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Purpose & Patient Population

To develop practice guidelines answering two questions:

What are the optimal methods to prevent acute skin reactions related to radiation therapy (RT) within the first six months of irradiation?
What are the optimal methods to manage acute skin reactions related to RT?

Type of Resource/Evidence-Based Process

Databases searched were PreMEDLINE, MEDLINE, CANCERLIT, and Cochrane Library between January 1980 and April 2004. The name of the initiative was the Cancer Care Ontario’s Program in Evidence-Based Care. The method used was the practice guidelines development cycle. Articles were included based on rigorous inclusion criteria (meta-analysis, systematic reviews, evidence-based practice guidelines, comparative studies, prospectively collected data in at least one trial arm, studies with reported outcomes—degree of skin reaction [using a validated skin reaction tool] and other outcomes reported and articles available as published articles or abstract reports). Exclusion criteria were also identified.

The systematic review included interprofessional members from the Supportive Care Guidelines Group of Cancer Care Ontario and the Program in Evidence-Based Care, an internationally recognized program at McMaster University, Hamilton, Ontario, Canada.

No conflict of interest was identified.

A systematic review of 28 clinical trials was included in analyses; 23 pertained to prevention and 5 addressed management of skin reactions. Two practice guides were reviewed: Oncology Nursing Society and British Columbia Cancer Agency (expert opinion and consensus).

Results Provided in the Reference

A table of clinical studies presented study descriptions and outcomes of the trials on prevention and management of skin reactions, pain, and itching.

The largest randomized trial compared calendula versus Biafine and was significant (p = 0.03) in reducing the severity of RT dermatitis.

Guidelines & Recommendations

Gentle skin washing with water alone or mild soap (unscented, lanolin-free) and water
Gentle shampooing of the scalp with mild shampoo if receiving RT to the head
Encourage personal hygiene habits to avoid psychosocial distress. Limiting personal hygiene practices is not recommended.
Patients who received breast irradiation may use calendula ointment to decrease the occurrence of a grade 2 or higher skin reaction.

Nursing Implications

Insufficient evidence existed to support or refute the use of

•Topical agents (corticosteroids, sucralfate cream, Biafine® (Ortho Dermatologics), ascorbic acid, aloe vera, chamomile cream, almond ointment, or polymer adhesive skin sealant)
•Oral agents (enzymes, sucralfate)
•Intravenous agents (amifostine)

Gentle skin and hair washing should be unrestricted in patients receiving RT. No barrier exists to using mild soap.

No trials answered the question on management.

Future Research:

Outcome assessment tools are required, including quality of life tools.
Trials to assess oral enzymes are needed to confirm studies showing potential for prevention benefit.
Randomized trials are needed (double-blinded, randomized, controlled trials) about the benefits of moisturizing cream as a preventive measure.
Randomized trials are needed that address moist desquamation management with the use of dressings as an intervention.
Trials are needed that explore sites with different risk factors and possible differing management.

Opinions of This Group:

Use plain, unscented, lanolin-free hydrophilic cream, but discontinue with skin breakdown.
Low-dose corticosteroid cream may be helpful with itching and irritation, but caution patients about overuse. More evidence is required to make firm recommendations.