especially Staphylococcus aureus (SA), have been shown to promote cutaneous inflammation in many dermatoses that disrupt the skin barrier.67-69 Published reports and experience of the authors describe frequent secondary infection in areas of RD.70,71 For these reasons, the panelists suggested bacterial culture in patients with moist desquamation and antimicrobial treatment if indicated. More research is needed to define the role of bacteria in the pathogenesis of RD.
The advisors acknowledged the lack of evidence to champion the efficacy of one particular dressing over another for treating moderate to severe RD cases, including moist desquamation.7 Wound dressings that maintain a moist wound bed and control exudate while not adhering to the wound bed are widely used.42,43,47,48,49,72 Depending on the condition and level of exudate, various dressings may be used, such as a hydrocolloid, a foam dressing, or a non-adherent silicone-coated dressing.42,43,47,48,49,72 Silicone-based agents may have anti-inflammatory properties and are available as a gel or coated wound dressings.42,43,47,48,49,72 Dressings comprising a hydrogel can offer soothing and cooling.7 The frequency of dressing changes depends on exudate level and is typically every 3 days.7
The continuation of emollients and TCS to the skin areas around the moist desquamation but not directly on the region was advised with the caveat that determining compliance to these instructions is an important consideration. In patients already using TCS before developing desquamation, secondary infection in areas of desquamation should be considered when deciding whether to continue TCS. In patients who have not been using TCS, the panel did not recommend initiating TCS when moist desquamation is first noted.
Pain can be managed by OTC non-steroidal anti-inflammatory drugs (NSAIDs). Clinically manifest secondary bacterial infections may be treated with mupirocin or oral antibiotics tailored to the microbial sensitivities, but the use of prophylactic topical antibiotics is generally discouraged from complying with antimicrobial stewardship preventing antibiotic resistance.7 Silver sulfadiazine cream to the desquamated region may be used until complete healing, although evidence is lacking. Highquality photographs and virtual consultation may be helpful methods to expedite access to a specialist.79
For CTCAE grade 4 RD and any cAEs deemed possibly dangerous or life-threatening, such as skin necrosis, ulceration of the full thickness dermis, or copious bleeding, further fractions of RT and/or bolus should be held until the desquamated region is clinically improved.7-14,19,23,24 The decision to hold RT must be carefully made by the radiation oncologist, who will need to weigh the tradeoffs of offering a treatment break for wound healing vs potentially reducing the efficacy of RT.74-76 Treatment breaks may negatively impact prognosis in highly proliferative tumors, such as head and neck cancer and inflammatory breast cancer which have high rates of local recurrence.74-76
Patients with large areas of moist desquamation, bleeding, or bullae should be referred to a wound-healing specialist or oncodermatologist.7 Breast cancer patients with a tissue expander or implant reconstruction, and moist desquamation in any part of their chest wall or axilla should be carefully assessed for secondary infection of the prosthesis by their plastic surgeon. Adequate pain control is essential, with a low threshold to offer narcotic medications as needed. Mucosal involvement, thinning of a flap with exposure to a breast prosthesis, and the presence of systemic symptoms such as fever, uncontrolled pain, and laboratory abnormalities such as elevated white blood cell counts or decreased hemoglobin and hematocrit signal urgent evaluation at an urgent care facility with subspecialty consultation by a dermatologist, plastic surgeon, infectious disease, or wound-healing specialist.7
The advisors acknowledged the lack of evidence to champion the efficacy of one particular dressing over another for treating moderate to severe RD cases, including moist desquamation.7 Wound dressings that maintain a moist wound bed and control exudate while not adhering to the wound bed are widely used.42,43,47,48,49,72 Depending on the condition and level of exudate, various dressings may be used, such as a hydrocolloid, a foam dressing, or a non-adherent silicone-coated dressing.42,43,47,48,49,72 Silicone-based agents may have anti-inflammatory properties and are available as a gel or coated wound dressings.42,43,47,48,49,72 Dressings comprising a hydrogel can offer soothing and cooling.7 The frequency of dressing changes depends on exudate level and is typically every 3 days.7
The continuation of emollients and TCS to the skin areas around the moist desquamation but not directly on the region was advised with the caveat that determining compliance to these instructions is an important consideration. In patients already using TCS before developing desquamation, secondary infection in areas of desquamation should be considered when deciding whether to continue TCS. In patients who have not been using TCS, the panel did not recommend initiating TCS when moist desquamation is first noted.
Pain can be managed by OTC non-steroidal anti-inflammatory drugs (NSAIDs). Clinically manifest secondary bacterial infections may be treated with mupirocin or oral antibiotics tailored to the microbial sensitivities, but the use of prophylactic topical antibiotics is generally discouraged from complying with antimicrobial stewardship preventing antibiotic resistance.7 Silver sulfadiazine cream to the desquamated region may be used until complete healing, although evidence is lacking. Highquality photographs and virtual consultation may be helpful methods to expedite access to a specialist.79
For CTCAE grade 4 RD and any cAEs deemed possibly dangerous or life-threatening, such as skin necrosis, ulceration of the full thickness dermis, or copious bleeding, further fractions of RT and/or bolus should be held until the desquamated region is clinically improved.7-14,19,23,24 The decision to hold RT must be carefully made by the radiation oncologist, who will need to weigh the tradeoffs of offering a treatment break for wound healing vs potentially reducing the efficacy of RT.74-76 Treatment breaks may negatively impact prognosis in highly proliferative tumors, such as head and neck cancer and inflammatory breast cancer which have high rates of local recurrence.74-76
Patients with large areas of moist desquamation, bleeding, or bullae should be referred to a wound-healing specialist or oncodermatologist.7 Breast cancer patients with a tissue expander or implant reconstruction, and moist desquamation in any part of their chest wall or axilla should be carefully assessed for secondary infection of the prosthesis by their plastic surgeon. Adequate pain control is essential, with a low threshold to offer narcotic medications as needed. Mucosal involvement, thinning of a flap with exposure to a breast prosthesis, and the presence of systemic symptoms such as fever, uncontrolled pain, and laboratory abnormalities such as elevated white blood cell counts or decreased hemoglobin and hematocrit signal urgent evaluation at an urgent care facility with subspecialty consultation by a dermatologist, plastic surgeon, infectious disease, or wound-healing specialist.7
LIMITATION AND STRENGTHS
Currently, there is a lack of rigorously designed, prospective clinical trials that test the efficacy of a multi-step treatment algorithm that combines medical recommendations such as TCS with OTC skincare regimens for the prevention and management of acute RD. Other limitations include the inherent bias and lack of important details in retrospective trials that may impact the incidence of RD, such as skin type, pigment, and RT technique, as discussed above. Strengths include the composition of a collaborative team including specialists from oncodermatology and radiation oncology to formulate a practical treatment algorithm based on a CTCAE v.5 grading methods for RD.
CONCLUSIONS
Despite the integral role of RT in the multidisciplinary
management of malignancies, RD and other dermatologic
complications from RT are common. Acute RD, when
suboptimally managed, can lead to cAEs and symptoms of pain
and pruritus, which can subsequently have a lasting impact on
patient QoL. When RD is severe, it can delay the receipt of a
full therapeutic course of RT. Enhanced patient education on
the prevention of RD and clarity of treatment recommendations
through a multidisciplinary, physician-developed algorithm can
help prevent and manage the various cAEs and improve the
overall care of patients receiving RT.
DISCLOSURES
JL receives clinical trial research funding from OnQuality and
Azitra. JL has served on advisory boards for La Roche Posay and
Sanofi Regeneron. MEL has a consultant role with Johnson and
Johnson, Novocure, Bicara, Janssen, Novartis, EMD Serono,
AstraZeneca, Innovaderm, Deciphera, DFB, Azitra, Kintara, RBC/
La Roche Posay, Trifecta, Varsona, Genentech, Loxo, Seattle
Genetics, Lutris, OnQuality, Oncoderm, NCODA, Apricity. Dr.
