Skin Manifestations on Radiotherapy Patients in Dr. Moewardi

General Hospital Surakarta

Fiska Rosita, Bobby Febrianto, and Muhammad Eko Irawanto

Dermatovenereology Departement

Dr. Moewardi General Hospital/Faculty of Medicine Sebelas Maret University, Surakarta

Keywords: radiotherapy, acute radiation dermatitis, chronic radiation dermatitis

Abstract:

Radiotherapy is a common treatment modality for cancer and 50% of cancer patients receive radiotherapy as

a preoperative, postoperative and palliative therapy. Radiotherapy treatments cause various reactions to the

skin and cause pain, discomfort, irritation, itching, and burning sensations. Side effects that occur in the skin

due to radiation is classified into two, namely acute radiation dermatitis and chronic radiation dermatitis. This

study aimed to determine the skin manifestations which occur in radiotherapy patients in Dr. Moewardi

General Hospital Surakarta. A retrospective descriptive was conducted in Dr. Moewardi General Hospital

with the patient of radiotheraphy. The data were taken from medical record and direct observation. Thirty two

patients were included in this study, 20 female patients and 12 male patients, with the age ranged from 32 to

78 years old. Nasopharyngeal cancer is the most patients radiotherapy. Of all 32 radiotherapy patients only

1 (3.2%) patient received radiotherapy dose 2.5 Gy per fraction, and 24 (75%) patiens had 66 Gy for total

dose. According to the National Cancer Institute grade 1 acute radiation dermatitis occurred in our

radiotherapy patient was erythematous patch with partial hyperpigmentation 48.3%.

1 INTRODUCTION

Radiotherapy is a common treatment modality for

cancer and 50% of cancer patients receive

radiotherapy as preoperative, postoperative and

palliative therapy (Ali et al., 2014). Radiotherapy

treatments cause various reactions to the skin and

pain, discomfort, irritation, itching, and burning

sensations. Skin-induced changes in radiation can

result in disruption of daily activity and quality of life.

Skin reactions to radiation largely depend on the

technique, total dose, volume, and variety of therapy

in each individual (McQuestion, 2011). Side effects

that occur in the skin due to radiation is classified into

two namely acute radiation dermatitis and chronic

radiation dermatitis. Manifestations of acute radiation

dermatitis include erythema, edema, burning,

pruritus, pigmentation, desquamation, hair loss, loose

nails, bullae, erosion and ulceration. While the

manifestations of chronic radiation dermatitis consist

of excessive wrinkling, skin atrophy,

hyperpigmentation, permanent hair loss, dryness of

the skin and keratosis (Ali et al., 2014).

1.1 Acute Radiation Dermatitis

Acute radiation dermatitis is one of the most common

skin reactions caused by radiotherapy and often

occurs within 90 days of exposure (Bray et al.,

2016).The severity of skin reactions may occur from

mild erythema, desquamation to ulceration. Erythema

can be the first symptom that appears 24 hours after

exposure. Erythema can subside within a few days.

And generalized erythema can occur in the second

week until the fourth week of therapy. Other skin

changes such as dry skin, hair loss, and

hyperpigmentation can also be seen (Hegedus et al.,

2016). During the third week to the sixth week of

treatment, if the cumulative radiation dose reaches 20

Gy, dry desquamation may occur. A more severe

reaction of moist desquamation is seen when the total

radiation dose on the skin is 40 Gy or more. The

severity of the disease can be assessed on a scale of

1-4 according to the National Cancer Institute. First

degree is dry desquamation along with widespread

erythema.

Second degree appears rapid erythema or local

slough. This reaction causes a moist desquamation

confined to the skin fold after the cumulative

Rosita, F., Febrianto, B. and Irawanto, M.

Skin Manifestations on Radiotherapy Patients in Dr. Moewardi General Hospital Surakarta.

DOI: 10.5220/0008152601410145

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 141-145

ISBN: 978-989-758-494-7

141

radiation dose reaches 40 Gy or more. The presence

of moist desquamation increases the risk of infection.

Patients may experience increased pain due to

exposure to nerve (Bray et al., 2016). Third

degree

occurs dermatitis with confluent desquamation.

Fourth degree is characterized by ulceration, and

necrosis (Hymes et al., 2006).

The classification of acute radiation dermatitis:

Grade 0 - None

Grade 1 - Faint erythema or dry desquamation

Grade 2 - Moderate to brisk erythema or patchy moist

desquamation, mostly confined to skin fold and

creases; moderate erythema

Grade 3 - Moist desquamation other than skin folds;

pitting edema, bleeding from minor trauma and

abrasion

Grade 4 - Skin necrosis or ulceration of full-thickness

epidermis; may have spontaneous bleeding from

affected area.

1.2 Chronic Radiation Dermatitis

The skin will look relatively normal for different

durations of time after radiotherapy and chronic

changes will not develop for months or years after

receiving radiotherapy (Bray et al., 2016). Severe

chronic skin reactions develop more than 90 days

after radiotherapy is complete. These skin reactions

include epidermal depletion, dermal atrophy,

vascular damage, fibrosis that develops as a

progressive induration with edema formation, and

thickening of the dermis. Other effects which will

occur later are depigmentation, telangiectasis, and

dermal necrosis with ulceration occurring after

radiotherapy (Hegedus et al., 2016). Chronic

radiation dermatitis is a true late-stage reaction that

develops months to years after exposure to

radiotherapy (Bray et al., 2016).

To determine the degree of skin reaction due to

exposure to radiotherapy requires thorough history

about the length of radiotherapy recieved, the first

appearance of skin reaction and then perform physical

examination. The results are then compared with the

National Cancer Institute classification for acute

radiation dermatitis. Therefore we conducted this

study to determine the skin manifestation in patient

undergoing radiotherapy in Dr. Moewardi General

Hospital Surakarta.

2 METHODS

This retrospective descriptive study was conducted in

the Radiotherapy Division of Dr. Moewardi General

Hospital Surakarta. All of the data were taken from

skin examination and from medical record data. Data

collected were sex, age, type of cancer, common

exposed areas, and dermatological status.

3 RESULTS

Our study obtained 32 subjects, 20 females and 12

males. Most patients receiving radiotherapy started at

the age of 46, this ranged from 46 to 65. Head and

neck (62.5%) were the most common exposed sites,

followed by mamae area (25%). The most cancer type

in our study is nasopharyngeal cancer (40.6%).

Erythematous patches with partial hyperpigmentation

(48.3%) was the most common skin manifestation,

while erythematous patches was less common

(28.1%). Based on national cancer institute all of skin

manifestation was grade 1 acute radiation dermatitis.

Of all 32 radiotherapy patients only 1 (3.2%) patient

received radiotherapy dose 2.5 Gy per fraction. The

most widely accepted total dose of radiotherapy

patients in Dr. Moewardi General Hospital was 66

Gy (Table 1)(Fig.1).

4 DISCUSSION

Intrinsic factors such as general skin condition,

nutritional status, age, comorbid disease (diabetes

mellitus and connective tissue disorders) and

ethnicity all modulate the risk of acute skin reaction (

Hegedus et al., 2016). Skin manifestation can affect

both sexes though in our study they mostly affected

female. According study by Mateusz Spalek in 2016

stated that female sex is still suspected as an

independent predictor of severe skin reactions

(Spalek, 2016). Skin reactions due to radiotherapy

based on the age are related to skin healing ability, as

they decrease with age. It is caused by aging, loss of

collagen, and decreased capillary tissue. Based on

radiotherapy exposure location, the head and neck

area was found to be the largest area affected 62.5%

so that it may cause increased skin reactions more

frequently due to the area having thin epidermal

layers on that area (Ali et al., 2014).

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

142

Table 1. The data of patiens receiving radiotherapy and their skin manifestation

Total

(n=32)

Percentage

(%)

Gender

Male

Female

37.5

62.5

Age (year)

26-35

36-45

46-55

56-65

>65

6.3

21.9

25.0

21.9

Expose area

Head and Neck

Breast

Abdomen

62.5

28.1

9.4

Type of cancer

Breast cancer

Nasopharyngeal cancer

Larynx cancer

Lung cancer

Ear cancer

Palatum cancer

Hypopharynx cancer

Cervix cancer

25.0

40.6

9.4

6.3

3.1

9.4

Skin manisfestation

Patch erythematous

Patch erythematous with partial

hyperpigmentation

Patch hyperpigmentation with crust

No skin manifestation

28.1

48.3

6.3

21.9

Degree of acute radiation dermatitis

First degree

Second degree

Third degree

Fourth degree

100

Fractional dose

2 Gy

2,5 Gy

96.8

3.2

Total dose of radiation

40 Gy

50 Gy

60 Gy

66 Gy

9.4

3.1

12.5

75.0

Study from Ahmad Ameri and Mona Malekzadeh,

2017 reported that radiation dermatitis is commonly

seen in patients with breast cancer, head and neck

cancer, lung cancer and sarcoma due to the superficial

position of these cancer and higher radiation dose

affect the skin (Ameri & Malekzadeh, 2017).

According to the National Cancer Institute grade

1 acute radiation dermatitis occurred in our

radiotherapy patients was erythematous patch with

partial hyperpigmentation. The severity of the skin

manifestation is related to both intrinsic and extrinsic

factors. Extrinsic factors include the total dosage of

radiation, fractioned delivery schedules, volume of

irradiated tissue and the radiosensitivity of the

involved tissue (Bray et al., 2016).

Skin Manifestations on Radiotherapy Patients in Dr. Moewardi General Hospital Surakarta

143

Figure. 1: First degree of acute radiation dermatitis

Among patients received radiotherapy in Dr. Moe-

wardi General Hospital, only 1 (3.2%) patient had

radiotherapy dose of 2,5 Gy per fraction and 24 (75%)

patients with total dose of 66 Gy. Radiation doses of

more than 2 Gy per fraction are linked with the

development of more severe delayed skin reactions

(Hegedus et al., 2016). The level of damage received

equates directly to the amount of radiation exposure

(Maddocks-Jennings,. et al., 2005). Based on the

Fanni Hegedus study, Laju M, Matthew, and Robert

Schwartz stated that a total of 40 Gy or more dose can

cause severe skin manifestations such as moist

desquamation. This is also supported by studies

conducted by Fleta N. Bray, Brian J. Simmons, Aaron

H. Wolfson, and Keyvan Nouri who also support it.

This is evidenced in a study by Rodrigo Mosca et al

in 2013 how the effect of total dose and dose

fractional affects the appearance of skin

manifestations in mice, whereas at 2 Gy fractional

dosage has caused transient erythematous. However,

in that study it was found that lower doses ranged

from 1 - 43.5 Gy, 2 - 58 Gy, 3 - 72.5 Gy did not result

in severe dermatitis reaction (Mosca et al., 2013). In

acute radiation dermatitis does not require immediate

treatment. The healing occurs about 28-40 days after

the peeling and can recover within 3-6 months after

exposure (Jaschke et al., 2017).

5 CONCLUSIONS

Based on our finding, it is necessary to have a

thorough examination when we have cancer patient

so that we can give better management for the skin

problem.

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