Skin Toxicity During Breast Irradiation: Pathophysiology and Management

Jennifer L. Harper, MD; Lynette E. Franklin, MSN; Joseph M. Jenrette, MD; Eric G. Aguero, MD

Disclosures

South Med J. 2004;97(10) 

In This Article

Preventing and Managing Radiation-Related Skin Toxicity

Skin injury incurred during breast irradiation can produce significant discomfort, limit daily activities, and result in breaks from treatment. Some of the commonly held beliefs regarding preventing skin toxicity have recently been investigated in randomized trials.

Washing the irradiated skin with soap and water was felt to exacerbate radiation dermatitis during the orthovoltage era. Roy et al[21] evaluated the impact of skin washing with soap and water on acute skin toxicity during breast irradiation using modern megavoltage radiotherapy. In this trial, 99 patients undergoing breast irradiation were randomized to skin washing with soap and water or no skin washing. Moist desquamation developed in 33% of those that did not wash the skin as compared with 14% of those that washed the skin. A multivariate analysis of this small trial showed acute skin toxicity correlated with patient's weight, concomitant chemoradiotherapy and regions of higher dose, while there was a trend toward increased toxicity in the nonwashing arm. It is hypothesized that washing may reduce moist desquamation by removing skin microbes which act as inflammatory stimuli at the basal layer of the skin. The authors concluded that washing the skin does not increase skin toxicity.

The efficacy of aloe vera gel, a therapy commonly used to prevent radiation skin toxicity, has been evaluated recently in two randomized trials. Williams et al[22] conducted two trials involving women receiving breast irradiation, and which compared skin toxicity between those receiving aloe vera gel and a control group. The first trial was a double-blinded trail in which 194 women were randomized to receive topical aloe vera gel or a placebo. In the second trial, 108 patients were randomized to aloe vera or no treatment. The scoring of skin toxicity was similar for both arms of the two trials. This suggests that aloe vera has no protective effect for those receiving breast irradiation.

Biafine (Medix Pharmaceuticals, Tampa, FL), a wound-healing product from France, has been touted to reduce radiation-related skin toxicity.[23] The wound-healing properties of Biafine are a result of its capacity to recruit macrophages to epidermal wounds and promote granulation tissue formation.[24] Biafine was compared with best supportive care, which consisted of Aquaphor (Biersdorf, Lindenhurst, NY) and aloe vera, in a randomized trial of women receiving breast irradiation. This trial demonstrated no statistical difference in skin toxicity between those receiving Biafine and those treated with best supportive care.[20]

Topical steroids are commonly used to treat radiation-induced skin inflammation. Corticosteroids have been shown to inhibit the upregulation of the proinflammatory cytokine IL-6 in response to ionizing radiation.[25] The efficacy of the corticosteroid cream mometasone furoate (MMF) as a prophylactic and therapeutic intervention was investigated in a randomized trial. Forty-nine patients receiving breast radiotherapy were randomized in a double-blinded placebo controlled trial to receive MMF and an emollient cream or a placebo emollient cream during their radiotherapy and for three weeks following. This trial demonstrated that prophylactic application of MMF combined with an emollient cream significantly decreased acute radiation dermatitis compared with emollient cream alone.[26]

While there is little empirical evidence to support the use of prophylactic topical therapies, advances in radiotherapy techniques are addressing treatment-related causes of skin injury. The contour of the breast and its varying thickness produces inhomogeneous distribution of the radiation dose. The regions of higher dose are at increased risk of skin injury. The use of three-dimensional (3D) planning systems, which incorporate computerized tomography-based images, allow for more accurate calculation of dose throughout the breast. Aref[27] compared the simple radiotherapy plan utilizing a single contour to a 3D plan using dose-based compensators and lung inhomogeneity corrections. The use of 3D planning, which allowed more accurate dose calculations and dose-based compensators, significantly decreased the volumes of breast that received doses that exceeded 100% of the prescribed dose. Intensity-modulated radiotherapy (IMRT) is a technique that further increases the homogeneity of dose in the breast. IMRT uses the dose calculations obtained from 3D planning and then decreases the transmission of radiation to regions of excessively high doses. In the initial clinical experience with IMRT at William Beaumont Hospital, none of the 32 patients receiving breast irradiation experienced RTOG grade III or greater skin toxicity.[28]

Although not evidence-based, the following practice guidelines to prevent skin injury during and after breast irradiation are recommended by many radiation oncology centers.

  • Avoidance of metallic-based topical agents is advised, as these may increase skin dose. Metallic agents include zinc oxide-based creams and deodorants with aluminum bases.

  • Avoiding traumatic shear and friction injuries by wearing loose cotton clothing is advised.

  • Use of nonadhesive wraps or securing devices allows for wound examination and exposure of the treatment site, without surrounding skin trauma. SNUG wraps (Assurity Medical, Atlanta, GA) are cotton wraps available in various sizes, used to protect wounds without skin adhesives.

Unfortunately, many women will experience some degree of skin injury during breast irradiation. Current therapies used in the treatment of dry and moist desquamation are reviewed below.

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