SoR | CoR Position statement on radiation induced skin reactions (RISR)

The Society and College of Radiographers (SoR | CoR) would like to acknowledge differences in how radiation induced skin reactions (RISR) can present across different skin tones. Research highlights that within certain radiotherapy treatment sites will develop more severe RISR than others ^1-6 . This can not only be physically traumatic but can also cause lasting psychological distress to patients ^1-2.   

Recent research has highlighted patients from ethnic backgrounds can have worse outcomes when compared to the white background patients ^7-8. A recent UK wide survey of therapeutic radiographers that identified significant drops in confidence with assessing, managing and teaching RISR between lighter and darker skin tones. People were more confident when looking at lighter skin tones when compared to darker skin tones. The SCoR is committed to inclusivity and with recent evidence, hopes to help tackle this health inequality to ensure we provide the best, person-centred care possible for patients undergoing radiotherapy treatment.

Evidence on RISR describes erythema, skin tightening and swelling as acute changes that can be seen in the skin ^1-6,9-12. However, there has been limited evidence in literature to how erythema can present on people with highly pigmented skin ^13-15. The British Association of Dermatology describe predicting erythema on an individual’s skin as difficult due to variations between skin tones and changes in colour spectrum within the affected area ¹⁴. On less pigmented skin tones, erythema can present as redness but on darker, highly pigmented skin tones, this can present as subtle darkening within the affected area or texture changes to the skin ^13-15.

An important caveat of this education is to highlight when gaining informed consent of patients undergoing radiotherapy treatment. Patient’s skin tones must be considered when providing information on how radiation induced erythema can present to fully inform them. This will empower patients to understand RISR better, aid health care professionals to distinguish a reaction more efficiently and lead to improved, inclusive management strategies for all patients ¹⁶.

If you are interested in RISR, radiotherapy skin care and helping tackle this health inequality we invited you to consider a new special interest group (SIG) being set up called the RISR SIG. This group aims to provide healthcare practitioners a platform to discuss and share RISR assessment, management and teaching information to better support all patients undergoing radiotherapy treatment. The group is being established by Naman Julka-Anderson and Samaneh Shoraka to improve access to RISR information and develop networks of multidisciplinary support throughout the UK and beyond. Iyna Butt will co-chair as a patient representative to lead on public and patient involvement to help ensure every patient voice is always heard. Expressions of interest will be taken shortly.

References:

1. The Society College of Radiographers. Radiation Dermatitis Guidelines for Radiotherapy Healthcare Professionals. The Society College of Radiographers. Report number: 1, 2020.
2. Burke G, Faithful S, Probst H. Radiation induced skin reactions during and following radiotherapy: A systematic review of interventions. Radiography. 2022:28(1) 232-239. Available from: 10.1016/j.radi.2021.09.006.
3. Fuzissaki MA, Paiva CE, Oliveira MA, Maia MA, Canto PPL, Maia YCP. A protective effect of morning radiotherapy on acute skin toxicity in patients with breast cancer A prospective cohort study. Medicine. 2021:100(42) 1-7. Available from: 10.1097/MD.0000000000027155.
4. Xie Y, Wang Q, Hu T, Chen R, Wang J, Chang H, Cheng J.  Risk Factors Related to Acute Radiation Dermatitis in Breast Cancer Patients After Radiotherapy: A Systematic Review and Meta-Analysis. Frontiers in Oncology. 2021;11(738851): 1-13. Available from: 10.3389/fonc.2021.738851.
5. Kawamura M, Yoshimura M, Asada H, Nakamura M, Matsuo Y, Mizowaki T.  A scoring system predicting acute radiation dermatitis in patients with head and neck cancer treated with intensity-modulated radiotherapy. Radiation Oncology. 2019;14(14): 1-9. Available from: 10.1186/s13014-019-1215-2.
6. Fu Z, Wang C, Chen J, Wang, Y, Zhang X. The incidence and risk factors of acute radiation-induced dermatitis in gynecologic malignancies treated with intensity modulated radiation therapy. Translational Cancer Research. 2020;9(10) 6063-6069. Available from: 10.21037/tcr-20-796.
7. Jagsi R, Griffith KA, Vicini F, Boike T, Burmeister J, Dominello MM. Toward Improving Patient’s Experiences of Acute Toxicity From Breast Radiotherapy: Insights From the Analysis of Patient-Reported Outcomes in a Large Multicenter Cohort. Journal of Clinical Oncology2020; 38(34): 4019-4029. DOI: 10.1200.JCO20.01703.
8. Abdelkarem, OA, Choudhury A, Burnet NG, Summersgill HR, West CML. Effect of Race and Ethnicity on risk of Radiotherapy Toxicity and Implications for Radiogenomics. Journal of Clinical Oncology2022; DOI: 10.1016/j.clon.2022.03.013
9. Wei J, Meng L, Hou X, Qu C, Wang B, Xin Y, Jiang X. Radiation-induces skin reactions: mechanism and treatment. Cancer Management and Research2019; 11:167-177. DOI: 10.2147/CMAR.S188655.
10. Harris R, Probst H, Beardmore C, James S, Dumbleton C, Bolderston A, Faithful S, Wells M, Southgate E. Radiotherapy skin care: A survey of practice in the UK. Radiography 2011; 18:21-7. DOI: 10.1016/j.radi.2011.10.040.
11. Bray FN, Simmons BJ, Wolfson AH, Nouri K. Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy. Dermatology and Therapy2016; 6(2):185-206. DOI: 10.1007/s13555-016-0120-y.
12. Baines CR, O’Rourke GA, McGuiness W. An integrative review of skin assessment tools used to evaluate skin injury related to external beam radiation therapy. Journal of Clinical Nursing2016; 26(7-8). DOI: 10.1111/jocn.13430.
13. Jothishankar B, Stein SL. Impact of skin color and ethnicity. Clinical Dermatology2019; 37(5): 418-429.
14. Wounds UK (2021) Best Practice Statement: Addressing skin tone bias in wound care: assessing signs and symptoms in people with dark skin tones. Wounds UK, London.
15. Julka-Anderson N. Ethnic Disparities in Outcomes with Radiation Therapy.Radiotherapy and Oncology2022; 170(1), S1-S1677. DOI: 10.1016/S0167-8140(22)03890-7.
16. Probst H, Rosbottom K, Crank H, Stanton A, Reed H. The patient experience of radiotherapy for breast cancer: A qualitative investigation as part of the SuPPORT 4 All study. Radiography 2021; 27(2): 352-9. DOI: 10.1016/j.radi.2020.09.011.