Cath Lab Digest

P ainful skin reactions can be a source of significant distress to a patient undergoing radiation therapy. Although technological developments have reduced the frequency and severity of skin reactions, they continue to cause pain and inconvenience for patients. Severe reactions cause interruptions in the patient's treatment schedule, possibly compromising the effectiveness of radiation treatment. In some cases, patients choose to discontinue treatment because of the discomfort.

In the first week of radiation, a very faint erythema may appear due to capillary dilatation. After 2 to 3 weeks, endothelial swelling and proliferation occurs, causing obstruction. Obstruction also occurs in the arterioles from endothelial disruption and intimal thickening. Cell production in the germinal layer of the epithelium decreases and dry desquamation, or scaling begins. After 3 to 4 weeks of daily radiation, moist desquamation may develop as a result of skin peeling, vascular dilatation, edema and oozing of serum from the denuded areas.¹

Pain perception due to skin changes varies widely among patients during radiation therapy. Some will report discomfort with the onset of erythema. Others will not complain of discomfort until moist desquamation occurs. In the authors' clinic, patients are evaluated weekly by their physician and nurse during treatment and daily by the radiation therapists with immediate referral to the clinic as needed. Skin pain is evaluated using the Numeric Pain Rating Scale (NPRS).

Although certain skin care principles are commonly used, physicians and institutions often employ a combination of guidelines and products they feel are most effective for patients. Patients are cautioned against using any skin care products not approved by their physician. Antimicrobials such as hydrogen peroxide, hypochlorite, acetic acid, and povidone iodine are not used because they interfere with new skin cell proliferation.¹ Gentle cleansing with mild soap and avoiding friction to the affected area are recommended.² Various dressings can be used to absorb exudate and prevent friction, although occlusive dressings should not be used. The choice of dressing can be a challenge; using tape on the irradiated skin is discouraged.

A new dressing, Mepilex Transfer (Molnlycke Health Care, Newtown, Pa.), has proven beneficial to the authors' patients' symptom management and quality of life. The dressing - an absorbent foam layer with a silicone coating on the side applied to the patient's skin - is useful on a variety of irradiated sites. It does not adhere to a moist wound area, does not require tape, does not tear skin when removed, and can be lifted and readjusted without losing its adherence. It was primarily designed to transfer exudate from a wound to an absorbent dressing. However, for radiation patients, it also has proven effective in reducing distress from painful skin irritation caused by friction and pressure (see Figure 1).