Multifaceted Targeted Nutrient Strategy Successfully Utilized To Reverse Grade 3-4 Radiation Dermatitis

This case describes a 65 year-old with T3N0M0 anal squamous cell cancer, treated with 5 weeks of capecitabine and mitomcyin chemoradiation, referred to wound care for persistent grade 3-4 radiation-induced skin necrosis unresponsive to standard care.
Exam revealed tender, ulcerated, bilateral wounds of the groin and labia.
Nutritional modification was prescribed:
<ol class="ol1">
<li class="li1">Healing smoothie: kefir, dark greens, dark berries, tart cherry concentrate, turmeric, black pepper, ginger, plant-based protein powder

<li class="li1">Brazil nuts

<li class="li1">Green tea

<li class="li1">Omega 3 and omega 6 supplements

<li class="li1">Vitamin A

<li class="li1">Multivitamin

8 days later, she reported dramatic improvement in pain and decreased doses of narcotics. Labial wounds closed. 4 weeks after compliance with nutritional modification, all wounds healed.
Chemoradiation, standard treatment of anal squamous cell carcinoma, can cause grade 2 dermatitis (up to 86%) and grade 3-4 dermatitis (up to 31%)1. Radiotherapy generates reactive oxygen and nitrogen species2,3, stimulates pro-inflammatory mediators NF-κβ, TNF-?, cytokines, chemokines, and interleukins, and triggers immune response to cellular debris.4,5 Acquired immunity, integral to wound healing, is linked to activation of pro-inflammatory cellular mediators. Additionally, chemoradiation impairs phase II detoxification reliant on nutrient-dependent enzymatic transformations.6
Algorithms specific to management of radiation-induced dermatitis are sparse, and do not emphasize nutritional modification.7, 8 Nutrients prescribed in this case modulate oxidative stress, immune signaling, and inflammatory pathways.9, 10 Standard of care for 4 weeks was ineffective. A nutrient-focused multifaceted strategy to target inflammation resolution and redox restoration of homeostasis resulted in rapid clinical improvement. This case suggests a novel strategy to resolve debilitating radiation-related perineal dermatitis may have utility. Translational research to explore benefits of targeted nutrients to support healing from dermal effects of radiation should be undertaken.
 

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References (if applicable): 1. Meulendijks D, Dewit L, Tomasoa NB, et al. Chemoradiotherapy with capecitabine for locally advanced anal carcinoma: an alternative treatment option. Br J Cancer. 2014;111(9):1726-1733.

2. Kim W, Lee S, Seo D, et al. Cellular Stress Responses in Radiotherapy. Cells. 2019;8(9).

3. Acharya A, Das I, Chandhok D, Saha T. Redox regulation in cancer: a double-edged sword with therapeutic potential. Oxid Med Cell Longev. 2010;3(1):23-34.

4. Kim JH, Kolozsvary AJ, Jenrow KA, Brown SL. Mechanisms of radiation-induced skin injury and implications for future clinical trials. Int J Radiat Biol. 2013;89(5):311-318.

5. Kono H, Rock KL. How dying cells alert the immune system to danger. Nature Reviews Immunology. 2008;8(4):279.

6. Miao L, St Clair DK. Regulation of superoxide dismutase genes: implications in disease. Free Radic Biol Med. 2009;47(4):344-356.

7. Cormier AC, Drapek L, Fahey J, et al. When the Patient Seeks Cure: Challenging Chemotherapy and Radiation Side Effects Requiring Creative Solutions. Clin J Oncol Nurs. 2016;20(2):117-120.

8. Rosenthal A, Israilevich R, Moy R. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm. J Am Acad Dermatol. 2019;81(2):558-567.

9. Anuranjani, Bala M. Concerted action of Nrf2-ARE pathway, MRN complex, HMGB1 and inflammatory cytokines - implication in modification of radiation damage. Redox biology. 2014;2:832-846.

10. Bernatoniene J, Kopustinskiene DM. The Role of Catechins in Cellular Responses to Oxidative Stress. Molecules. 2018;23(4).