Radiation therapy has an incidence of 43 procedures per 1000 persons of all ages in the United States.1 Two national consensus conferences have determined that breast conservation using lumpectomy and radiation treatment is the preferred treatment in early-stage breast cancer.2 The author notes that the incidence of acute radiation dermatitis among women undergoing radiation treatment for breast cancer may be as high as 95%. Radiation dermatitis also can occur in those undergoing radiation treatment for other cancers.
Despite an exhaustive search for skin care guidelines during and after radiation therapy, standard guidelines do not exist. Multiple institutional Web sites were also searched. Two broad themes emerged. First, the skin should be cleansed with only mild soap and water during treatment. Second, the radiologist performing the radiation therapy would advise the patient on treatment of areas of irritation or blistering, should they develop. The potential for varied treatments with unclear outcomes exists because of lack of skin care guidelines during radiation therapy.
During treatment, the preferred skin care is mild soap and water. Based on our knowledge of the normal protective pH of the skin, a pH-balanced product is recommended, such as pHisoderm (Chattem Inc, Chattanooga, Tenn), rather than alkaline commercial soaps. Although individuals may advocate emolliating or protecting the skin with such agents as aloe or commercial emulsions (Biafine, Medix Pharmaceuticals Americas, Inc., Largo Fla), no benefit has been proven.3,4 It is also important to assess the patient for the use of any products that may increase the risk of radiation dermatitis during radiation therapy. Many medications and herbal supplements increase the risk of photosensitivity, so a thorough assessment of use of prescription and over-the-counter products, including herbal treatments, is necessary.5
If radiation dermatitis occurs during treatment, the skin must be treated with hydrophilic agents so nothing interferes with the radiation beam. Hydrophilic agents include amorphous hydrogels, such as CarraSyn Hydrogel (Carrington Labs, Irving, Tex); emulsions, such as Biafine; or sheet hydrogels, such as Elasto-Gel (Southwest Technologies, Inc, N. Kansas City, Mo). One added benefit of the sheet hydrogels is that they may be removed, placed in the refrigerator, and reapplied. The coolness of the refrigerated hydrogel sheet may provide additional relief.
If radiation dermatitis extends beyond the time of radiation therapy, the need for hydrophilic agents no longer exists, although many practitioners continue the use of these products until epithelialization occurs. Use of Xenaderm Ointment is innovative because the product provides a barrier between the damaged skin and the external environment and promotes epithelialization. This product is approved for use on partial-thickness ulcerations. However, use of Xenaderm could not be considered during radiation therapy because it is hydrophobic. The manufacturers of Xenaderm recommend the product be used with or without a dressing. Depending on the severity and location of the radiation dermatitis, several dressing options could be considered. A dressing such as Mepitel Soft Silicone Wound Contact Layer (Molynlyke, Newtown, Pa) may be considered because it adheres to intact skin but not to open wounds. Mepitel may be removed to allow application of the Xenaderm and reapplied. Mepitel, however, is challenging to work with because of its adhesion to intact skin. This may make it difficult for the patient to apply and remove. Mepitel generally also requires a secondary dressing. Other nonadherent options include Telfa (Tyco Health Care/Kendall, Mansfield, Mass) or an emulsion-impregnated dressing, such as ADAPTIC Non-adhering Dressing (Johnson & Johnson Medical, Somerville, NJ) or Mepilex Transfer or Mepilex Foam (Molnlyke). Telfa and Mepilex Foam do not require secondary dressings; however, ADAPTIC and Mepilex Transfer do. If the patient's soft cotton brassiere without under wires6 or other garments secure dressings satisfactorily, the addition of tape is not necessary.
Cost may be a factor in the selection of interventions for radiation dermatitis during and after radiation therapy. Price for the aforementioned products were compared (Table 1) using the catalog of a mail-order supplier.7 The cost of Xenaderm to the pharmacy was derived by interview with a long-term acute care pharmacist. Because areas of radiation dermatitis are not routinely debrided, Medicare Part B would likely not cover the cost of the dressings. Other healthcare insurance providers may provide some coverage, particularly for the Xenaderm, because it is not available over the counter. Because the sheet hydrogels require less frequent application, they may be more cost-effective than the amorphous hydrogels, particularly because they do not require a secondary dressing. Although the Mepitel or Mepilex Transfer add expense to the use of the Xenaderm, it also may provide a cost benefit because it may be reapplied. Moreover, if epithelialization occurs in 2 weeks, as it did for the patient in the case study, product refills would be unnecessary.
Radiation therapy can affect the skin long after treatment. The patient may recover without difficulty from radiation dermatitis. Any skin exposed to radiation, however, is forever changed. The skin may darkened, and the patient may be at greater risk for impaired skin integrity compared to similar patients not exposed to radiation therapy.8 Should the patient experience a future wound in the irradiated area, that wound will be more difficult to heal. The patient should be counseled to share her history of radiation therapy with healthcare providers.
The use of Xenaderm to promote epithelialization is a novel and viable option for care, as demonstrated by this case study. As with all patient scenarios, however, appropriateness, ease, and cost of care must be evaluated on an individual basis.
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