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4 Interventions for Breast Cancer Patients with Acute Radiation Dermatitis

4 Interventions for Breast Cancer Patients with Acute Radiation Dermatitis

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7



Breast Cancer



Cancer Treatment Group trial [131] reported no

difference in the maximum grade of CTCAE

v3.0 toxicity (provider assessed) or incidence of

grade 3 toxicity when comparing 0.1 % mometasone furoate with a placebo cream. However, the

use of the steroid cream significantly decreased

the patient-reported symptoms of pruritus and

skin irritation. The potency of the steroid cream

which best achieves maximum benefit is

unknown. Prolonged use of high-potency creams

should be avoided to decrease the risk of skin

atrophy.

Barrier-forming products include Cavillon

No Sting Barrier (spray on), Mepilex Lite dressings, and Mepitel Film. These products provide

protection from friction and rubbing of the skin.

The film formulation of the Cavillon No Sting

Barrier was shown in a small trial to reduce the

severity of acute radiation dermatitis in breast

cancer patients [132]. However, the cream formulation, which also contained emollients and

dimethicone, did not produce similar results in a

randomized trial of 333 postmastectomy patients

[21]. Mepitel Film (Safetac-based soft silicone)

was reported to completely prevent moist desquamation in a small trial of 78 women receiving

postmastectomy radiation [38]. Bolus was used

in only 18 % of the patients. It was estimated that

the film had a 0.12 mm bolus effect. In contrast,

Mepilex Lite dressings have been reported to

decrease the severity of the acute reactions but

not significantly decrease the incidence of moist

desquamation [133]. Their bolus effect is reported

to be 0.5 mm [38]. Mepitel Film is worn continuously even in the shower and during the radiation

treatment. Mepilex Lite dressings cannot be worn

in the shower and should not be worn during

treatment.



7.4.2



Treatment



Dry desquamation is characterized by hyperpigmented or erythematous, peeling, dry flaky, and

pruritic skin. The goal of treatment for dry desquamation is to minimize patient discomfort

and maintain the moisture balance of the skin.



99



We start with a mild enzymatic wound cleanser

such as Skintegrity. The wound cleanser is mild,

does not irritate the skin, and promotes gentle

exfoliation. This allows moisturizers to better

penetrate the skin. Moisturization can then be

achieved by the use of emollient, occlusive, or

humectant moisturizers such as calendula, A&D

Ointment, white petroleum, or Medihoney with a

hydrogel base or secondary dressing. Topical steroids can be used to treat the associated pruritus

if the skin remains intact.

Dressings such as Mepilex Lite, hydrogel colloidal sheets with or without Medihoney, can be

applied to the areas such as the inframammary

fold or axilla to reduce friction, and irritation, and

to assist in maintaining the skin’s hydration.

Medihoney works well with dry desquamation as

it is soothing, is healing, and promotes hydration.

Care should be taken when removing the hydrogel sheets that are self-adhering as they can cause

a skin tear upon removal. Patients are instructed

to remove these dressings in the shower if they do

not easily lift off.

Maintaining adherence of the soft silicone

dressing (Mepilex) can be difficult once the skin

is moisturized. Patients are advised to wait

30–60 min to apply the dressing or spray the area

with Cavillon No Sting Barrier to promote adherence of the dressing.

Moist desquamation is characterized by a loss

of the integrity of the epidermis with weeping of

the tissues. Secondary Staphylococcus aureus

infections have occurred in patients with

untreated or prolonged moist desquamation.

Hydrocolloid and or hydrogel dressings have

been used and suggested in the management of

moist desquamation. The dressings maintain a

moist environment for skin reepithelialization.

Moist environments have been found to promote

wound healing. However, a study by Mcmillan

et al. [134], comparing the effects of hydrogel to

a dry dressing on the healing time of moist desquamation, reported that healing time in the

hydrogel dressing group was significantly prolonged. It is possible that the prolonged moisture

in this patient population can lead to increased

maceration.



B. Fowble et al.



100



We have seen this anecdotally in some of our

patients with moist desquamation. Our approach

to moist desquamation is to promote drying,

healing, and patient comfort during this time. We

have used a combination of therapies including

topical anti-infectives such as zinc and bacitracin, in a one-to-one mixture, with a secondary

cover dressing of Telfa to minimize skin trauma

and a cover dressing such as soft absorbent silicone (Mepilex Lite or Mepilex). Following the

wound care literature, we leave the dressing in

place for 24 h to minimize trauma to the wound.

The dressing is removed daily and cleansed with

a 0.5 % Hibiclens solution or Skintegrity. The

area is redressed and left in place for another

24 h. Healing usually occurs over 3–4 days.

Silver ion dressings such as Aquacel Ag or

Mepilex Ag have been applied directly to the

wound that has been cleansed with Skintegrity or

0.5 % Hibiclens solution. This has been effective

in prevention of infection and promotion of healing through maintenance of adequate moisture

balance, allowing wound healing and preventing

maceration. The dressing is left in place for



24–48 h. Healing usually occurs over 3–4 days.

All of these dressings provide immediate comfort

for the patients’ wounds and promote healing of

moist desquamation.



7.5



Photographs

and Recommendations



Below are general skin care recommendations

(Table 7.2), week-by-week treatment instructions, and photographs that demonstrate typical

skin reactions over time for patients undergoing

breast-conserving surgery (Table 7.3), mastectomy with autologous reconstruction (Table 7.4),

mastectomy with implant-based reconstruction

(Table 7.5), and mastectomy without reconstruction (Table 7.6). Photographs of skin reactions

varying by ethnicity are provided in Table 7.7,

and photographs of special cases and reactions,

with treatment instructions, are provided in

Table 7.8 [135]. Figure 7.1 is a suggested general

treatment algorithm for skin care for breast cancer patients.



Table 7.2 General principles of skin care for breast cancer patients

Patient should:

• Cleanse daily with mild soap and water

• Use lotions and creams recommended by provider

• Continue to wear garments that provide support to the breast such as bras, tube tops, and tank tops

Patient should not:

• Rub, put pressure on, or scratch radiated area

• Take hot water showers or baths, use wash cloths, or use loofahs

• Apply any lotion, cream, or ointment within the 3 hours prior to radiation treatment

• Wash off lotion, cream, or ointments if applied three or more hours before radiation treatment

• Apply drying agents to the skin unless instructed to do so



7



101



Breast Cancer



Table 7.3 Examples of typical acute skin reactions and recommended interventions for women undergoing breastconserving surgery and whole breast radiation are provided below

Week

1



Skin reaction

48-year-old Filipino, S/P

breast-conserving surgery



Reaction type

No reaction



Intervention

• Cleanse daily with mild soap

and water

• Apply Lotion Soft twice a day



2



No reaction







Cleanse daily with mild soap

and water

• Apply Lotion Soft twice

a day



3



Hyperpigmentation

and early erythema in

the inframammary fold







4



Erythema most

prominent in the

inframammary fold

and axilla with

hyperpigmentation







Cleanse daily with mild soap

and water

• Switch to calendula cream and

apply twice a day

• Avoid application 3 h prior to

receiving radiation



Apply Skintegrity spray

once a day to skin before

shower and rinse off after

1–2 min

• Continue calendula twice a day

• Liberally apply A&D Ointment

to radiated site once a day at

bedtime. It does not need to be

washed off in the morning.

Patient can wear an old cotton

tee shirt as the ointment has a

faint yellow tinge and can stain

sheets and undergarments

(continued)



B. Fowble et al.



102

Table 7.3 (continued)

Week

5



Skin reaction



Reaction type

On treatment;

combination of early

moist desquamation,

dry desquamation, and

hyperpigmentation



Intervention

• Continue Skintegrity once a day

to the entire radiation site

• Manually debride areas of dry

desquamation

• Continue calendula once to

twice a day



5



Moist desquamation

with Mepilex Ag







1 week post

radiation



Dry desquamation;

evidence of peeling

has occurred









Apply Mepilex Ag to areas

of moist desquamation to protect

and allow healing

• Ensure dressings are completely

removed from skin prior to

radiation treatment

• Continue A&D Ointment, to the

undressed area, once a day

before bed















2 weeks

post

radiation



Resolution of

desquamation and

resolving of

hyperpigmentation











Continue Skintegrity once a day

Manually debride peeling skin

with tweezers or gently with

clean gauze

Continue calendula twice a day

Continue A&D Ointment once a

day at bedtime

Avoid agents that will dry the

skin (Domeboro, aloe vera) as

this will cause discomfort to the

patient

Mepilex Lite to the

inframammary fold and axilla as

needed to reduce skin friction

and promote comfort

Cleanse daily with mild soap

and water

Moisturize daily with an agent

of patient’s choice

May continue or discontinue

Skintegrity



7



103



Breast Cancer



Table 7.4 Examples of typical acute skin reactions and recommended interventions for women undergoing mastectomy with autologous reconstruction and postmastectomy radiation are provided below

Week

1–2



Skin reaction

58-year-old Caucasian female

with stage III right breast

cancer S/P deep inferior

epigastric perforator (DIEP)

reconstruction. Custom bolus

used every other day



Reaction type

No reaction



Intervention

• Cleanse daily with mild soap and

water

• Apply a thin coat of 1 %

hydrocortisone cream twice a day

• Apply Lotion Soft twice a day

• Avoid application 3 h prior to

receiving radiation



3



Diffuse mild

erythema







4



Erythema and

follicular

reaction on

upper inner

quadrant







Cleanse with Skintegrity spray once a

day. Allow to remain on the skin for

1–2 min and then rinse off

• Continue to apply a thin coat of 1 %

hydrocortisone cream twice a day

• Switch to calendula cream and apply

twice a day

• Avoid application 3 h prior to

receiving radiation

Continue to cleanse with Skintegrity

spray once a day

• Continue hydrocortisone twice a day

• Continue to apply calendula cream

once or twice a day

• Liberally apply A&D Ointment to

radiated site once a day at bedtime. It

does not need to be washed off in the

morning. Patient can wear an old

cotton tee shirt as the ointment has a

faint yellow tinge and can stain

sheets and undergarments

(continued)



B. Fowble et al.



104

Table 7.4 (continued)

Week

5



Skin reaction



Reaction type

Erythema with

pruritic

follicular

reaction



Intervention

• Continue to cleanse with Skintegrity

spray once a day

• Medihoney HFC pad to follicular

reaction. Leave in place for 24–48 h

(remove prior to treatment)

• Continue hydrocortisone twice a day

to remaining skin

• Continue to apply calendula cream

and A&D ointment once a day to the

uncovered skin







6 months

post

radiation



Continue to moisturize the skin daily

with a moisturizing agent of the

patient’s choice



Table 7.5 Examples of typical acute skin reactions and recommended interventions for women undergoing total skinsparing mastectomy with implant-based reconstruction and postmastectomy radiation are provided below

Week

1–2



Skin reaction

47-year-old Caucasian female

with Stage III breast cancer S/P

total skin-sparing mastectomy

(TSSM). Custom bolus used

every other day



Reaction type

No reaction



Intervention

• Cleanse daily with mild soap and

water

• Apply a light moisturizer such as

Lotion Soft twice a day



(continued)



7



Breast Cancer



105



Table 7.5 (continued)

Week

3



Skin reaction



Reaction type

Mild hyperpigmentation



Intervention

• Cleanse daily with mild soap and

water

• Continue light moisturizer twice

a day

• Avoid application 3 h prior to

receiving radiation



4



Early erythema







Cleanse with Skintegrity spray

once a day. Allow to remain on

the skin for 1–2 min and then

rinse off

• Switch to calendula cream and

apply twice a day

• Avoid application 3 h prior to

receiving radiation



5



Follicular reaction and

mild erythema

Medihoney HFC pad

applied to follicular

reaction







Continue to cleanse with

Skintegrity spray once a day

• Continue calendula twice a day

• Apply 1 % hydrocortisone cream

to the follicular reaction, twice a

day, or apply Medihoney HFC

pad to the area and leave in place

till next radiation treatment

• Liberally apply A&D Ointment

to radiated site once a day at

bedtime. It does not need to be

washed off in the morning.

Patient can wear an old cotton tee

shirt as the ointment has a faint

yellow tinge and can stain sheets

and undergarments



(continued)



Table 7.5 (continued)

Week

1 week

post

radiation



Skin reaction



Reaction type

Brisk erythema with

continued follicular

reaction







Continue to cleanse with

Skintegrity spray once a day

• Continue to apply calendula

twice a day

• Apply Mepilex Ag to moist

desquamation to allow healing

and prevent infection

• Cleanse daily with mild soap and

water. Moisturize area with agent

of choice



2 weeks

post

radiation



1 week

post

radiation



Intervention

• Manually debride areas of dry

desquamation

• Continue treatment as above



43-year-old Asian female with

chest wall recurrence. S/P total

skin-sparing mastectomy and

permanent implant. Treated with

custom bolus every other day



Moist desquamation

and marked erythema

























Cleanse with diluted 0.5 %

Hibiclens wash or Skintegrity

spray once a day. Allow to

remain on the skin for 1–2 min to

and then rinse off

Apply Aquacel Ag (or similar

dressing) cut to fit over the area

of moist desquamation. Cover

this with a secondary dressing,

such as Mepilex Lite

May apply Cavillon No Sting

Barrier under the edges of the

Mepilex to help it adhere to the

skin better

Do not use tape or adhesives on

the radiated skin

Continue calendula cream to

undressed skin

Change dressing every 24 h

Wet the primary dressing

thoroughly if it does not come off

easily to avoid traumatizing new

skin with dressing removal



(continued)



Table 7.5 (continued)

Week

2–3

weeks

post

radiation



Skin reaction



Reaction type

Resolved moist

desquamation with

residual

hyperpigmentation



Intervention

• Continue to moisturize the skin

daily with calendula or

a moisturizing agent of the

patient’s choice



Table 7.6 Examples of typical acute skin reactions and recommended interventions for women undergoing mastectomy without reconstruction. Bolus used every other day

Week

3–4



4–5



Skin reaction



Reaction type

Hyperpigmentation and

mild erythema



Intervention

• Cleanse the site daily with

Skintegrity. Spray once a day to

the skin and rinse off after

1–2 min in shower

• Discontinue Lotion Soft

• Switch to calendula cream and

apply twice a day

• Avoid application 3 h prior to

receiving radiation



Moderate erythema,

hyperpigmentation, and

dry desquamation in the

axilla































Cleanse the site daily with

Skintegrity spray once a day to the

skin, allow it to sit for 1–2 min,

and then rinse it off in the shower

Continue calendula twice a day

Liberally apply A&D Ointment to

radiated site once a day before

bed. It does not need to be washed

off in the morning. Patient should

wear an old cotton tee shirt as the

ointment has a faint yellow tinge

and can stain sheets and

undergarments

Continue A&D Ointment for 1

week post radiation and then

discontinue

Manually debride peeling skin

with tweezers or gently wipe the

area with clean gauze if tolerated

by the patient

Avoid agents that will dry the skin

(Domeboro, aloe vera) as this will

cause discomfort to the patient

Mepilex Lite can be applied to the

axilla as needed to reduce friction

Ensure dressings are completely

removed from the skin prior to

radiation treatment

(continued)



B. Fowble et al.



108

Table 7.6 (continued)

Week

2 weeks

post

radiation



6 months

post

radiation



Skin reaction



Reaction type

Resolution of

desquamation and

reduction of

hyperpigmentation



Intervention

• Cleanse daily with mild soap and

water

• Discontinue Skintegrity

• Discontinue A&D Ointment

• Avoid agents that will dry the skin

• Moisturize daily with calendula or

an agent of patient’s choice



Mild residual

hyperpigmentation







Moisturize daily with agent of

patient’s choice



Asian



Caucasian



African American



Table 7.7 Skin reaction by ethnicity: week five, breast-conserving surgery plus radiation

Filipino



Hispanic



7

Breast Cancer

109



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