Effectiveness of semi-permeable dressings to treat radiation-induced skin reactions. A systematic review.

The aim of this systematic review is to assess the available evidence concerning the effectiveness of semi-permeable dressings, on the full range of skin reactions, related to radiation therapy in cancer patients, from local erythema to moist desquamation, including subjective symptoms such as pain, discomfort, itchiness, burning and the effect on daily life activities. The bibliographic search was carried out looking for Randomised Clinical Trials (RCTs) indexed in PubMed, Cinhal, Cochrane plus and Biblioteca Nacional de Salud, published in the English and Spanish language, between 2010 and 2015. Data extraction and evaluation of study quality was undertaken by peer reviewers using the Critical Appraisal Skills Programme (CASP). Of 181 studies, nine full texts were assessed. Finally, six RCT were included in the final synthesis: three analysed the application of Mepilex® Lite in breast cancer and head & neck cancer; one evaluated the application of Mepitel® Film in breast cancer; and two assessed the use of silver nylon dressings in breast cancer and in patients with lower gastrointestinal cancer. The results show that semi-permeable dressings are beneficial in the management of skin toxicity related to radiation therapy. However, rigorous trials showing stronger evidence are needed.

Psychological stress affects the severity of radiation-induced acute skin reactions in breast cancer patients.

Psychological stress exacerbates many pathological conditions including inflammatory skin conditions. The effect of psychological stress on acute radiation-induced skin reactions has not been documented before. Here, we aimed to explore if psychological stress could aggravate skin reaction severity in breast cancer patients. We conducted a secondary analysis of patient data obtained during a randomised, controlled clinical trial for acute radiation-induced skin reaction severity in 78 breast cancer patients. Patients were assessed three times a week during treatment. Skin reaction severity was measured using the modified Radiation-Induced Skin Reaction Assessment Scale (RISRAS) and Radiation Therapy Oncology Group grades. Stress levels were determined using a 5-point LIKERT scale to rate physical well-being, managing stress levels, house, family, work and other commitments. A total of 20 patients (26%) of the 78-patient cohort were considered stressed. Skin reaction severity in stressed patients was twice that of non-stressed patients (p < 0.001) and stressed patients were five times more likely to develop moist desquamation. Our results show that psychological stress aggravates skin reaction severity during radiation therapy. This research needs to be validated in a more rigorous manner by incorporating a validated scale such as the Distress Thermometer and Impact Thermometer in future skin trials.

Radiotherapy-induced skin reactions: prevention and cure.

This article describes the prophylactic use of Mepitel Film in three breast-cancer patients undergoing adjuvant radiotherapy. Each patient had significant risk factors for developing severe radiotherapy-induced skin reactions. This article details the experience encountered by these patients through their treatment courses, with observations by the review radiographers responsible for the care and support of these patients during their radiotherapy and the patients themselves. The film was found to be easy to use by the clinical team and resulted in a significant reduction in adverse side effects to the skin, with an associated improvement in patient satisfaction. There was found to be a financial benefit with the use of Mepitel Film when compared to the foam dressings often required for wound management if the patients had suffered moist desquamation.

Radiation recall dermatitis after pre-sensitization with pegylated liposomal doxorubicin.

Radiation recall dermatitis (RRD) is a rare cutaneous reaction occurring within a previously irradiated field, precipitated by certain drugs. We report a case of RRD occurring after pre-sensitization with pegylated liposomal doxorubicin (PLD) in a woman with Stage IV breast cancer. The RRD occurred in one of the patient's four previous radiotherapy fields. We discuss the time/dose factors of radiation exposure and measure the corresponding skin dose. In our case the radiation dose was low and below previously reported thresholds, and illustrates that there is a more complex interaction between the radiotherapy and the trigger agent than has previously been considered.

Use of a Polylactide-based Copolymer as a Temporary Skin Substitute for a Patient With Moist Desquamation Due to Radiation.

Skin reactions are known adverse effects of radiation therapy. Despite advances in skin care products, there is still a demand for optimal skin care products to improve the therapy of these lesions. The authors report the use of a polylactide-based copolymer (Suprathel, PolyMedics Innovations GmbH, Denkendorf, Germany) as a temporary skin substitute for covering the skin defects of a patient with moist desquamation due to radiation.

[Hyperbaric oxygen and radiotherapy: From myth to reality]. / Oxygénothérapie hyperbare et radiothérapie : entre mythe et réalité.

Worldwide, more than a million people receive each year a curative radiotherapy. While local control and overall survival are steadily increasing, 5 to 15% of patients still develop above grade 2 late toxicities. Late toxicities treatments are complex. Hyperbaric oxygenation was shown to induce revascularization and healing of injured tissues, but indications are still debated. Through a literature review, we summarized the hyperbaric oxygenation indications in radiation-induced late toxicities. We also studied the knowledge and practice of French local radiation therapists. It seems that hyperbaric oxygen therapy can be a conservative treatment of haemorrhagic cystitis and radiation-induced pain, in case of drug therapies failure. Often associated with a significant morbidity and mortality, surgery could be avoided. The risk of complications in case of tooth extraction in irradiated tissues is also reduced. However, the role of hyperbaric oxygenation for mandibular osteoradionecrosis, radiation-induced proctitis, enteritis, lymphoedema, brachial plexopathy, skin and neurological sequelae seems more questionable since studies results are conflicting. Future outcomes of phase III studies are expected to clarify the role of hyperbaric oxygenation in the management of radio-induced toxicities, including for head and necks complications.

[Radiation-induced cutaneo-muscular fibrosis (III): major therapeutic efficacy of liposomal Cu/Zn superoxide dismutase]. / La fibrose cutanéo-musculaire radio-induite (III): efficacité thérapeutique majeure de la superoxyde dismutase Cu/Zn liposomiale.

Sub-cutaneous and muscular fibrosis are common and irreversible late effect of radiation on normal tissues. An experiment was designed to test the effectiveness of superoxide dismutase in reducing late radiation injury. This study was performed in an experimental porcine model of acute localized gamma irradiation simulating human accidental overexposure: 12 Large White pigs were irradiated on the thigh with a collimated gamma 192Ir source, so that the dose was 160 Gy/skin (100%) and 40 Gy/2 cm depth (25%). In this model, fibrosis appears in 4 to 5 months. The heterogeneous sclerotic tissue is composed of stable fibrotic areas poorly cellularized and active areas with a high density of myofibroblasts and inflammatory perifibrotic part. Lipsod administration modalities were six intramuscular injections during 3 weeks (twice weekly) either 10 mg/inj (five pigs) or of 100 mg/inj (five pigs). A methodic evaluation by two examiners consisted of measurements being taken before and after treatment: sum of the two largest perpendicular measurable dimensions, cutaneous projected surface of palpated fibrotic block, ultrasound fibrosis deepness and extrapolated volume. We conclude that Lipsod is the first drug ever described that reduces radiation-induced fibrosis. Its efficacy in this model was highly significant, with a regression higher than 40% in size and 70% in surface and volume, 12 weeks after the end of treatment. This response was rapid, reproducible without dose-effect or toxicity in the limits studied. This work confirms previously published results in humans.

A case study to evaluate a new soft silicone dressing, Mepilex Lite, for patients with radiation skin reactions.

Radiation skin reactions are a known side effect of radiation therapy. Moist desquamation reactions are not only painful but also may be a focus for infection and can be dose limiting. There is a challenge to find a dressing which is protective, comfortable, and a traumatic to delicate irradiated skin. The primary aim of this study was to evaluate patient comfort when using Mepilex Lite in the management of dry and moist desquamation. Secondary objectives included safety, tolerance, and influence on healing. Sixteen patients were recruited at 2 centers in the United Kingdom and in Sweden when they had a RTOG score of 3 and 1 symptom measured by the Radiation-Induced Skin Reaction Assessment tool. Digital photography was used at each weekly visit. Patients completed the Radiation-Induced Skin Reaction Assessment, daily diary cards, and open diaries for quantitative and qualitative evaluation. Some patients found that the dressing minimized pain during dressing changes and was easily lifted and adjusted without loss of adherent properties. A new dressing had a soothing or cooling effect on the skin, and some reported a more normal sleep pattern. The dressing had no negative effect on wound healing. The researchers conclude that the dressing provides a promising alternative to existing dressings and is worthy of further research.

Expression of HIF-1 alpha in irradiated tissue is altered by topical negative-pressure therapy.

BACKGROUND AND PURPOSE: Despite the enormous therapeutic potential of modern radiotherapy, common side effects such as radiation-induced wound healing disorders remain a well-known clinical phenomenon. Topical negative pressure therapy (TNP) is a novel tool to alleviate intraoperative, percutaneous irradiation or brachytherapy. Since TNP has been shown to positively influence the perfusion of chronic, poorly vascularized wounds, the authors applied this therapeutic method to irradiated wounds and investigated the effect on tissue oxygenation in irradiated tissue in five patients. MATERIAL AND METHODS: With informed patients' consent, samples prior to and 4 and 8 days after continuous TNP with -125 mmHg were obtained during routine wound debridements. Granulation tissue was stained with hematoxylin-eosin, and additionally with CD31, HIF-1 alpha (hypoxia-inducible factor-1 alpha), and D2-40 to detect blood vessels, measure indirect signs of hypoxia, and lymph vessel distribution within the pre- and post-TNP samples. RESULTS: In this first series of experiments, a positive influence of TNP onto tissue oxygenation in radiation-induced wounds could be demonstrated. TNP led to a significant decrease of 53% HIF-1 alpha-positive cell nuclei. At the same time, a slight reduction of CD31-stained capillaries was seen in comparison to samples before TNP. Immunostaining with D2-40 revealed an increased number of lymphatic vessels with distended lumina and an alteration of the parallel orientation within the post-TNP samples. CONCLUSION: This study is, to the authors' knowledge, the first report on a novel previously not described histological marker to demonstrate the effects of TNP on HIF-1 alpha expression as an indirect marker of tissue oxygenation in irradiated wounds, as demonstrated by a reduction of HIF-1 alpha concentration after TNP. Since this observation may be of significant value to develop possible new strategies to treat radiation-induced tissue injury, further investigations of HIF-1 alpha regulation under TNP are warranted.

Treatment of chronic radiation ulcers with recombinant platelet-derived growth factor and a hydrophilic copolymer membrane.

We report on a 59-year-old woman suffering from cutaneous T-cell lymphoma of the mycosis fungoides type, who developed chronic ulcerating radiation dermatitis after total body electron beam irradiation with a cumulative dose of 36 Gy. The painful and easily bleeding ulcers could be markedly improved using a combined approach with topical platelet-derived growth factor gel and hydrophilic copolymer membranes.

[The therapy of acute radiogenic epitheliolysis with a dressing of hydrocolloids and polymers (Biofilm). A report on clinical experience]. / Therapie akuter radiogener Epitheliolysen mit einem Verband aus Hydrokolloiden und Polymeren (Biofilm). Ein Erfahrungsbericht.

Acute skin lesions following radiotherapy are uncomfortable and unacceptable side effects. They are observed predominantly after high surface doses as in conventional roentgen or electron beam therapy. To accelerate the wound healing we tested a bandage consisting of hydrocolloids and polymers, which is permeable for gas and water. Handling, compatibility and effectiveness of this plaster were tested in this study. According to the RTOG scoring system 19 irradiated fields with grade II to IV lesions were treated. Densitometric measurements of verification films with and without Biofilm showed no energy absorption. The bandage was comfortable for the patients and easy to handle.

Intraindividual comparison of two different skin care conceptions in patients undergoing radiotherapy of the head-and-neck region. Creme or powder?

OBJECTIVES: This study evaluated for the first time in intraindividual comparison the conception of care with creme or powder. Acute skin reactions on the left and right side of the neck during symmetrically performed radiotherapy and subjective impairment were assessed. PATIENTS AND METHODS: Twelve patients receiving radiotherapy of the head-and-neck region up to 50, 60, 66 and 72 Gy, respectively, were asked to treat one side of the neck with creme, the contralateral side with powder after random assignment. Objective and subjective assessment and photodocumentation were performed at therapy onset and weekly during therapy. The photodocumentation provides an impressive course of acute skin reactions under these care concepts. RESULTS: Altogether we saw no relevant difference in favor of care with creme or powder according to objective as well as subjective assessment criteria (Figure 2 and 3). In this intraindividual comparison the results are independent from interindividual different sensitivity to radiotherapy, total dose or fractionation. Therefore the small patient number is a minor limitation for evidence. Our results are in accordance to trials comparing other care concepts. CONCLUSIONS: A relevant effect concerning onset and degree of acute skin reactions or differences in symptom relief could not be demonstrated. Both conceptions are to be regarded equal in terms of subjective symptom relief and in extent of acute skin reactions. The lack of differences may be explained by the fact that the underlying pathophysiological processes cannot be influenced by topical agents.

[Prevention and therapy of acute radiation injuries of the skin and mucosa. I. Results of a German multicenter questionnaire]. / Prophylaxe und Therapie akuter Strahlenfolgen an Haut und Schleimhaut. Teil I: Ergebnisse einer bundesweiten Erhebung.

BACKGROUND: The acute radiation related morbidity is an essential factor for the patient's outcome in radiotherapy. The prophylactic and therapeutic management of acute side effects has a wide clinical range between different radiation oncology departments. In this work, it was to evaluate the remedies, which are used for prevention and therapeutic management of acute radiation related morbidity of the skin and mucosa (mouth, pharynx, esophagus, small and large bowel, rectum and vagina). METHODS: A questionnaire was sent to 130 radiotherapeutic departments in Germany in July 1995. The questionnaire had been designed with 22 open questions concerning the preventive and therapeutic management of acute radiation related morbidity of skin and mucosal sites. It has been correlated to the scoring system of the RTOG/EORTC and its German modification according to Seegenschmiedt and Sauer. The evaluation was performed anonymously. RESULTS: From 130 questionnaires, 89 (68.4%) were sent back till August 1995. All of them were evaluable. The recommendations showed a broad spectrum for each site. Especially the oral mucositis was treated in many different ways and combinations. The prevention and therapy of complicating superinfections seem to be the joint principle of most of the recommendations. CONCLUSIONS: The management of the acute radiation related morbidity has a wide clinical spectrum among different radiation therapy centers. Systematic prospectively designed investigations are necessary in order to achieve a further reduction in the radiation related acute morbidity. Therefore, a multicenter collaborative working group has been founded.