However, no benefits were reported from formulations containing aloe vera,34 chamomile,8,44 ascorbic acid, pantothenic acid, and trolamine.50 Topical agents that contain soothing ingredients such as niacinamide, panthenol, squalene, glycerin, and allantoin have been shown to be beneficial for reducing RD symptoms.8,13,33 Finally, a thermal water-containing skincare regimen comprising two types of cleansers, a moisturizer, a healing balm, and an SPF50+ sunscreen has been shown to be beneficial for RD prevention and reduction of symptoms.33 In this study, 253 women with mostly early-stage breast cancer undergoing postoperative RT showed significantly (P ≤ 0.0001) less incidence of severe (grade 3 CTCAE vs 524 and higher) RD in the self-reported frequent users who once daily used the total skincare regimen than those who self-reported using parts of the skincare regimen infrequently.33
The application of emollients in moderation just prior to daily administration of RT has not been shown to interfere with or increase the radiation dose to the skin.66 Encouraging patients to apply skin care daily and liberally without restrictions is likely to improve adherence to the skincare regimen and quality of life (Appendix 2).7,66
Photoprotection Protection
Before starting RT, educational pointers should include adopting sun-protective measures to prevent RT-induced photosensitivity, which is primarily UVA exposure-related, not only during RT but also after RT.7-14,19,23,25 During and immediately after RT, while the skin is healing, the treated area should be protected from direct sunlight with the daily use of sunblock of SPF 30 or higher and UVA-protective clothing over sun-exposed areas.7-14,19,23,25 Patients are permitted to swim in chlorinated pools and oceans but should rinse immediately afterward using a gentle cleanser followed by applying a moisturizer and re-application of sunscreen as needed (eg, after swimming or heavy perspiration).7,25
Initiation of Topical Corticosteroids on Day 1 of RT
The rationale behind topical corticosteroid (TCS) use during RT is based on its anti-inflammatory properties, which are exploited to prevent and prolong the time to development of RD, when used in combination with other skin care.7,30,37-40,58-66
The panel unanimously recommended initiating a mid-potency TCS cream (such as mometasone furoate 0.1% or triamcinolone 0.1%), on the first day of RT for up to 2 weeks after the completion of RT.7,58-64 The recommendations by the panelists were based on high-level evidence, including a meta-analysis demonstrating that mild to potent TCS significantly prevented the incidence of any RD and moist desquamation.37 Furthermore, the use of TCS during RT has been shown to prolong the time to development of grade three RD.58-64 The caveat is that prolonged (beyond 2 weeks after RT) or inappropriate use on the face, neck, or genitalia can lead to skin atrophy and permanent striae.28,60,64 Other cAEs, such as the development of hematomas, tearing of the skin, telangiectasias, hypertrichosis, and localized infections, are uncommonly associated with TCS. Patients may be reassured that systemic side effects from TCS, such as infections and adrenal suppression, are extremely rare.7,28,60,64
Finally, the panel recommended that the continuation of a gentle cleansing and moisturizing regimen should be concurrently performed with the application of TCS, even after the completion of RT.7
Continual Assessment of RD
During RT, providers should directly inspect the irradiated region for the development of cAEs on, at least, a weekly basis, with more frequent examinations when brisk erythema or the development of dry desquamation occurs.7-14,19,23,24 Providers should inquire about any symptoms secondary to cAEs, such as pain, burning, pulling, tenderness, dryness, scaling, flaking, peeling, or pruritus and prescribe supportive medications as needed.7-14,19,23,24 Consistent grading of RD based on the CTCAE v 5.0 level should be documented, along with the location and size of any desquamation. Inclusion of longitudinal photographs of the irradiated region in the electronic medical record, including a pre-RT timepoint, is particularly helpful when multiple providers are caring for the patient and allows objective visualization of the progression and/or improvement of cAEs.
In addition, accurate documentation of the onset of symptoms, skincare regimen, and the impact of RD on daily living activities such as sleeping and diet is important.7-14,19,23,24 The fraction of RT and cumulative dose of RT as well as the timing of other types of anticancer therapies and medications such as hormone therapy, antibody therapies, or immunotherapy should be noted. If the patient has been medicating with analgesics, antibiotics, or antifungals, both subjective and objective responses to these medications should be consistently reported.7-14,19,23,24
Algorithm-Based Management of RD
The proposed algorithm (Figure 2) tailors treatment to the grade of RD determined by CTCAE v.5 but differentiates between grade 2 RD with or without moist desquamation. For CTCAE grade 1-2 RD with erythema and no desquamation, patients may continue their prescribed course of RT. In the meantime, understanding pre-RT education and compliance with skincare regimen +/- TCS should be checked and reinforced.
For CTCAE grade 2 with any moist desquamation or grade 3 RD, daily cleansing of the wound and peri-wound skin with water, gentle cleanser, and/or saline soaks was recommended.
The panel recommended culturing the desquamated region, especially if purulent, for the presence of bacteria. Skin bacteria,
The application of emollients in moderation just prior to daily administration of RT has not been shown to interfere with or increase the radiation dose to the skin.66 Encouraging patients to apply skin care daily and liberally without restrictions is likely to improve adherence to the skincare regimen and quality of life (Appendix 2).7,66
Photoprotection Protection
Before starting RT, educational pointers should include adopting sun-protective measures to prevent RT-induced photosensitivity, which is primarily UVA exposure-related, not only during RT but also after RT.7-14,19,23,25 During and immediately after RT, while the skin is healing, the treated area should be protected from direct sunlight with the daily use of sunblock of SPF 30 or higher and UVA-protective clothing over sun-exposed areas.7-14,19,23,25 Patients are permitted to swim in chlorinated pools and oceans but should rinse immediately afterward using a gentle cleanser followed by applying a moisturizer and re-application of sunscreen as needed (eg, after swimming or heavy perspiration).7,25
Initiation of Topical Corticosteroids on Day 1 of RT
The rationale behind topical corticosteroid (TCS) use during RT is based on its anti-inflammatory properties, which are exploited to prevent and prolong the time to development of RD, when used in combination with other skin care.7,30,37-40,58-66
The panel unanimously recommended initiating a mid-potency TCS cream (such as mometasone furoate 0.1% or triamcinolone 0.1%), on the first day of RT for up to 2 weeks after the completion of RT.7,58-64 The recommendations by the panelists were based on high-level evidence, including a meta-analysis demonstrating that mild to potent TCS significantly prevented the incidence of any RD and moist desquamation.37 Furthermore, the use of TCS during RT has been shown to prolong the time to development of grade three RD.58-64 The caveat is that prolonged (beyond 2 weeks after RT) or inappropriate use on the face, neck, or genitalia can lead to skin atrophy and permanent striae.28,60,64 Other cAEs, such as the development of hematomas, tearing of the skin, telangiectasias, hypertrichosis, and localized infections, are uncommonly associated with TCS. Patients may be reassured that systemic side effects from TCS, such as infections and adrenal suppression, are extremely rare.7,28,60,64
Finally, the panel recommended that the continuation of a gentle cleansing and moisturizing regimen should be concurrently performed with the application of TCS, even after the completion of RT.7
Continual Assessment of RD
During RT, providers should directly inspect the irradiated region for the development of cAEs on, at least, a weekly basis, with more frequent examinations when brisk erythema or the development of dry desquamation occurs.7-14,19,23,24 Providers should inquire about any symptoms secondary to cAEs, such as pain, burning, pulling, tenderness, dryness, scaling, flaking, peeling, or pruritus and prescribe supportive medications as needed.7-14,19,23,24 Consistent grading of RD based on the CTCAE v 5.0 level should be documented, along with the location and size of any desquamation. Inclusion of longitudinal photographs of the irradiated region in the electronic medical record, including a pre-RT timepoint, is particularly helpful when multiple providers are caring for the patient and allows objective visualization of the progression and/or improvement of cAEs.
In addition, accurate documentation of the onset of symptoms, skincare regimen, and the impact of RD on daily living activities such as sleeping and diet is important.7-14,19,23,24 The fraction of RT and cumulative dose of RT as well as the timing of other types of anticancer therapies and medications such as hormone therapy, antibody therapies, or immunotherapy should be noted. If the patient has been medicating with analgesics, antibiotics, or antifungals, both subjective and objective responses to these medications should be consistently reported.7-14,19,23,24
Algorithm-Based Management of RD
The proposed algorithm (Figure 2) tailors treatment to the grade of RD determined by CTCAE v.5 but differentiates between grade 2 RD with or without moist desquamation. For CTCAE grade 1-2 RD with erythema and no desquamation, patients may continue their prescribed course of RT. In the meantime, understanding pre-RT education and compliance with skincare regimen +/- TCS should be checked and reinforced.
For CTCAE grade 2 with any moist desquamation or grade 3 RD, daily cleansing of the wound and peri-wound skin with water, gentle cleanser, and/or saline soaks was recommended.
The panel recommended culturing the desquamated region, especially if purulent, for the presence of bacteria. Skin bacteria,
