Painful skin reactions may develop in as many as 95% of patients receiving radiotherapy treatments for cancer. Patients report that it affects their quality of life and that purchasing interventions to soothe their skin increases their out-of-pocket costs. Supporting patients who experience the side effect is critical for their well-being.
The ONS GuidelinesTM for Cancer Treatment-Related Radiodermatitis provide evidence-based recommendations for practitioners to manage the skin condition in patients with cancer. The full guideline by Gosselin et al. was published in the November 2020 issue of the Oncology Nursing Forum.
Cancer Treatment-Related Radiodermatitis
As radiation therapy repeatedly penetrates the same area of skin during the course of treatment, it can break down the tissue and lead to pain, itching, and burning. Radiodermatitis may not only have a significant impact on a patient’s quality of life, but it can also require treatment interruption if it becomes severe.
Treatment-related aspects that contribute to radiodermatitis risk include volume, daily dosage and total dose, energy and type of radiation therapy, and total treatment time, Gosselin et al. said. Patients with a higher body mass index, smokers, older patients, and those with certain genetic variants are also at increased risk to develop radiodermatitis.
Gosselin et al. emphasized that measuring radiodermatitis’s severity enables clinicians to better understand and manage the condition as modalities and fractionation schemas change. According to the standardized Common Terminology Criteria for Adverse Events scale, grade 1 symptoms involve faint erythema or dry desquamation, grades 2 and 3 progress to include moist desquamation, grade 4 adds life-threatening skin necrosis, and grade 5 results in death.
Clinician preference tends to guide choice of topical treatments for radiodermatitis, often without firm evidence of effectiveness. Researchers have studied a variety of skincare products on the market, many of which are available over the counter, and found mixed results. The ONS Guidelines panel reviewed the most recently published research and provided evidence-based recommendations on interventions for the management of radiodermatitis during and after cancer treatment.
Evaluation of Radiodermatitis Interventions
The ONS Guideline provides the expert panel’s evidence-based recommendations regarding common interventions studied in the literature.
Recommended interventions: To prevent or minimize the development of radiodermatitis in patients receiving radiation therapy, use standard washing and skincare regimens rather than topical nonsteroidal interventions, which the ONS Guidelines panel classified as a strong recommendation with a moderate certainty of evidence. The evidence the panel reviewed studied specialty topical interventions, not general emollients and creams, which are part of standard skin care. An additional option to prevent or minimize radiodermatitis is use of semipermeable dressings plus standard washing and skincare regimens rather than standard washing or skincare regimens alone, although the guidelines panel classified the recommendation as conditional with a low level of evidence.
To both minimize the development of and treat radiodermatitis once it occurs, use topical steroids plus standard washing and skincare regimens rather than standard washing and skincare regimen alone for the minimization of radiodermatitis, which the panel classified as a conditional recommendation with a low level of evidence. The studies the panel reviewed reported on both prescription and over-the-counter steroid creams. Patients may find over-the-counter creams more affordable or accessible.
Although the products themselves are not an intervention for minimizing or treating radiodermatitis, patients receiving radiation to the truncal or chest region may ask whether using antiperspirants or deodorants would affect their development of the side effect. The ONS Guidelines panel made a conditional recommendation with a very low level of evidence that patients may use deodorants or antiperspirants plus standard washing and skincare regimens or standard washing or skincare regimens alone, depending on their preferences and values. Oncology nurses should educate patients that antiperspirants and deodorant do not seem to cause harm, decrease sweating or odor, and do not increase risk of grade 2 or 3 radiodermatitis.
Not recommended interventions: Based on the evidence, the panel recommended against two interventions, both when used with standard washing or skincare regimens: calendula, which it classified as a conditional recommendation with a low level of evidence, and emu oil, which it classified as a conditional recommendation with a very low level of evidence.
Not enough evidence: The ONS Guidelines panel found insufficient evidence for two interventions and could not provide a recommendation: aloe vera and aloe vera formulations, as well as oral curcumin. For both products, the panel recommended their use in the context of clinical trials that would build the knowledge base for future evaluation.
The panel reported that the overall lack of evidence for radiodermatitis interventions was a challenge in making recommendations. It advised that future research should focus on comparing interventions that have demonstrated efficacy and that the studies should be well designed, address underlying mechanisms that lead to skin damage, and consistently include patient-reported outcomes and cost.
For more information about the ONS Guidelines for Cancer Treatment-Related Radiodermatitis, including an overview of the methods used to develop the guidelines, refer to the full article by Gosselin et al. Or listen to an interview with ONS member Lauren Suarez, RN, MSN, OCN®, CBCN®, member of the guideline panel, on the Oncology Nursing Podcast, then subscribe to the podcast on your favorite listening platform to get other episodes about the ONS Guidelines and more—all with free NCPD—delivered directly to your phone.