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Erythema - diagnosis and treatment

» How soon can one expect to see radiation-induced erythema in the clinical practice of radiological interventional procedures?

As is the case when discussing radiation doses, the time after irradiation needed for erythema to occur should be expressed as a range. In a few cases where doses are very high, erythema can be observed a few hours after irradiation. This timing makes the recognition of the possible link between the irradiation and skin symptoms easier, but this situation is rare.

In most cases there is a delay between the induction of the injury and the recognition of symptoms. Typically about two to three weeks’ time is required before symptoms emerge, and three to four weeks before the symptoms are sufficiently irritating for the patient to see a doctor. Thus, if not informed in advance, physicians and patients do not usually associate the skin reaction with a radiological procedure. 

» Should all patients undergoing interventional procedures be expected to have risk of skin injuries and asked to report back for a skin check-up?

No.

A systematic ‘follow-up’ check-up of all patients undergoing an interventional radiology procedure is not necessary. Only patients who are suspected to have received doses high enough to cause skin injuries should be followed-up. This fact makes it most important that each interventional facility keeps accurate records of patient dose and implement a rigorous quality assurance practice at all times.

Further, it is of utmost importance that all patients undergoing such procedures be aware of the possibility of skin symptoms, so that they can report any skin symptoms occurring in the relevant areas. Other patients who require follow-up are those with conditions associated with higher radiosensitivity e.g. ataxia telangiectasia. Moreover, this awareness about the possibility of erythema on the part of doctors performing radiological procedures and also among dermatologists is essential. An understanding of dose and information about the dose delivered to the patient can be helpful in avoiding unnecessary follow-up or concern. 

The patient should be advised about the areas on the skin of the back (in cardiac interventions) where erythema might develop. This is best given to the patient in writing in the form of a letter or brochure that will inform the patient of what to look for and remind them to check for possible complications from the irradiation event. The patient should be asked to examine himself or herself until about 2 to 3 weeks after the procedure for any skin changes in those areas. Some facilities place a follow-up call to the patient during this time to ask about skin irritation and this is found to be effective in ensuring that a patient who develops skin irritation does not seek medical help at a place where there may be a chance of missing the correct diagnosis.

The Society of Interventional Radiology guidelines for patient radiation dose management recommend a 2 week skin check when the procedure has involved 60 minutes of fluoroscopy, which is considered a rough indicator of high dose procedures.

» What approach can help to diagnose radiation-induced erythema after a radiological procedure?

In clinical practice, the diagnosis of radiation induced erythema may be either extremely difficult if it is not recognized by the medical professionals caring for the patient (as has been the case in many patients in the past) or very easy, if the association between the radiological procedure and the skin changes is made.

The worst situation may occur when the patient has not been informed at all about possible skin effects, and when little or no follow-up of any kind is planned. In such a situation, the patient leaves the facility with no knowledge about the potential skin effects. If an effect develops, the patient is less likely to associate it with the procedure that was performed previously. If the patient seeks medical help for the erythema, the physician might not realize that the radiological procedure could have caused the effect and will look for other diagnoses, all of which would be incorrect. Care will be delayed and rather misplaced.

The literature reports on many cases in which weeks have been lost in trying to put a name on strange and unusual skin lesions presented by a patient, with a succession of ineffective therapies. Everything should be done to avoid such situations. Finally, if health care professionals fail to recognize the cause and effect between irradiation and skin changes, the facility will have no feedback that this has occurred, leaving the interventionalist to incorrectly assume that he or she used safe practice, when in fact, this was not the case.

On the other hand, the diagnosis becomes much easier if the patient has been provided with a brochure providing information about the possibility of skin symptoms (reddening, itchy skin changes) in the area treated. In such a situation, he/she can report immediately to his/her interventionalist, who will easily identify the link with the radiological procedure. If the patient seeks the advice of a dermatologist or of any physician, he/she will be able to then mention his/her recent radiological procedure as possibly responsible for such a skin lesion, and this will help the physician to identify the direct link between the irradiation exposure and the skin erythema.

The appearance of skin erythema is quite typical in that the skin changes draw a precise outline of the exposed areas.

» How can erythema be treated?

Local management of erythema remains a matter of discussion, with some controversy and on-going scientific investigation. The first (transient) early phase usually does not require any treatment, and frequently subsides before any therapy can be started.
The second erythema phase (if correctly recognized) usually requires some prescription medication.

One of the most popular therapies is Aloe Vera, given in lotion or ointment form. Although it has not been proven very effective in radiotherapy induced erythema, nor shown to be superior to other ointments or creams through several trials, it remains a frequently prescribed treatment.

Biafin cream is also frequently prescribed, particularly by the radiotherapy community. However, there is no randomized trial supporting its use. Its use is actually questioned by some authors.

Trolamin has been tested in several trials; no advantage was found for its use in a series of 547 patients irradiated for cancers of the head and neck. One trial showed superiority over Biafin, but another showed inferiority over Calendula.

Calendula Officinalis is one of the rare treatments of early phase skin reactions for which a clear advantage (versus Trolamin) has been demonstrated in a randomized trial: 254 patients irradiated for breast cancer were randomly assigned either to Calendula local therapy (126 Cases) or to Trolamin (128). The incidence of grade 2 radiodermatitis was less with Calendula (41 %) than with Trolamin (63 %) (p<0.001).

Local steroids (ointments) are also commonly used, but a randomized trial has not indicated much success in using this therapy as a prevention of radiation-induced erythema in radiotherapy. This treatment may however help reduce the inflammatory reaction.
Hyaluronic acid may be a possible treatment of early radiation-induced skin reactions; a double-blind, randomized trial has shown that the prophylactic use of a cream with hyaluronic acid was able to reduce the incidence of high-grade radiodermatitis compared to a placebo.
When the level of injury reaches moist desquamation, eosin and anti-pain therapies are usually necessary, combined with antibiotics and steroids in selected cases that require them.

Management of necrosis exceeds the scope of this document. The management of large areas of radiation-induced necroses is usually difficult and should be managed by experienced teams, and may require skin grafting.

Large excisions of the necrotic tissue and surrounding tissue are needed as there is no chance of recovery. Such excisions may be increasingly guided by imaging such as MRI. Reconstruction of the soft tissues in the affected area may require autologous skin grafts, but may necessitate in some cases much more sophisticated approaches (such as grafting of artificial dermis in an intermediate phase, musculo-cutaneous rotational or ‘free’ flaps, epiploïc flaps, etc.).

References:

  • Balter, S., Hopewell, J.W., Miller, D.L., Wagner, L.K, Zelefsky, M.J., Fluoroscopically guided interventional procedures: A review of radiation effects on patients’ skin and hair. Radiology 254 2 (Feb. 2010) 327-341. 
  • INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, 2000. Radiopathology of skin and eye and radiation risk. ICRP Publication 85, Pergamon Press, Oxford (2000). 
  • Wagner, L.K., Radiation injury is a potentially serious complication to fluoroscopically-guided complex interventions, Biomed. Imaging Interv. J.3 2 (2007) e22. 
  • Elliott, E.A., Wright, J.R., Swann, R.S., Nguyen-Tân, F., Takita, C., Bucci, M.K., Garden, A.S., Kim, H., Hug, E.B., Ryu, J., Greenberg, M., Saxton, J.P., Ang, K., Berk, L.,Phase III Trial of an Emulsion Containing Trolamine for the Prevention of Radiation Dermatitis in Patients With Advanced Squamous Cell Carcinoma of the Head and Neck: Results of Radiation Therapy Oncology Group Trial 99-13, J. Clin. Oncol. 24 13 (May 2006) 2092-2097. 
  • Pommier, P., Gomez, F., Sunyach, M.P., D'Hombres, A., Carrie, C., Montbarbon, X., Phase III Randomized Trial of Calendula Officinalis Compared With Trolamine for the Prevention of Acute Dermatitis During Irradiation for Breast Cancer, J. Clin. Oncol. 22 8 (Apr. 2004) 1447–1453. 
  • Boström, A., Lindman, H., Swartling, C., Berne, B., Bergh, J., Potent corticosteroid cream (mometasone furoate) significantly reduces acute radiation dermatitis: results from a double-blind, randomized study, Radiother. Oncol. 59 3 (Jun. 2001) 257-265. 
  • Schmuth, M., Wimmer, M.A., Hofer, S., Sztankay, A., Weinlich, G., Linder, D.M., Elias, P.M., Fritsch, P.O., Fritsch, E., Topical corticosteroid therapy for acute radiation dermatitis: a prospective, randomized, double-blind study, Br. J. Dermatol. 146 6 (Jun. 2002) 983-991. 
  • Liguori, V., Guillemin, C., Pesce, G.F., Mirimanoff, R.O., Bernier, J., Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy, Radiother. Oncol. 42 2 (Feb. 1997) 155-161. 
  • Hymes, S.R., Strom, E.A., Fife C., Radiation dermatitis: clinical presentation, pathophysiology, and treatment, J. Am. Acad.Dermatol. 54 (Jan. 2006) 28 –46.