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Radiation Skin Reactions

Radiation Skin Reactions. Peter R Hancock RN. Learning Outcomes . Recognise Levels/grades of radiation Skin reactions Gain Knowledge with regards to correct evidence based care for management of radiation skin reactions Recognise possible incorrect care procedures

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Radiation Skin Reactions

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  1. Radiation Skin Reactions Peter R Hancock RN

  2. Learning Outcomes • Recognise Levels/grades of radiation Skin reactions • Gain Knowledge with regards to correct evidence based care for management of radiation skin reactions • Recognise possible incorrect care procedures • Gain increased ability to adapt care procedures for individual patient scenarios

  3. What are Radiation Skin Reactions

  4. What are Radiation Skin Reactions • An outward manifestation of cellular effect of radiation therapy on the skin • As radiation travels through the skin to treat the disease process, it “interferes” with skin cells’ ability to regenerate, resulting in dry, red, itchy, and sometimes painful skin in the treatment area. •  Radiation works by breaking/Damaging DNA molecules inside the cancer cell, which in turn keeps the cell from growing, dividing, and spreading

  5. Measurement Scales • RTOG (Radiation Therapy Oncology Group) • RisRas (Radiation Induced Skin Reaction Assessment Scale)

  6. RTOG • Includes a simple 0 – 4 scaling • 0 = no reaction • 1= faint erythema, dry desquamation, epilation • 2= moderate erythema, wet desquamation, oedema • 3= Widespread erythema, wet desquamation, intense oedema • 4= ulceration haemorrhage, necrosis

  7. RTOG • Used for over 25 years • Is it the best system? • What are you thoughts?

  8. What Scale score?

  9. What Scale Score?

  10. What Scale Score?

  11. Limitations

  12. Limitations • One limiting factor of the RTOG scale is that dry desquamation and erythema are scored equally on the scale, yet the appearance of either side effect can vary dramatically from patient to patient • Eg : A patient received radiation treatment for head and neck or oesophageal cancer can suffer severe dry desquamation, in which the affected skin can become cracked and painful

  13. Limitations • The development of erythema presents quite differently yet the RTOG scale rates both reactions with the same score. • A further limitation of the scale is that the scale is quite subjective. The scale only measures reactions by the clinical judgement of the nurse in question and has no facility for patient feedback

  14. Positive Points • It has been shown within this literature that skin assessments performed by clinical professionals using this scale have been able to pinpoint patients who are at risk of progressing to a higher RTOG scale rating, thus allowing for preventative interventions to be implemented • In the clinical enviroment it is shown that the ease of use of the RTOG scale allows for the most inexperienced clinician or reliever to effectively use the scale to plan their care interventions

  15. Positive Points • Concurring literature proceeds to show evidence that experienced clinicians can use their experience to account for the shortfalls of the scale whilst providing evidence based wound care for the patients • My experience is that patient assessments in radiation outpatient units are conducted daily, the shortfalls described in the literature can be seen as inconsequential when this is the clinical practice.

  16. Risras • Developed by Noble-Adams in 1999 • rectifies the RTOG issue of differences in treatment side effects • Includes both a patient self reporting symptom scale and a clinical professional variance scale

  17. Conceptual Framework of predictors for radiation skin reactions

  18. Caring for Radiation Skin Reactions

  19. Caring for radiation skin reactions

  20. Caring for radiation skin reactions

  21. Caring for radiation skin reactions

  22. Caring for radiation skin reactions • Hygiene cares conducted with lukewarm water and mild-sensitive soap is now recommended as routine care for all patients receiving any form of radiation therapy • There is inconclusive evidence to recommend any particular sensitive soap to wash with whilst receiving radiation treatment. General data garnished from dermatology sources, anecdotal nursing reports all suggest that patients use ph-neutral or non alkalating soap during treatment

  23. Caring for Radiation Skin Reactions • There is a study conducted by Frosch and Klingman (1979) that determines the irritant tendencies of soaps by using a soap chamber. This study showed that Dove sensitive soap made by unilever as the only technically “mild” soap out of eighteen tested varieties • As hygiene care and shampooing hair are socially expected norms preventing patients from adhering to their normal routines may cause additional emotional stressors without any proven benefits

  24. Caring for Radiation Skin Reactions • The usage of deodorant in the specific area of treatment has created a large amount of clinical controversy as there are concerns that there may be an increase in surrounding surface skin doses caused by potential bolus effects of having matter on the skin surface • Due to the effect that radiation therapy has on the sweat glands the need for deodorising therapy is diminished significantly after the first few weeks of radiation therapy.

  25. Caring for radiation skin reactions • A study conducted by Burch in 1997 used a specially designed ionization chamber to measure the surface dose of 15 deodorising products and there ingredients. Samples were compared between normal application thickness and a sample size 5 times thicker than normal • There was no reported increase in surface dose with normal application of deodorant. No difference was reported between metallic based and non-metallic based deodorising products

  26. Surprised?

  27. Caring for radiation skin reactions • This directly challenged the previous cannon that products containing magnesium, aluminium or zinc would increase surface dose leading to an increase in radiation skin toxicities • Some Studies suggest that an increase in radiation skin reactions may be attributed to irritating chemical ingredients in the products such as sodium laureth sulphate rather than a bolus effect with normal deodorant application.

  28. Caring for radiation skin reactions • Due to the granulating nature of healing wounds knitted cellulose acetate dressings such as adaptic™ are used to prevent the wound bed from adhering to the external dressing • Hydrogel products are used to effect autolytic debridement and prepare the wound bed in all types of wounds

  29. Radiation Skin care products

  30. Radiation Skin Care • Intrasite Gel’s partially hydrated formulation allows the gel to donate moisture to drier environments and absorb in wetter environments, creating a moist wound healing environment.  • moisturizing of the skin in the treatment area at least twice a day during the treatment. This moisturizing routine should continue for at least six months as per studies after the treatment. This in theory allows for the area to retain its elasticity and prevent radiation recall

  31. Food for thought?

  32. Clinical Resources

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  35. References • Cibul, J., & Starita, A. (2002). Companion Summer 2002: ideas and resources for recovery. Skin savvy: coping with a common side effect of radiation. MAMM, 2A(2), 32-33. from • Cox, C. E. (2006). Self-help. To protect and soothe: skin care during radiation therapy. MAMM, 8(1), 54-55. • Currie, G., & Wheat, J. (2006). Wheatgrass extract as a topical skin agent for acute radiation skin toxicity in breast radiation therapy. Journal of the Australian Traditional-Medicine Society, 12(1), 7-11. • D'Haese, S., Van Roy, M., & Bate, T. (2010). Management of skin reactions during radiotherapy in flanders: a study of nursing practice before and after the introduction of a skin care protocol. European Journal of Oncology Nursing, 14, 367-372. • D'Haese, S., Van Roy, M., Bate, T., Bijdekerke, P., & Vinh-Hung, V. (2010). Management of skin reactions during radiotherapy in Flanders (Belgium): A study of nursing practice before and after the introduction of a skin care protocol. European Journal of Oncology Nursing, 14(5), 367-372. • Davies, A. (2003). Wound care. Nursing a patient with a malodorous fungating non-healing wound. Nursing Times, 99(13), 58.

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