Skin care Regime for Radiation Oncology Patients



Canberra Hospital and Health ServicesClinical Procedure Skin care Regime for Radiation Oncology PatientsContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc501526505 \h 1Purpose PAGEREF _Toc501526506 \h 2Alerts PAGEREF _Toc501526507 \h 2Scope PAGEREF _Toc501526508 \h 2Section 1 – Introduction PAGEREF _Toc501526509 \h 2Section 2 – Goals and product choices in caring for skin reactions during radiotherapy PAGEREF _Toc501526510 \h 4Section 3 – Assessment and Treatment of the skin during radiotherapy PAGEREF _Toc501526511 \h 6Section 4 – Skin care from initial day of treatment PAGEREF _Toc501526512 \h 6Section 5 – Grade 1 Erythema (RTOG 1) PAGEREF _Toc501526513 \h 7Section 6 – Grade 2 Erythema (RTOG 2) PAGEREF _Toc501526514 \h 8Section 7 – Grade 2.5 Erythema (RTOG 2.5) and Grade 3 Erythema (RTOG 3) PAGEREF _Toc501526515 \h 8Section 8 – Post Radiotherapy treatment upon completion of Radiation PAGEREF _Toc501526516 \h 9Section 9 – Follow up care post treatment PAGEREF _Toc501526517 \h 10Implementation PAGEREF _Toc501526518 \h 11Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc501526519 \h 11References PAGEREF _Toc501526520 \h 12Definition of Terms PAGEREF _Toc501526521 \h 12Search Terms PAGEREF _Toc501526522 \h 12PurposeThe purpose of this procedure is to provide clinicians with information on a safe and effective way to assess and manage radiation induced skin reactions. This document is based on practice evidence on skin management pre and post radiotherapy.This procedure document provides standardisation of skin management for both the inpatient and outpatient receiving radiotherapy. To achieve optimum skin care during radiotherapy many factors should be considered, including patient education prior to and during radiotherapy, patient involvement with skin care during treatment, minimising pain and providing psychological support.1Back to Table of ContentsThis Standard Operating Procedure (SOP) describes for staff the process to ScopeAlertsCreams recommended in this document should only be used during radiotherapy.The treatment creams/moisturisers used during treatment should not be mixed together (refer to the Table in section 2).Avoid using adhesive tapes in the treatment field and on treatment tattoos. Extend dressings out of the treatment field and adhere to intact skin with paper tape.Minimise friction at skin surface by securing dressings.If there are signs of infection ensure wound swab and report to medical officer.Back to Table of ContentsScopeThis document applies to:Nurses and Midwives who are working within their scope of practice (Refer to Scope of Practice for Nurses and Midwives Policy).Student Nurses under direct supervision of Registered nurses.Back to Table of ContentsSection 1 – IntroductionRadiotherapy can cause skin changes and damage healthy skin in the treatment area. Radiation skin reactions occur as a result of damage to the basal cell layer of the skin and the resultant imbalance between the normal production of cells in this layer and the destruction of cells at the skin surface.Intrinsic and extrinsic predisposing factors that may worsen radiotherapy induced skin reactions:Intrinsic FactorsAgeNatural ageing process affects the epidermal cell cycle which can result in extended healing times.NutritionUndernourished patients may be at increased risk of skin damage, ensure adequate intake.Smoking and alcoholCapillary blood flow and oxygen levels are decreased increasing the severity of the skin reaction and impairing the body to heal and fight infection.Co-morbiditiesPre-existing medical conditions and medications can impair healing.ObesityAdipose tissue can compromise healing and exacerbate skin toxicity due to the extra skin folds.InfectionPresence of bacterial and/or fungal infection.Extrinsic factorsRadiotherapyHigher doses; larger fields, increased volume and presence of bolus can all lead to increased skin reactions.Energy of radiotherapyHigher energy megavoltage beams tend to have a lower/lesser skin reaction. However, patients receiving superficial radiation treatment or electrons, receive maximum dose close to the surface of the skin, these patients are expected to develop a skin reaction.Radiosensitisers Many chemotherapy agents are radiosensitisers and therefore increase the severity of the skin reaction if given at the same time as bination of chemotherapy during radiotherapy.Chemical/ Thermal / Mechanical irritants can exacerbate the skin reaction and delay the healing processChemicals such as deodorants, perfume, talcum powder, and aftershave, metal-contained in dressings and creamsExtremes in temperature e.g. hot or cold packsFriction by rubbing skin, shaving with razor or wearing tight fitting clothing.The severity of skin reactions can peak around 7-10 days after treatment has finished.This is due to the continuing lack of new cells being produced to replace old cells.Post radiotherapy skin should improve significantly if not fully healed by 4-6 weeks.Goals should promote comfort, reduce the risk of infection, further trauma, and promote healing.The use of a recognised assessment tool is essential to promote consistency and continuity of care. Refer to Radiation Therapy Oncology Group (RTOG) grading system in section 3 table.Back to Table of ContentsSection 2 – Goals and product choices in caring for skin reactions during radiotherapy The goals of skin and wound care during radiotherapy include:Maintaining integrity and hydration of the skinReducing potential for further exacerbation of the skin reactionMinimise skin traumaReduce painPromote comfortMinimise the risk of infection, control bleeding, odour, excessive exudates and promote a moist wound healing environment in the stages where skin is broken.During weekly treatment reviews, the skin is checked for erythema and dry moist desquamation. Procedure for every skin review is as below:Check positive patient identification and allergies against clinical notes/stickers and verbally with patient.Attend hand hygiene before touching the patient by either hand washing or using alcohol based hand rub (ABHR).Ensure patient privacy at all times.Grade the skin as per Radiation Therapy Oncology Group (RTOG) grading system (located in section 3) and document in patient’s clinical notes.Provide the patient with education on skin changes.Provide a solution to assist with minimising the discomfort, a pain support proactive solution to the dressing/coverage of the skin options during therapy.Monitor patient pain levels at all dressing changes.Give appropriate pain relief or discuss with medical officer to get adequate pain relief organised.Once the assessment is complete, document in the patient’s clinical record and discuss the outcomes and management plan with patient. If required refer to community nursing through Community Health Intake (CHI) for wound care.The following products are used routinely for skin and wound care during radiation therapy:ProductsPurposeAqueous creamHydrates skinNormal saline soaks/compresses Reduce discomfort due to inflammation or skin irritationCleanse open areasLoosen dressingsRatio 1 litre cool unsterile water (H20) : 1 teaspoon table saltSitz BathsProvide perineal hygiene where the skin is tender and inflamed.Use at any time for any dermatitis in the perineal/peri-rectal area.Cavilon? (No sting) barrier film)Provides waterproof barrier.Prevents skin maceration from exudateReduces epithelisation strippingMoulds into difficult skin surface areas e.g. nipples, anal cleftEnsure product is dry at skin surface prior to dressing applicationDo not use on infected areas of the skin surfaceEmulsifying ointmentEmulsifying ointment or olive oil can be applied to soften crusts, for patients receiving superficial radiation, to enable easier removal before treatment. Crusty skin – can result from exudating cells which harden and become painful, in the treatment region. A dressing should be applied to promote comfort and reduce the risk of infection. IntraSite?GelHydrogel, cool soothing, debriding agent in autolytic debridementContributes moisture to wound bed, cover with Jelonet? Primary dressing, daily changeRequires suitable secondary dressing Mepilex?, Mesorb? or Zetuvit?Solugel ?Wound care gelHydrogel, cool soothing, debriding agent in autolytic debridementPrimary dressing Jelonet? or Atrauman? daily change.Requires suitable secondary dressing Mepilex?, or Mesorb?Mepilex?Lite dressingFoam dressingsHighly comfortable and reduces friction and trauma at skin and treatment field e.g. inframammary fold (IMF)Reduced pain on removal due to silicone interfaceMepilex?Border dressingReduces friction and trauma at skin Reduced pain on removal due to silicone interface, self-adhering Moderate exudate managementZinc and Castor Oil Cream-Zinc Oxide 7.5% & Castor Oil 50%Post radiation on dry desquamation (Grade 2 erythema) – apply thinlyBOZ ointment –Contains: Boric Acid.25%, Zinc Oxide 7.5% & Olive OilPost radiation on moist desquamation (Grade2.5 and Grade 3 erythema) – apply thinlyBoric Acid – provides mild antiseptic and antifungal propertiesConveen? EasiCleanse No rinse cleanser maintains the skin’s natural moisture and pH balance. Aids the removal of zinc based creams. Can be used post radiation treatment, second daily, to remove excess Zinc Cream/ BOZ ointment before re application.Back to Table of ContentsSection 3 – Assessment and Treatment of the skin during radiotherapyIntervention Guidelines – RTOG Grading System:RTOG Assessment Tool and Intervention Rationales – Gloucestershire HospitalsBack to Table of ContentsSection 4 – Skin care from initial day of treatment Equipment – (outpatient or inpatient setting)Aqueous Cream Non perfumed soap Procedure Wash, bathe, or shower using lukewarm water and non-perfumed soap. Rinse well and pat the skin dry gently with a soft towel, avoid friction at skin surface. Apply Aqueous Cream to the treatment field twice daily, from the first day of treatment. (Do not apply the cream in the two hours prior to radiotherapy treatment). Hair can be washed with a mild baby shampoo, even if the head is being treated.Protect patient’s skin from the sun at all times however please don’t use sunscreen in the radiotherapy treatment field. Non-essential shaving in the treatment field should be avoided as the rubbing may exacerbate a skin reaction. Shaving in the treatment field during radiotherapy should only be done with an electric razor.Advise the patient to wear loose fitting clothes (preferably cotton clothing). Do not use powders, perfumes, aftershave and regular deodorant in the radiotherapy treatment field. Crystal deodorant can be used in the treatment field during. Radiotherapy (available in health food stores, chemists, or supermarkets).Normal deodorant and perfume can be used outside their radiotherapy treatment field.Salt water baths or compresses are found to be soothing and will also provide relief for itchy skin. Refer to product table. Use cotton cloth on skin surface for 15 minutes twice per day. Same dilution ratio can be used to make a salt bath, beneficial for patients receiving pelvic radiotherapy.Please also refer to the Consumer handout Form “Things to remember while having radiotherapy”. If your patient requests to use products other than the above recommendations check with their treating doctor.Back to Table of ContentsSection 5 – Grade 1 Erythema (RTOG 1) Grade 1 Erythema (RTOG 1) – faint erythema or dry desquamation Equipment Aqueous CreamSilicone based self-adhering foam dressing - e.g. Mepilex?Lite No-sting barrier film - Cavilon?Procedure Apply aqueous cream twice daily to the skin surface in the treatment field.Secondary dressing may be beneficial to reduce friction in the treatment field e.g. Mepilex?Lite dressings.Non sting barrier film Cavilon? provides a long lasting waterproof barrier. Cavilon? can be applied to skin surfaces and is useful on nipples, natal cleft and periwound regions protecting intact or damaged skin. If using this product ensure that the skin is completely dry before applying a dressing or covering with clothing. This product can be used within the radiation field. Back to Table of Contents Section 6 – Grade 2 Erythema (RTOG 2) Grade 2 Erythema (RTOG 2) - Moderate to brisk erythema or patchy, moist desquamation confined to skin folds and creases. Moderate swelling may be present.Equipment Normal saline soaks/compresses Aqueous CreamEmulsifying OintmentHydrogel - Solugel?Hydrocortisone cream 1%No-sting barrier film - Cavilon?Procedure Apply normal saline soaks/compresses to skin surface in the treatment field for 10-15 minutes/ twice daily. Pat skin dry after removal. Then apply aqueous cream twice daily to the skin surface in the treatment field.Crusty skin – can result from exudating cells which harden and become painful. Emulsifying ointment can be applied to soften these crusts to enable easier removal before superficial radiotherapy treatment. Non sting barrier film Cavilon? provides a long lasting waterproof barrier. It can be applied to skin surfaces and is useful on nipples, natal cleft and periwound regions and protects intact or damaged skin. If using this product ensure that the skin is completely dry before applying a dressing or covering with clothing. Erythema that is itchy use a hydrogel - Solugel? For severe itch, low dose hydrocortisone may be beneficial for itching and irritation on non-broken skin. In the treatment field a combination of the above products may be used together to address different stages of erythema.Secondary dressing may be beneficial to reduce friction in the treatment field e.g. Mepilex?Lite dressings.Back to Table of Contents Section 7 – Grade 2.5 Erythema (RTOG 2.5) and Grade 3 Erythema (RTOG 3)Grade 2.5 Erythema is moist desquamation and Grade 3 Erythema is confluent, moist desquamation, greater than 1.5cm in diameter, which is not confined to skin folds. Pitting oedema and swelling may be present.Equipment Normal saline soaks/compresses Hydrogel - Solugel?No-sting barrier film - Cavilon?Tulle Gras Dressings - Jelonet? or Atrauman?Silicone based foam dressing self-adhering - e.g. Mepilex?Lite, Mepilex?BorderMulti absorbent non adhesive pad (non waterproof) - Mesorb?/ Zetuvit?Securing agents - crepe bandage, Tubinet?, Tubifast?Olive oil (cold)ProcedureFor this RTOG grading Aqueous Cream should NOT be usedApply normal saline soaks to the skin surface in the treatment field for 10-15minutes/twice a day. Pat skin dry after removal.Apply hydrogel - Solugel? or IntraSite?Gel to moist desquamation.Cover skin with a non-adhering dressing, then an absorbent dressing, changed daily.For highly exudating skin in the treatment field, use IntraSite?Gel.To soften crusts to enable easier removal, apply olive oil (cold) or Emulsifying Ointment to skin surface. A build-up of shedding skin cells and exudate fluid can harden and become crusty and painful on removal.All dressings require soaking with saline or olive oil prior to removal as to avoid skin trauma. All multi absorbent pads can be carefully moistened during showering for easier removal, being gentle so the skin surface is not damaged during removal.Tulle Gras or Atrauman? can be covered with a secondary dressing choice of, foams and/ Mesorb? or Zetuvit?. Secure to the skin or limb with crepe bandage (retention) or Tubinet?. Change as wound drainage warrants.Back to Table of Contents Section 8 – Post Radiotherapy treatment upon completion of RadiationEquipment Olive oil (cold)Normal saline soaks/compresses Zinc & Castor Oil creamBOZ ointmentConveen? EasiCleanse (pH Cleanser) Tulle gras - Jelonet?Appropriate sized moisture management pads, Mesorb?/ Zetuvit?Combines provide no moisture management but comfort.Procedure Grade 1 skin reaction – No reactionContinue with Aqueous Cream application or a non-perfumed moisturiser twice daily.Grade 2 Skin reaction – Bright erythema/dry desquamation. Sore itchy and tight skinApply normal saline soaks to skin surface for 10-15minutes twice daily. Pat skin dry after removal. Thinly apply Zinc and Castor Oil cream twice daily to the all skin surfaces in the treatment field. Cream may also be directly applied to moisture manage pad, or comfort pad combine.Do not allow for excess Zinc and Castor Oil cream to build up through over application. Excess Zinc and Castor Oil cream can gently be removed when required with olive oil or Conveen?EasiCleanse.A secondary dressing should be applied to cover the cream. Grade 2.5 Skin reaction – Patchy moist desquamationYellow/pale green exudate/oedemaGrade 3 Skin reaction – Confluent moist desquamationYellow/pale green exudate/oedema Apply normal saline soaks to skin surface for 10- 15 minutes twice daily. Pat skin dry after removal. Thinly apply BOZ Ointment twice daily to all skin surfaces in the treatment field.Cover with Jelonet?/Atrauman? and cover with secondary dressing Mesorb?/Zetuvit? or combines. Secure dressings with Tubinet? or another fixative dressing. Change as drainage warrants. Do not allow for excess BOZ ointment to build up through over applicationExcess BOZ ointment can gently be removed as required with olive oil or Conveen? EasiCleanse.A secondary dressing should be applied to promote comfort, contain drainage and create an environment conducive to healing.Consider wound swab and referral to medical officer if wound infection is suspected.Back to Table of Contents Section 9 – Follow up care post treatment Patients to be reminded that the severity of skin reactions can increase and “peak” around 7-10 days after treatment has finished.ACT and Queanbeyan residents should be provided with information on the Nurse Led Clinic (NLC) in the Radiation Oncology Department TCH for review and follow up care.Appointments can be booked in the NLC for the review of radiation induced side effects for up to 6 weeks post radiation.Referral to ACT Health Community nursing and or interstate nursing as required.All breast patients that have prosthetic implants/or expanders insitu require an appointment in the Nurse Led Clinic 7-10 days post completing their radiation treatment. Back to Table of ContentsImplementation This procedure will be implemented with ward in-services and continuing education to Radiation Oncology staff. Dissemination to the wider health community through presentations, and educational sessions.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentScope of practice policy for nurses and midwivesProceduresCHHS Healthcare Associated Infections Clinical ProcedureCHHS Patient Identification and Procedure Matching PolicyCHHS Clinical Handover procedureCHHS Aseptic Non Touch TechniqueCHHS Clinical procedure – Wound ManagementGuidelines Consumer handout – Things to remember while having RadiotherapyRTOG Radiation Therapy Oncology Group LegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Privacy Act 1988Back to Table of ContentsReferencesBritish Journal of Nursing 2014 and 2016 doi/abs/10.12968/bjon.2016.25.4.S18Cancer Council Australia Information booklets- First published documents 1995. Updated in (2016).RTOG Assessment Tool and Intervention Rationales – Gloucestershire HospitalsThe Joanna Briggs Institute Radiotherapy (Skin Changes): ManagementManaging Radiotherapy Induced Skin Reactions- St James’s Institute of Oncology3M, (2014), “3M Cavilon No string barrier film: Clinical evidence summaries,” available at 3M Cavilon – No Sting Barrier Film Product information Saint James’s Institute of Oncology, (2011) “Managing radiotherapy induced skin reactions,” available at BC Cancer Agency, (updated 2017), “Symptom management guidelines: Radiation dermatitis,” available at Eviq – Cancer Treatments Online information for patients and clinicians to Table of ContentsDefinition of Terms Registered nurse (RN) Patient (Pt)Normal Saline (n/s) Nurse Led Clinic (NLC)Alcohol Based Hand Rub (ABHR),Back to Table of ContentsSearch Terms Radiotherapy, skin care, Aqueous Cream, erythema, desquamation, exudate, Amorphous Hydrogel - Solugel or Intrasite gel Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 20/12/2017New DocumentKath Wakefield, A/g DON CACHSCHHS Policy CommitteeThis document supersedes the following: Document NumberDocument Name ................
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