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BREAST CANCER SKIN REACTION IN RADIOTHERAPY TREATMENT Yan Bramayanto

Radiotherapy Review Specialist Royal Free Hospital, London

Introduction Skin is vulnerable to the effects of radiation due to its continuous state of cellular renewal. Patients receiving radiotherapy are at risk of experiencing skin reaction because the radiation beams must pass through the skin surface. The severity of reaction will depend on the total dose of radiation, the daily dose of radiation, the size of treatment field and area being treated.

The severity of the skin reaction can attributed to the following factors:

1

Area of the body treated

2

Use of bolus (extra material which is equivalent with the body tissue, applied at area treated)

3

Total dose

4

Fractionation schedule (how much treatment given per day.

5

Energy of radiation used

6

Volume of normal tissue included in the treatment field

7

General Health

8

Previous and recent medical history (chemotherapy treatment)

.

9

Patient compliance

The skin consists of epidermis, dermis and subcutis, together with hair follicles, sweat glands, blood vessels, lymphatics and nerves. When the skin is irradiated the basal cells of epidermis break down. There are four stages of skin reaction that may occur during radiotherapy. The four stages are:

1 Erythema

2 Dry-desquamation

3 Moist-desquamation

4 Skin necrosis

Erythema appears as dry, red, warm skin that may feel sensitive and tight.

Erythema maybe seen during the first week and a full reaction starts to occur 2-3 weeks into treatment. It subsides 2-3 weeks after treatment is completed and is delineated by the radiation field. Also, if repopulation of the cells does not keep track with cells being lost, then dry desquamation occurs. If new cell proliferation is inadequate and the epidermis layer becomes broken, moist-desquamation occurs. Skin necrosis is rare in the modern radiotherapy practice.

Skin Care

The aims of skin care for irradiated breast are:

1 Prevent reaction, this is achieved by reducing friction to the skin and by avoiding agents which will sensitise the skin, e.g. perfumes.

2 Minimising of skin reaction, preventing skin reaction from deteriorating and becoming more of a problem to the patient and, in extreme cases causing the suspension of treatment.

3 Promotion of healing. In order to promote skin or wound healing, the environment of the wound bed must be:

i.

Moist

ii.

Clean

iii.

Warm

iv.

Protected from friction and damage

Treatment

Aqueous Cream

Aqueous cream is water based moisturising cream which is contains no substances likely to cause further irritation or itching. This soothes the skin so that the patient will not scratch the irradiated skin causing desquamation and skin damage.

Aloe Vera Gel

Aloe Vera Gel is a colourless enzyme gel obtained from the tissues and cells in the fresh leaves of Aloe Vera plant. It has been used traditionally used as a natural remedy for burns and radiation reaction.

It is difficult to avoid scratching or rubbing irritated or itchy skin and impossible when asleep! The patients should be discouraged from rubbing

and scratching irritated skin and should keep their fingernails short and clean. Loose cotton cloths help to minimise the irritation.

Hydrocortisone 1% Ointment

Hydrocortisone is a topical steroid and should be used sparingly, particularly on inflamed skin where it has an increased absorption. It reduces irritation, itching and soreness.

Geliperm

Geliperm is a polyacrylamide-agar composite Hydrogel which has 90% water content. It soothes irritation, itchy/sore areas as required.

Mepitel Dressing

Mepitel is a soft silicone dressing, non-sticking and causing minimal trauma on removal even in critical situations when the exudates start to dry out. The principles of moist wound healing need to be applied when treating radiation-induced moist desquamation. Mepitel dressings are applied as primary dressing with sterile gauze as secondary dressing, replacing gauze when wet to soothe and to aid the healing process.

Skin Care after Treatment

Normally skin reaction or irritation takes 4 weeks to subside. Any skin reaction will peak in the 7-10 days following the completion of treatment. Continue to use aqueous cream or Aloe Vera Gel until the tube runs out and wait 2-3 weeks before using a deodorant if armpit was in the treated area. It is advisable to avoid exposing the treated area to the sun for 8 weeks. It is recommended using factor 30 sun cream or above for one year after treatment and be cautious of exposing the area treated to the sun.