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Radiation skin reactions are a result of damage to the basal cell layer of the skin

How to measure radiation dermatitis 

Predicting the severity of skin reactions can be difficult due to the varying radio-sensitivity of the skin and a number of contributing factors. Intrinsic and extrinsic factors may significantly increase the severity of radiation therapy skin reactions which may delay the healing process.

Individuals with darker skin may notice that the skin in the treatment field starts to darken. Regular skin assessments are essential to ensure that the right interventions are implemented at the right time. The skin reactions of every patient are different which demands a close observation of the patients’ side effects.33

First symptoms: 10 – 14 days after the first radiation therapy dose

In general, radiation skin damage can be seen approximately 10–14 days after the first dose of radiation. This corresponds with the time it takes for impaired cells to migrate to the surface of the skin. If the new cells reproduce faster than the old cells are shed, the skin will become dry and flakey (dry desquamation).33

When radiotherapy continues, the body may not produce enough new cells to replace the old ones. As a result, the outer layer of the skin may break and start to ooze – so called moist desquamation has developed.15

The severity of skin reactions may increase for 2 more weeks after the completion of radiation therapy. Each hospital has a different way of managing radiation dermatitis, based on the skin’s condition.

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Radiation dermatitis: scales and grading systems

A number of different systems have been developed to measure and describe the spectrum of radiation dermatitis. The research institutes which define the radiation dermatitis scales include organizations such as the National Cancer Institute (NCI), the Radiation Therapy Oncology Group (RTOG), the World Health Organization (WHO) and the European Organization for Research and Treatment of Cancer (EORTC) to describe the spectrum of radiation dermatitis.

Each assessment tool can be used to identify grades or ranges of skin reactions from erythema to dry and moist desquamation. Most of the tools are practitioner or observer assessments. A skin assessment should be initiated at baseline, prior to initiation of the treatment, and reassessments should occur minimally at weekly treatment appointments. They should include an evaluation of observed physical changes and record symptoms and side effects. Issues to assess include changes in color, appearance of erythema, patchy dry desquamation, patchy or confluent moist desquamation, drainage, odor, possible infection, and sensations of dryness, pruritus, or pain. The distress and impact of radiation dermatitis on the quality of life, daily living, self-care ability, and financial impact of skin reaction treatment products also are important areas of assessment.
One of the most important scales is the RTOG score which describes radiation-caused side effects in a reproducible way, which explains why it is extensively used.
The RTOG scoring criteria does not take account of the subjective aspects of skin damage such as pain and discomfort. 23-25 Another one is the RISRAS scale which is based on observer assessments of patients and health care professionals. It takes the patients’ perspective regarding tenderness, itching, burning etc. into account. As it is a subjective scaling system it is not widely used in practice research.
A third example to be mentioned is the National Cancer Institute – Common Terminology Criteria for Adverse Events (NCI–CTCAE) grading system also called “common toxicity criteria”. It concentrates on any abnormal clinical finding temporally associated with the use of a therapy, where the reason of it is of no importance. The toxicity grade is defined from 1 to 5, whereas the final grade denotes a fatality. 30, 32