factor beta (TGF-beta), can be expressed within hours after the first fraction of RT.33 Demographic or disease-related intrinsic patient factors influence the severity of ARD.33 Several other patient-related risk factors possibly affecting the development or severity of ARD include, for example, smoking, breast size, age, ethnic origin, coexisting diseases, hormonal status, tumor site, and genetic factors.21-24 RT-treatment-related factors include, for example, beam energy, total radiation dose, treatment techniques, volume and the fraction of radiation, chemotherapy, and tamoxifen therapy.22-30
Types and Severity of Radiation Dermatitis
Radiation Therapy Oncology Group (RTOG) and Common Terminology Criteria for Adverse Events (CTCAE) v5 are standard classification tools for grading RD (Table 1).32,34 The CTCAE scale has 5 grades: 1 = faint erythema and dry desquamation to 5 = death. The scale distinguishes between moist desquamation within skin folds vs flat areas.32,34
The RTOG assessment tool has 6 grades (0 = no visible signs of RD, 1, 2, 2.5, 3 to 4 = ulceration, bleeding, and necrosis. The scale separates patchy moist desquamation (grade 2.5) from confluent moist desquamation (grade 3).32,34 The advisors used the CTCAE v5 grading system for ARD for the NECOM 3 algorithm.32
Nordic European Cutaneous Oncodermatology Management 3: A Practical Algorithm for the Prevention and Management of Acute Radiation Dermatitis
The practical algorithm for ARD uses information from the NECOM 2 skincare algorithm for cAEs.7 The skincare algorithm for cancer patients and survivors starts before cancer treatment with education, skincare, and behavioral measures, followed by an evaluation of cancer treatment-related cAEs (Figure 2).7 The oncology nurse-led triage determines the condition [life threatening, severe, or not severe], followed by a patient-specific treatment approach.7 The oncology nurse is central in coordinating the individual cancer patients' care and performing triage of the cAEs, seeking urgent care via an oncologist and/or emergency department (ER) if needed.6,7 The individual patient’s care organization depends on the presented cAEs, the patient’s general and skin conditions, and the healthcare system.
The practical algorithm for ARD starts with skin-preserving therapy, as detailed below, followed by measures on day 1 of RT. After each RT session, the patients are instructed to inspect their skin condition for possible cAEs (ie, erythema, dry or moist desquamation, skin necrosis, or ulceration). If the skin is clear, the skin-preserving therapy is continued. If cAEs are detected, or the patient has concerns, the oncology nurse (in person, by email, or via telemedicine) performs triage. The cleansing and treatment interventions are tailored to the CTCAE grade if ARD is present.32,34 The oncology nurse seeks urgent care for the patient via an oncologist or ER in case of fever, sepsis, deep ulcers, or severe pain.
Skin-Preserving Therapy
Patient education on proactive measures is needed to maintain healthy skin and prevent the development of RT-related cAEs. Therefore, education is an essential first step for clinicians to discuss with patients before starting RT.6,7 Skin preserving therapy comprises education on skincare, including cleansers, moisturizers, and protection using moisturizing sunscreen (SPF 50+) in combination with avoidance of irritants and sun exposure. Recommendations include avoiding skin irritants, products with an elevated pH (>7), and scented products.6,7 Patients should avoid skin trauma or friction caused by excessive rubbing or scratching or the use of adhesive bandages and tape that could potentially peel skin upon removal.6,7 Comfortable clothing made from breathable, non-abrasive fabrics, and supportive bras (for women receiving breast RT) is recommended during RT.6,7,21,34,35 Using electric shavers for hair removal, waxing, or other depilatory pre-shave and after-shave products is generally not recommended during RT if these
