Notes on Practice: Managing Radiation Skin Injury

    During and after radiation therapy, patients may experience dryness, itching, erythema, hair loss, rash, and dry desquamation — ie, scaly, flaking skin. Wet desquamation, which resembles a second-degree burn, is seen less frequently. Transient erythema may appear as early as the first treatment; a lasting reaction generally appears during the second or third week of treatment. The early reaction is inflammatory and results from activation of proteolytic enzymes and increased capillary permeability. Radiation skin reactions are confined to the area of treatment, which may include the site of entrance of the beam of radiation as well as the exit site.^1,2

    Variables that can increase the degree of skin reactions from radiation therapy include:
  • total dose, type of radiation
  • area and volume of body being treated
  • location of the lesion
  • skin folds
  • bony prominences
  • scars
  • altered nutrition and hydration
  • immuno-compromised state
  • combining chemotherapy and prescribed drugs
  • skin differences.^1,2

    The following case study discusses the management of a patient exhibiting moist and dry desquamation with erythema following radiation treatment post mastectomy. The 3-week care protocol, which included application of a balsam of Peru-castor oil-trypsin ointment, lessened the patient’s pain, increased her ability to manage dressing changes on her own, and generally improved her quality of life.

History

    Mrs. C was a 69-year-old woman who had a left modified radical mastectomy for breast cancer in March 2003. She had no previous health problems and took no medications. Divorced and living alone, Mrs. C had her daughter stay for the duration of her radiation therapy.

    Mrs. C completed radiation therapy on June 23 and subsequently developed redness within the entire field of radiation. Her daughter applied Domeboro soaks (an aspirin-like powder dissolved in water manufactured by Bayer Consumer Products, Morristown, NJ) twice a day as prescribed by her primary care physician. The daughter reported that her mother became nearly immobilized with pain, stopped eating and drinking, was unable to sleep, and was extremely depressed. She had fallen at home, sustaining only minor injuries, three days before coming to the Wound Center. The fall most likely was related to dehydration, loss of appetite, and fatigue.

Diagnosis

    Mrs. C was admitted to the Wound Center by her primary care provider with a diagnosis of radiation skin reaction. She exhibited both moist and dry desquamation with erythema on the left chest and back. Her mucous membranes were dry, skin turgor poor, and urinary output concentrated.

Treatment

    After the initial evaluation, the clinic nurse initiated the care protocol, which consisted of cleansing with normal saline (patient may choose to shower to aid in dressing removal and skin cleansing), applying a thin film of balsam of Peru-castor oil-trypsin ointment (Xenaderm Ointment, Healthpoint Ltd., Fort Worth, Tex.) twice daily, covering the area with a non-adherent dressing, covering the first dressing with Kerlix (Tyco Health Care/Kendall, Mansfield, Mass.), and securing the area with a snug-fitting cotton T-shirt.

    Mrs. C liked the idea of a “less medical” wound dressing appearance as compared to gauze dressings held in place with stretchable net. Mrs. C’s daughter was relieved that her mother experienced less pain with the new dressing protocol and said she was confident she could manage her mother’s care without assistance from Home Health. In addition, a group I air mattress overlay (EHOB Inc., Indianapolis, Ind.) was provided for Mrs. C’s bed to promote comfort and sleep. She left the clinic in a wheelchair and reported a decrease in her pain level from 10 to 5. Mrs. C returned weekly to the wound center for wound assessment.

    Week one. Initially, the left chest wound measured 14 cm x 30 cm (see Figure 1a) and the back wound measured 13.5 cm x 12 cm (see Figure 2a). After 1 week using the care protocol, the wounds were 98% debrided enzymatically by the ointment, with 50% granulation and epithelialization present (see Figures 1b, 2b). Pain was decreased from 10 out of 10 to 1 to 2 out of 10. Mrs. C’s appetite and fluid intake improved and she was sleeping well and walking independently. The same twice-daily wound care was continued.

    Week two. The wounds were 100% debrided and the wound was 75% epithelialized. Mrs. C’s pain decreased to 1 out of 10. Dressing changes were reduced to once daily, using only the castor oil-balsam of Peru-trypsin ointment and cotton T-shirt dressing. Mrs. C was able to resume her hobby of folk art painting.

    Week three. Mrs. C’s radiation skin reaction was completely healed (see Figures 1c, 2c). She was instructed to apply a non-occlusive skin cream (Sween Cream, Coloplast Corp., Marietta, Ga.) twice a day to provide moisture and to avoid tight clothing and sunlight on the areas. Mrs. C presented her nurse with a beautiful folk art painted gift.

Discussion

    The rationale for using the balsam of Peru-castor oil-trypsin ointment, a new product for this wound care center, was based on the type of wounds and the unique needs of the patient and her caregiver. The product contains trypsin (90 units/g), balsam of Peru (87.0 mg/g) castor oil (788 mg/g), safflower oil, and aluminum magnesium stearate. The manufacturer’s literature recommends use on partial-thickness wounds.³ Maas-Irslinger et al⁴ conducted four clinical studies to determine safety and efficacy of the ointment. Clinical findings revealed that applying the product to the skin increased peripheral blood flow 45.4% (P = 0.01 after 3 hours of application) as evidenced by laser Doppler. It also reduced wound erythema (P <0.05) and enhanced re-epithelialization (P <0.05). Scabbing was significantly less when compared to lesions treated with saline (P <0.05) and skin sensitization testing revealed no potential for skin irritation or evidence of contact sensitization. These factors enhance healing rates and improve patient quality of life.

    The goals for Mrs. C’s plan of care were to improve her quality of life by managing her pain and to provide debridement, wound cleansing, moist wound healing, infection control, and cost effectiveness. According to the manufacturer, the castor oil component of the ointment acts as a protective barrier against external irritation, reducing pain and improving epithelialization. The trypsin component provides debridement and proteolytic cleansing. Balsam of Peru has an antibacterial action and promotes moist wound healing by increasing blood flow.^3,5 Mrs. C’s supplemental insurance policy covered the expense of this prescription product. Mrs. C and her daughter were able to manage wound care independently with no further complications. All of the patient’s goals for wound healing were achieved.

Prognosis

    Mrs. C’s wounds epithelialized within 26 days using the balsam of Peru-castor oil-trypsin ointment. She and her physician decided not to pursue additional radiation treatment after the skin reactions were healed, even though more was recommended clinically. She developed lymphedema of the left arm and underwent treatment including massage, compression garments, and a sequential intermittent pump. She was discharged from the wound center and instructed to use mild soaps, rinse well, and pat the skin dry; moisturize dry skin twice daily with appropriate lotions; avoid skin irritants (topical products containing perfume, alcohol or astringents, deodorants and mechanical products such as jewelry, adhesives, and products that are difficult to remove); avoid exposure to heat (eg, heating pads, hot tubs, sun lamps) and cold (eg, ice packs); and protect skin from direct sunlight (use a sunblock with a high sun protection factor should be applied before sun exposure) and wind exposure.^1,2

1. Belcher AE, Eelekof J. Skin care for the oncology patient. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, Pa.: HMP Commuications;2001:711–720.

2. Goldberg M, McGinn-Byer P. Oncology-related skin damage. In: Bryant R. Acute and Chronic Wounds: Nursing Management, Second Edition. St. Louis, Mo.: Mosby, Inc.;2000:379–384.

3. Xenaderm product insert. Healthpoint, Ltd., Fort Worth, Tex.

4. Maas-Irslinger R, Hensby C, Farley K. Experimental methods to demonstrate the efficacy and safety of Xenaderm ointment: a novel formulation for treatment of injured skin due to pressure ulcers. WOUNDS. 2003;15:2S–8S.

5. Carson S, Wiggins C, Overall K, Herbert J. Using a castor oil-balsam of Peru-trypsin ointment to assist in healing graft donor sites. Ostomy Wound Manage. 2003;49(6):60–64.