Journal of Community Nursing - page 22

22 JCN
2013,Vol 27, No 4
SKIN CARE
Promoting a moist wound
healing environment when
indicated
Supportive wound management
— fungating wounds, bleeding,
odour.
Patients require both verbal and
written information, which should
include:
How and why reactions occur
When and where they are likely
to appear
How the reaction may feel
and look
How it will be treated
Self-care strategies
Risk factors that can exacerbate
the reaction.
Management of a radiotherapy-
induced skin reaction is grade
specific, with interventions
changing in line with progression
of the reaction. General skin care
information should be given to all
patients at the start of treatment to
support self-management, including
advice on bathing, hygiene, suitable
skin care products, exposure of the
treatment field and how to avoid
further damage.
Grade-specific management
and interventions
The primary aim of initial
interventions (RTOG 0–2) is to
promote comfort, assist hydration
and maintain clean, intact skin.
From the start of radiotherapy, it is
important to keep the area clean
and hydrated and patients are
encouraged to continue with their
‘normal’ hygiene practices.
However, as the skin becomes
more sensitive during the course
of radiotherapy, the use of non-
irritant toiletries and skin care
products (those that are colour-,
fragrant- and soap-free) is
often recommended to avoid
further irritation. A common
recommendation is to apply
aqueous cream to intact skin at
the beginning of treatment to aid
hydration and comfort. However,
some recent studies involving
patients with atopic dermatitis have
highlighted potential problems
(irritation and stinging at the site
of application) associated with the
use of aqueous cream as a leave-on
moisturiser (Cork and Danby, 2011).
Consequently, it has been suggested
that this product should no longer
be used for radiotherapy-induced
skin reactions due to the inclusion
of known irritants, i.e. sodium lauryl
sulphate (SLS) (Patel et al, 2013).
In light of this, there has been
increasing interest in using an
SLS-free aqueous cream as a
simple, moisturising agent, but
more research trials are needed to
support this in clinical practice. It
is also important to mention that
many patients are reassured by
the fact that they can participate
in their care by ‘doing something’
to help manage potential side-
effects and alleviate symptoms.
The therapeutic value of proactive
management should not
be underestimated.
Management of moist
desquamation (RTOG 2.5–4)
focuses on minimising trauma and
discomfort, preventing infection
and promoting healing. Once
the reaction has progressed to
this stage, there are additional
considerations in relation to
compromised skin integrity. The
development of patchy or moist
desquamation necessitates the use
of appropriate dressings to cover
the broken areas.
Grade 4 reactions (ulceration
and necrosis) are rarely seen, but
require specialist management and
advice from a clinical oncologist
or specialist practitioner. There
is limited evidence to support
or refute the use of dressings
promoted as suitable for the
management of radiotherapy-
induced skin reactions. However,
to avoid causing the patient further
trauma, there are several types of
dressing that should be considered
(Trueman, 2011):
Atraumatic: to reduce pain at
dressing change
Non-adhesive or silicone-based:
to avoid adhesion and further
damage to delicate, irradiated
skin
Absorbent: to contain exudate
Conformable: for difficult-to-
dress areas
Comfortable: to reduce
discomfort and friction
and promote compliance
with treatment
Easily applied and removed:
to support self-care and
patient involvement.
Infected skin reactions are rare,
although possible. It is widely
accepted that the use of metallic-
based topical agents and products
are not recommended while the
patient is receiving radiotherapy
due to the association with
radiation ‘scatter’ (a secondary
radiation which occurs as a result
of the beam intercepting an object
causing some x-rays to scatter) and
increased surface dose (Kumar et al,
2001; Wells and MacBride 2003).
If there are indications of wound
infection once treatment has been
completed, appropriate infection
management should be initiated.
This may include antimicrobial
products such as silver dressings,
however, specialist advice should
always be sought.
Education and training
Lack of knowledge and skills
can be a barrier to caring for this
patient group, purely because staff
who are not based in radiotherapy
centres rarely encounter these skin
reactions.
Additionally, confusion
regarding choice of dressings and
requests for unfamiliar products can
lead to unsuitable alternatives being
used, causing further trauma, pain
and delayed healing (Harris et al,
2011). To help solve this problem,
a joint working initiative with
healthcare partners, culminated in
the production of an educational
toolkit to support and guide
healthcare professionals (DH, 2008).
The combination of background
knowledge and clinical guidance
provided a framework to assist
clinicians in the assessment and
management of radiation-induced
skin reactions.
Conclusion
Skin reactions are one of the most
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