Radiation Dermatitis: new treatment options are finally on the horizon

Another day; another cancer patient faced with the additional burden of radiation dermatitis (RD). In fact, RD affects up to 90% of patients undergoing radiotherapy for cancer treatment.1–6

RD can have devastating consequences on patient outcomes, including psychological stress, negative body image, and pain.7,8 Most worryingly, however, RD can disrupt radiotherapy, harming patient prognosis in the process.9–11 This makes the lack of RD treatment options all the more baffling and frustrating. Physicians continue to use the same standardized treatments for RD with negligible efficacy. Guidelines offer minimal instructions, with daily hygiene directions and corticosteroids being two of few treatments finding consensus across the globe.12

Fear of RD treatments interfering or altering radiation dose during radiotherapy, influences RD treatment plans. 13–15 However, it may be time to question the foundations on which these RD treatment decisions are based.15,13 Many are formed through outdated dogma based on orthovoltage radiation therapy methods used until the 1950s.13

When radiation dermatitis rears its ugly head, the combination of all of the above inevitably leads to a feeling of helplessness. Diving into the literature only exacerbates this feeling, with no new treatments showing any real potential—until now.

New treatment options

Mepitel® barrier film, photobiomodulation therapy, and Silverlon® wound dressing are quickly emerging as three of the most promising treatments for RD.

Mepitel® and photobiomodulation therapy were included in updated clinical practice guidelines published by the Multinational Association of Supportive Care in Cancer (MASCC) in April 2023 for the prevention and treatment of radiation dermatitis.16

Silverlon®, a silver-coated wound dressing, was granted FDA 510K clearance for use in radiation dermatitis treatment in October 2022.

An increase in quality-of-life and a decrease in grade ≥2 RD are among some of the main benefits of these treatments.

The following highlights the details of these treatments so that you can determine whether they may benefit your RD patients.

Mepitel®

Mepitel® film is a Safetac-based barrier film in the form of a breathable, soft silicone dressing. It can be applied as a prophylactic measure before the beginning of radiotherapy. Mepitel® can be kept in place for 1-2 weeks or changed when needed and, due to its transparency, does not need to be removed for skin assessments.17

With the relative ease of application comes promising results. Numerous studies of Mepitel® use in patients with breast cancer and head and neck cancer have shown a significant reduction in grade ≥ 2 radiation dermatitis.18–21 Additionally, a reduction of moist desquamation by 26% using Mepitel® versus using a cream was shown by Herst et al., when Mepitel® was used prophylactically.21 A Danish intra-patient randomized multicentre study reported statistically significant lower levels of pain, skin sensitivity, itching, burning sensation, and edema two weeks following radiotherapy. 22

The presence of any substance on the skin during radiotherapy is always met with caution due to concerns it may increase radiation dose delivered to the skin.15,13 The bolus effect of Mepitel® film is 0.12mm, which is clinically insignificant, thereby making it safe to use in this instance.21

Silverlon®

The use of silver-containing creams and dressings during radiotherapy has also previously been approached with caution.13,14 Silverlon, a silver-nylon contact wound dressing, falls into this category.

Silverlon® is a non-adherent, single-use wound contact layer that can be used up to 7 days and, like Mepitel®, also profits from a straightforward application method. The fabric itself permits passage of oxygen to and from the wound, creating favorable conditions for healing. In addition, the silver in the dressing provides an antimicrobial barrier, greatly reducing infection rate.23

Silverlon has been shown as an effective treatment for first- and second-degree thermal burns and its efficacy in radiation dermatitis treatment rests on the same principles.24 Present studies are focusing on generating more robust data in breast cancer patients, whereas a previous phase III clinical trial showed silver-nylon dressing use reduced RD in patients with lower gastrointestinal cancer.25

It was previously thought that silver-containing treatments may affect radiotherapy dose distribution. However, studies examining such claims measured no such difference in MV or kV radiotherapy with silver-containing creams.13,14

Photobiomodulation therapy

An RD treatment option that has no possibility of interfering with radiotherapy dose distribution is photobiomodulation therapy (PBM). PBM uses a light-emitting diode (LED) to stimulate cell metabolism, resulting in increased wound healing, as well as producing an anti-inflammatory effect.26

In the setting of adjuvant breast cancer therapy and head and neck cancer therapy, PBM application resulted in significantly reduced RD symptoms including grade ≥ 2 epithelitis.27–30 In addition, quality-of-life scores also increased in cohorts treated with PBM compared to the placebo control group.27

PBM therapy requires the light source to be placed close to the skin so that the energy emitted can penetrate the tissue.31 So far, positive RD treatment results have been achieved when patients received PBM therapy 2x per week from the beginning of radiotherapy.27–29

To date, no significant adverse effects are associated with PBM. However, there are some concerns about potential long-term effects, such as malignant transformation of healthy cells when PBM is applied close to the tumor site.32 A subsequent study, with a mean follow-up time of 66 months, showed reassuring results.33 PBM during breast cancer therapy had no impact on disease-free state, cancer-free survival or overall patient survival.33 It is recommended that particular attention should be paid to the physical parameters applied for each treatment case. The exact replication of protocols used in published studies is advised.34

There is finally hope on the horizon for patients with RD and for the physicians treating them. Mepitel® film and photobiomodulation therapy have been added to the MASCC clinical practice guidelines for breast cancer patients suffering from RD, and additional clinical study results on Silverlon are expected shortly. These new treatment options can help you give your patients effective care when dealing with the burden of RD during cancer treatment.

Pass on this article to colleagues and discuss implementing some of these treatments into routine radiation dermatitis care and management at your institution.

1. Hickok, J. T., Morrow, G. R., Roscoe, J. A., Mustian, K. & Okunieff, P. Occurrence, severity, and longitudinal course of twelve common symptoms in 1129 consecutive patients during radiotherapy for cancer. J. Pain Symptom Manage. 30, 433–442 (2005).

2. Hymes, S. R., Strom, E. A. & Fife, C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J. Am. Acad. Dermatol. 54, 28–46 (2006).

3. Brown, K. R. & Rzucidlo, E. Acute and chronic radiation injury. J. Vasc. Surg. 53, 15S-21S (2011).

4. Bray, F. N., Simmons, B. J., Wolfson, A. H. & Nouri, K. Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy. Dermatol. Ther. 6, 185–206 (2016).

5. Singh, M., Alavi, A., Wong, R. & Akita, S. Radiodermatitis: A Review of Our Current Understanding. Am. J. Clin. Dermatol. 17, 277–292 (2016).

6. Leventhal, J. & Young, M. R. Radiation Dermatitis: Recognition, Prevention, and Management. Oncol. Williston Park N 31, 885–887, 894–899 (2017).

7. Burke, G., Faithfull, S. & Probst, H. Radiation induced skin reactions during and following radiotherapy: A systematic review of interventions. Radiography 28, 232–239 (2022).

8. Sutherland, A. E., Bennett, N. C. & Herst, P. M. Psychological stress affects the severity of radiation-induced acute skin reactions in breast cancer patients. Eur. J. Cancer Care (Engl.)26, e12737 (2017).

9. Ludmir, E. B., Kachnic, L. A. & Czito, B. G. Evolution and Management of Treatment-Related Toxicity in Anal Cancer. Surg. Oncol. Clin. N. Am. 26, 91–113 (2017).

10. Rades, D. et al. Locally Advanced Stage IV Squamous Cell Carcinoma of the Head and Neck: Impact of Pre-Radiotherapy Hemoglobin Level and Interruptions During Radiotherapy. Int. J. Radiat. Oncol. 70, 1108–1114 (2008).

11. Fesinmeyer, M. D., Mehta, V., Blough, D., Tock, L. & Ramsey, S. D. Effect of Radiotherapy Interruptions on Survival in Medicare Enrollees With Local and Regional Head-and-Neck Cancer. Int. J. Radiat. Oncol. 78, 675–681 (2010).

12. Wong, R. K. S. et al. Clinical practice guidelines for the prevention and treatment of acute and late radiation reactions from the MASCC Skin Toxicity Study Group. Support. Care Cancer 21, 2933–2948 (2013).

13. Baumann, B. C. et al. Assessing the Validity of Clinician Advice That Patients Avoid Use of Topical Agents Before Daily Radiotherapy Treatments. JAMA Oncol. 4, 1742–1748 (2018).

14. Fackrell, D., Kirby, D., Sanghera, P. & Hartley, A. The effect of silver sulfadiazine and zinc oxide creams on dose distribution during radiotherapy. J. Radiother. Pract. 14, 111–116 (2015).

15. Brown, S. A. & Pinnix, C. C. Avoiding Topical Agents Before Daily Radiotherapy: Debunking Dogma. JAMA Oncol. 4, 1748 (2018).

16. Behroozian, T. et al. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: international Delphi consensus-based recommendations. Lancet Oncol. 24, e172–e185 (2023).

17. Fernández-Castro, M., Martín-Gil, B., Peña-García, I., López-Vallecillo, M. & García-Puig, M. E. Effectiveness of semi-permeable dressings to treat radiation-induced skin reactions. A systematic review. Eur. J. Cancer Care (Engl.) 26, e12685 (2017).

18. Robijns, J. et al. Barrier Films and Dressings for the Prevention of Acute Radiation Dermatitis: A Systematic Review and Meta-Analysis. Support. Care Cancer 31, 219 (2023).

19. Yan, J. et al. Mepitel Film is superior to Biafine cream in managing acute radiation‐induced skin reactions in head and neck cancer patients: a randomised intra‐patient controlled clinical trial. J. Med. Radiat. Sci. 67, 208–216 (2020).

20. Wooding, H. et al. The effect of Mepitel Film on acute radiation-induced skin reactions in head and neck cancer patients: a feasibility study. Br. J. Radiol. 91, 20170298 (2018).

21. Herst, P. M. et al. Prophylactic use of Mepitel Film prevents radiation-induced moist desquamation in an intra-patient randomised controlled clinical trial of 78 breast cancer patients. Radiother. Oncol. 110, 137–143 (2014).

22. Møller, P. K. et al. Breast cancer patients report reduced sensitivity and pain using a barrier film during radiotherapy – A Danish intra-patient randomized multicentre study. Tech. Innov. Patient Support Radiat. Oncol. 7, 20–25 (2018).

23. Tisosky, A. J. et al. Use of a Silver Nylon Dressing Following Total Hip and Knee Arthroplasty Decreases the Postoperative Infection Rate. JAAOS Glob. Res. Rev. 1, e034 (2017).

24. Aurora, A., Beasy, A., Rizzo, J. A. & Chung, K. K. The Use of a Silver–Nylon Dressing During Evacuation of Military Burn Casualties. J. Burn Care Res. 39, 593–597 (2018).

25. Niazi, T. M. et al. Silver Clear Nylon Dressing is Effective in Preventing Radiation-Induced Dermatitis in Patients With Lower Gastrointestinal Cancer: Results From a Phase III Study. Int. J. Radiat. Oncol. 84, e305–e310 (2012).

26. Kuffler, D. P. Photobiomodulation in promoting wound healing: a review. Regen. Med. 11, 107–122 (2016).

27. Robijns, J. et al. Prevention of acute radiodermatitis by photobiomodulation: A randomized, placebo-controlled trial in breast cancer patients (TRANSDERMIS trial): PHOTOBIOMODULATION PREVENTS RADIODERMATITIS. Lasers Surg. Med. 50, 763–771 (2018).

28. Censabella, S., Claes, S., Robijns, J., Bulens, P. & Mebis, J. Photobiomodulation for the management of radiation dermatitis: the DERMIS trial, a pilot study of MLS® laser therapy in breast cancer patients. Support. Care Cancer 24, 3925–3933 (2016).

29. Robijns, J. et al. Photobiomodulation therapy for the prevention of acute radiation dermatitis in head and neck cancer patients (DERMISHEAD trial). Radiother. Oncol. 158, 268–275 (2021).

30. Fife, D. et al. A Randomized, Controlled, Double-Blind Study of Light Emitting Diode Photomodulation for the Prevention of Radiation Dermatitis in Patients with Breast Cancer. Dermatol. Surg. 36, 1921–1927 (2010).

31. Dompe, C. et al. Photobiomodulation—Underlying Mechanism and Clinical Applications. J. Clin. Med. 9, 1724 (2020).

32. Sonis, S. T., Hashemi, S., Epstein, J. B., Nair, R. G. & Raber-Durlacher, J. E. Could the biological robustness of low level laser therapy (Photobiomodulation) impact its use in the management of mucositis in head and neck cancer patients. Oral Oncol. 54, 7–14 (2016).

33. Robijns, J. et al. A long‐term follow‐up of early breast cancer patients treated with photobiomodulation during conventional fractionation radiotherapy in the prevention of acute radiation dermatitis. Lasers Surg. Med. 54, 1261–1268 (2022).

34. Klausner, G., Troussier, I., Canova, C.-H. & Bensadoun, R.-J. Clinical use of photobiomodulation as a supportive care during radiation therapy. Support. Care Cancer 30, 13–19 (2022).