Acute radiation dermatitis
Radiodermatitis; acute radiation skin reaction; ARSR
Acute radiation dermatitis is an expected and dose-dependent toxicity affecting nearly all patients receiving cutaneous or breast / head-and-neck radiotherapy with sufficient skin dose. Severity ranges from mild erythema (RTOG 1) through brisk moist desquamation (RTOG 3) to necrosis (RTOG 4). Onset begins 1–2 weeks into a fractionated course, peaks 1–2 weeks after completion, and typically resolves over the following 4–6 weeks. Management is supportive — emollients, gentle skin hygiene and topical steroids; secondary infection and pain control deserve attention. Late effects (telangiectasia, hyperpigmentation, fibrosis, alopecia) are covered separately under radiation fibrosis.
Clinical features and RTOG grading
- Onset 1–2 weeks after the start of fractionated RT; peaks 1–2 weeks after the last fraction.
- RTOG / CTCAE grading:
- Grade 0 — no change.
- Grade 1 — faint or dull erythema, dry desquamation, epilation.
- Grade 2 — tender or bright erythema, patchy moist desquamation, moderate oedema.
- Grade 3 — confluent moist desquamation other than skinfolds, pitting oedema.
- Grade 4 — skin necrosis or ulceration, full-thickness loss.
- Most severe in skinfolds (axilla, inframammary, perineal), where moisture and friction worsen the reaction.
- Affects 80–90% of patients to some degree, with Grade 3+ in 10–20% of breast / head-and-neck RT and a smaller proportion of skin-cancer RT depending on schedule and fractionation.
Risk factors
- Higher total dose and dose-per-fraction.
- Larger fields and skinfold inclusion.
- Concurrent chemotherapy (especially fluoropyrimidines, anthracyclines) — radiation recall and synergistic dermatitis.
- Higher BMI, smokers, Fitzpatrick I–II skin.
- Pre-existing skin conditions in the field.
- Lymphoedema / chronic skin damage from prior surgery.
Management
- Prophylaxis — daily gentle washing with pH-neutral soap; emollients (Cetraben, Diprobase, urea-based creams) from day 1; avoid perfumed products, hot water, vigorous towel drying, occlusive dressings on intact skin.
- Grade 1 — continue emollients; protective clothing.
- Grade 2 — topical mid-potency corticosteroid (e.g. mometasone, hydrocortisone butyrate) twice daily; non-adherent dressing for desquamated areas.
- Grade 3 — topical potent / superpotent steroid; non-adherent / hydrogel dressings (Mepilex, Allevyn); analgesia; bacterial swab if superinfection suspected; consider treatment break if dose-limiting.
- Grade 4 — wound care team, dressings, possible debridement; treatment interruption usually required.
- Photoprotection of the irradiated field for at least 12 months — even when healed, the skin is photosensitive.
Practice points
- Set patient expectations before treatment — the rash is expected and manageable.
- Counsel that swimming pools, hot tubs and saunas are contraindicated during the reaction.
- Use of metallic / aluminium-containing antiperspirants in the field is debated — most contemporary breast RT protocols permit them.
- Recovery is the norm; refer to dermatology / wound care for non-healing or atypical reactions, persistent ulceration, or features suggesting infection.
- Document the field and dose for any future skin lesion in the area — recurrent cancer, post-RT atypical vascular lesion or angiosarcoma can arise in irradiated skin and be misattributed to RT change.
References
- Cox JD et al. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer. Int J Radiat Oncol Biol Phys; 1995.
- Hymes SR, Strom EA, Fife C. Radiation dermatitis — clinical presentation, pathophysiology, and management. J Am Acad Dermatol; 2006.
- RCR / SCoR / IPEM. Dose fractionation in cutaneous radiotherapy.
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