into the management of acute skin reactions from tangential breast irradiation. Canadian Journal of Medical Radiation Technology, 28, 169-173.
    Merchant, T. E., Bosley, C., Smith, J., Baratti, P., Pritchard, D., Davis, T., … Xiong, X. (2007). A phase III trial comparing an anionic phospholipid-based cream and aloe vera-based gel in the prevention of radiation dermatitis in pediatric patients. Radiation Oncology, 2, 45. doi:10.1186/1748-717X-2-45
    Mobacken, H., & Zederfeldt, B. (1973). Influence of a cationic triphenylmethane dye on granulation tissue growth in vivo. An experimental study in rats. Acta Dermato-Venereologica, 53, 161-172.
    Momm, F., Weibenberger, C., Bartelt, S., & Henke, M. (2003). Moist skin care can diminish acute radiation-induced skin toxicity. Strahlentherapie und Oncologie, 179, 708-712. doi:10.1007/s00066-003-1142-9
    Moore-Higgs, G. (2005). Basic principles of radiation therapy. In M. Haas, W. Hogle, G. Moore-Higgs, & K. Gosselin-Acomb (Eds.), Radiation therapy: A guide to patient care (pp. 8-24). St. Louis, MO: Mosby Elsevier.
    Morganti, A. G., Digesu, C., Panunzi, S., De Gaetano, A., Macchia, G., Deodato, F., … de Gaetano, G. (2009). Radioprotective effect of moderate wine consumption in patients with breast carcinoma. International Journal of Radiation Oncology, Biology, Physics, 74, 1501-1505. doi:10.1016/j.ijrobp.2008.10.089
    National Cancer Institute Cancer Therapy Evaluation Program. (2010). Common terminology criteria for adverse events [v.4.03]. Bethesda, MD: National Cancer Institute.
    Noble-Adams, R. (1999a). Radiation-induced skin reactions 2: Development of a measurement tool. British Journal of Nursing, 8, 1208-1211.
    Noble-Adams, R. (1999b). Radiation-induced skin reactions 3: Evaluating the RISRAS. British Journal of Nursing, 8, 1305-1312.
    Norrby, K., & Mobacken, H. (1972). Effect of triphenylmethane dyes (brilliant green, crystal violet, methyl violet) on proliferation in human normal fibroblast-like and established epithelial-like cell lines. Acta Dermato-Venereology, 57, 476-483.
    Olsen, D. L., Raub, W., Jr., Bradley, C., Johnson, M., Macias, J. L., Love, V., & Markoe, A. (2001). The effect of aloe vera gel/mild soap versus mild soap alone in preventing skin reactions in patients undergoing radiation therapy. Oncology Nursing Forum, 28, 543-547.
    Omidvari, D., Saboori, H., Mohammadianpanah, M., Mosalaei, A., Ahmadloo, N., Mosleh-Shirazi, M. A., … Namaz, S. (2007). Topical betamethasone for prevention of radiation dermatitis. Indian Journal of Dermatology, Venereology, and Leprology, 73, 209. doi:10.4103/0378-6323.32755
    Pignol, J. P., Olivotto, I., Rakovitch, E., Gardner, S., Sixel, K., Beckham, W., … Paszat, L. (2008). A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. Journal of Clinical Oncology, 26, 2085-2092. doi:10.1200/JCO.2007.15.2488
    Pommier, P., Gomez, F., Sunyach, M. P., D'Hombres, A., Carrie, C., & Montbarbon, X. (2004). Phase III randomized trial of calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. Journal of Clinical Oncology, 22, 1447-1453. doi:10.1200/JCO.2004.07.063
    Porock, D., & Kristjanson, L. (1999). Skin reactions during radiotherapy for breast cancer: The use and impact of topical agents and dressings. European Journal of Cancer Care, 8, 143-153.
    Primavera, G., Carrera, M., Berardesca, E., Pinnaro, P., Messina, M., & Arcangeli, G. (2006). A double-blind, vehicle-controlled clinical study to evaluate the efficacy of MAS065D (XClair), a hyaluronic acid-based formulation, in the management of radiation-induced dermatitis. Cutaneous and Ocular Toxicology, 25, 165-171.
    Robson, V., & Cooper, R. (2009). Using leptospermum honey to manage wounds impaired by radiotherapy: A case series. Ostomy Wound Management, 55, 38-47.
    Roper, B., Kaisig, D., Auer, F., Mergen, E., & Molls, M. (2004). Theta-cream versus Bepanthol lotion in breast cancer patients under radiotherapy. A new prophylactic agent in skin care? Strahlentherapie und Oncologie, 180, 315-322. doi:10.1007/s00066-004-1174-9
    Roy, I., Fortin, A., & Larochelle, M. (2001). The impact of skin washing with water and soap during breast irradiation: A randomized study. Radiotherapy and Oncology, 58, 333-339.
    Ryan, J. L., Bole, C., Hickok, J. T., Figueroa-Moseley, C., Colman, L., Khanna, R. C., … Morrow, G. R. (2007). Post-treatment skin reactions reported by cancer patients differ by race, not by treatment or expectations. British Journal of Cancer, 97, 14-21. doi:10.1038/sj.bjc.6603842
    Schmuth, M., Wimmer, M. A., Hofer, S., Sztankay, A., Weinlich, G., Linder, D. M., … Fritsch, E. (2002). Topical corticosteroid therapy for acute radiation dermatitis: A prospective, randomized, double-blind study. British Journal of Dermatology, 146, 983-991. doi:10.1046/j.1365-2133.2002.04751.x
    Schreck, U., Paulsen, F., Bamberg, M., & Budach, W. (2002). Intraindividual comparison of two different skin care conceptions in patients undergoing radiotherapy of the head-and-neck region. Strahentherapie und Onkologie, 178, 321-329.
    Shukla, P. N., Gairola, M., Mohanti, B. K., & Rath, G. K. (2006). Prophylactic beclomethasone spray to the skin during postoperative radiotherapy of carcinoma breast: A prospective randomized study. Indian Journal of Cancer, 43, 180-184.
    Sparks, S. (2007). Radiodermatitis. In M. Haas, W. Hogle, G. Moore-Higgs, & T. K. Gosselin-Acomb (Eds.), Radiation therapy: A guide to patient care (pp. 511-522). St. Louis: Mosby Elsevier.
    Szumacher, E., Wighton, A., Franssen, E., Chow, E., Tsao, M., Ackerman, I., … Hayter, C. (2001). Phase II study assessing the effectiveness of Biafine cream as a prophylactic agent for radiation-induced acute skin toxicity to the breast in women undergoing radiotherapy with concomitant CMF chemotherapy. International Journal of Radiation Oncology, Biology, Physics, 51, 81-86.
    Theberge, V., Harel, F., & Dagnault, A. (2009). Use of axillary deodorant and effect on acute skin toxicity during radiotherapy for breast cancer: A prospective randomized noninferiority trial. International Journal of Radiation Oncology, Biology, Physics, 75, 1048-1052. doi:10.1016/j.ijrobp.2008.12.046
    Vavassis, P., Gelinas, M., Chabot Tr, J., & Nguyen-Tan, P. F. (2008). Phase 2 study of silver leaf dressing for treatment of radiation-induced dermatitis in patients receiving radiotherapy to the head and neck. Journal of Otolaryngology—Head and Neck Surgery, 37, 124-129.
    Vogler, B. K., & Ernst, E. (1999). Aloe vera: A systematic review of its clinical effectiveness. British Journal of General Practice, 49, 823-828.
    Vuong, T., Franco, E., Lehnert, S., Lambert, C., Portelance, L., Nasr, E., … Freeman, C. (2004). Silver leaf nylon dressing to prevent radiation dermatitis in patients undergoing chemotherapy and external beam radiotherapy to the perineum. International Journal of Radiation Oncology, Biology, Physics, 51, 809-814.
    Wells, M., Macmillan, M., Raab, G., MacBride, S., Bell, N., MacKinnon, K., … Munro, A. (2004). Does aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomized controlled trial. Radiotherapy and Oncology, 73, 153-162.
    Westbury, C., Hines, F., Hawkes, E., Ashley, S., & Brada, M. (2000). Advice on hair and scalp care during cranial radiotherapy: A prospective randomized trial. Radiotherapy and Oncology, 54, 109-116. doi:10.1016/S0167-8140(99)00146-2
    Wickline, M. M. (2004). Prevention and treatment of acute radiation dermatitis: A literature review. Oncology Nursing Forum, 31, 237-247. doi:10.1188/04.ONF.237-247
    Williams, M. S., Burk, M., Loprinzi, C. L., Hill, M., Schomberg, P. J., Nearhood, K., … Eggleston, W. D. (1996). Phase III double-blind evaluation of an aloe vera gel as a prophylactic agent for radiation-induced skin toxicity. International Journal of Radiation Oncology, Biology, Physics, 36, 345-349.