Skip to Main Content

Case history

image A 55-year-old woman underwent right wide local excision and sentinel node biopsy for an invasive ductal cancer of the breast. Histology confirmed a 15 mm grade 1, oestrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative tumour. Sentinel lymph node biopsy was free from cancer.

She was discussed at the breast multidisciplinary team meeting and adjuvant radiotherapy was recommended to the breast. She completed an uneventful 3 week course of radiotherapy 40 Gy in 15 fractions.

Seven days later she attended the radiotherapy department complaining of red, itchy skin and a swollen, uncomfortable breast. Radiation Therapy Oncology Group (RTOG) grade 1 skin reaction was diagnosed and the patient was given advice on skin care. Paracetamol for pain relief was prescribed along with 1% topical hydrocortisone cream. The rash settled over the next week, with no subsequent sequelae.

How does radiotherapy affect the skin?

What factors affect a radiotherapy reaction?

What advice should be given to patients to reduce the risk of a radiotherapy-induced skin reaction?

How should the patient be assessed?

How should acute skin reactions due to radiotherapy be managed?

How does radiotherapy affect the skin?

All patients having radiotherapy are at risk of developing an acute skin reaction in the treated radiation field. Acute skin reactions are one of the most common acute effects of external beam radiotherapy. Skin reactions cannot be prevented, but all patients should be given consistent general skin care advice before starting treatment, including avoidance of exacerbating factors, which may help to delay the onset of reaction and maintain skin integrity.

The skin has two main layers: the outer epidermis and the underlying dermis. The epidermis is made up of several layers, which include the basal cell layer (Figure 21.1). Radiotherapy causes damage in the cells by affecting DNA during mitosis and activates a normal physiological inflammatory response.1 Damaged cells in the basal layer are replaced by cells moving into the active cell cycle from the resting phase.

Erythema develops 10–14 days after starting treatment, when damaged basal cells migrate to the skin surface. Patients experience warm, reddened (erythematous) skin, which may also be itchy. Ongoing radiation exposure causes an increase in mitotic activity and further damage as the skin tries to replace damaged cells. New cells are produced more quickly than old cells are lost, which causes the skin to become dry and flaky (dry desquamation). Production of new skin cells diminishes as epidermal cells continue to peel from the surface, causing the outer layer of the epidermis to become broken, with an exudate (moist desquamation).

Skin reactions may peak 7–10 days after completion of the radiotherapy course, as this is the length of time taken by the most damaged cells to migrate ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.