What is Radiation-Induced Skin Ulcer?
In 2016, around 1.7 million new cancer cases were discovered. We estimate that there’s around 484 new cases for each 100,000 people. More and more people are living longer after a cancer diagnosis, with estimates of 14.5 million survivors in 2014, increasing to an expected 19 million by 2024.
It’s expected that half of all cancer patients will receive radiation therapy. Unfortunately, about 95% of these patients will experience skin injuries because of this therapy. Other causes of skin injuries due to radiation can come from exposure accidents in the workplace.
Taking care of either sudden or longstanding skin injuries that are caused by radiation can be tricky. These injuries can range from simple skin redness to hidden chronic wounds.
Long-term effects of radiation injuries can cause over time issues such as the skin becoming hardened and scarred, sores that don’t heal, damage to the bone, muscle damage, and surgical closures coming undone.
What Causes Radiation-Induced Skin Ulcer?
The skin is always renewing itself, which usually happens about every 26 days. Because of this constant renewal, the skin is the organ most susceptible to damage from a type of energy called ionizing radiation. This kind of energy creates unstable molecules and reactive substances containing oxygen.
These unstable substances can cause harm to our DNA and proteins, the building blocks of our cells. They can also damage the membranes that protect our cells, especially those cells that are rapidly growing and multiplying. This makes the skin particularly sensitive to this type of damage.
Risk Factors and Frequency for Radiation-Induced Skin Ulcer
About 95% of people who undergo radiation therapy experience a range of skin injuries, from skin redness (erythema) to long-lasting wounds. People also risk radiation injury from occupational exposure or accidents. Certain body areas, including the face, neck, torso, and limbs, are more prone to radiation damage.
- About 95% of patients undergoing radiation therapy experience skin injuries.
- These injuries vary from skin redness (erythema) to long-lasting wounds.
- Radiation injury can also occur from work-related exposure or accidents.
- The face, neck, torso, and limbs are more prone to this kind of damage.
Signs and Symptoms of Radiation-Induced Skin Ulcer
When examining a patient who has received radiation therapy, the doctor needs to know about their initial diagnosis and the part of the body that was exposed to radiation. It’s also important to find out the total amount of radiation that was received and when the skin changes first appeared. If the patient also had chemotherapy, the doctor must record the types of drugs that were used. Some of these drugs, like doxorubicin, docetaxel, paclitaxel, tamoxifen, and methotrexate, can increase the risk of radiation-related complications. Other drugs, including doxorubicin, bleomycin, disulfiram, cisplatin, and mafenide acetate, are generally not recommended in combination with a treatment called hyperbaric oxygen treatment, which is often used for severe skin changes caused by radiation.
- Initial diagnosis for which radiation was used
- Body part exposed to radiation
- Total radiation dose received
- When skin changes first appeared
- Types of chemotherapy drugs used
A detailed history is vital as it assists in deciding on the best treatment plan, especially if it includes hyperbaric oxygen treatment. A full physical examination is also crucial, specifically checking the extent of the skin injury. This will help in selecting the most appropriate treatment method based on the radiation injury’s severity. Skin damage due to long-term exposure to radiation can include dryness, thickening, reduced or no sweating, thinning and discoloration of the skin, dead tissue resulting in deep wounds, and more.
It’s important to identify any factors that may prevent the use of hyperbaric oxygen treatment. The doctor will pay special attention to the head and neck area, checking the eyes for cataracts. The eardrums must also be checked for any scarring or abnormalities that could prevent pressure equalization in the inner ear. A chest x-ray should be taken to ensure the absence of any acute diseases and to check for a certain type of lung disease, given the risk of lung collapse during hyperbaric oxygen therapy, which uses pressure higher than sea-level atmospheric pressure.
Testing for Radiation-Induced Skin Ulcer
If you have a skin injury because of radiation therapy, your doctor will need to run some tests before starting a specific treatment plan – like using a hyperbaric oxygen chamber. You might have to get a chest x-ray, a hemoglobin A1C test (which measures your average blood sugar levels over the past three months), a sedimentation rate (a blood test to check for inflammation), and a complete blood count (a test that measures different parts of your blood) to check if there might be an infection.
Your doctor might need to order other tests as well, depending on your condition when you first see them or if you experience complications during your treatment.
Treatment Options for Radiation-Induced Skin Ulcer
When dealing with skin damage due to radiation, the treatment should always match the severity of the injury. This means taking care of any dead skin, managing inflammation and infection, ensuring the wound stays moist, and keeping track of the healing process. The style of treatment might need to change based on how well the skin is re-growing. This all comes down to basic wound care, but with some changes due to the nature of the injury, which could range from mild redness to a serious chronic wound.
Before, during, and after radiation therapy, patients should be educated on how to take care of their skin. This includes maintaining personal hygiene, minimizing discomfort, avoiding further damage to the affected skin, and dealing with radiation dermatitis (skin inflammation caused by radiation).
The choice of skin products should reflect the extent of the injury. Products such as Natural Care Gel, Eucerin cream, Lubriderm, and corticosteroid cream can help with redness and dry peeling skin. If there’s an infection, antibiotic creams like Neosporin or silver sulfadiazine 1% may be used. The need for systemic antibiotics (taking them by mouth or injecting them) would also need to be evaluated.
There are various treatments available for radiation-induced skin damage, and these can vary depending on the specific problem:
1. If the radiation has caused fibrosis (the thickening and scarring of connective tissue), a drug called pentoxifylline may reverse some of the damage, and alpha-tocopherol (a form of vitamin E) might also help. In severe cases, surgery might be needed to remove the damaged tissue and replace it with a graft (patch) of skin. Hyperbaric oxygen treatment, where you breathe in pure oxygen in a pressurized environment, could be used as an additional therapy.
2. If there’s a persistent wound, or if soft tissue is dying, initial treatment could involve hyperbaric oxygen treatment and pentoxifylline as well, followed by surgical removal of the damaged tissue and surgical reconstruction of the area.
Osteoradionecrosis/chondronecrosis refers to the death of bone or cartilage due to radiation, and this usually happens in the facial bones (such as the jawbone). Things like dental extraction and infection can bring this on, and management strategies could range from getting teeth pulled before radiation therapy to using pentoxifylline and vitamin E before pulling teeth in already radiated tissue. Again, hyperbaric oxygen treatment has been used with success for these chronic radiation injuries.
Hyperbaric oxygen treatment is often used for delayed radiation injuries, and almost a third of patients receive this therapy for their radiation injury in the United States. Even though radiation mainly causes harm through low oxygen levels and increased tissue scarring, hyperbaric oxygen treatment can increase the growth of new blood vessels, thereby improving oxygen levels and potentially reducing tissue scarring. This hasn’t been fully studied, though.
Another way radiation might cause delayed injury is by hurting stem cells (the body’s ‘master cells’). Some researchers are now looking into whether hyperbaric oxygen treatment might increase the number of stem cells at the site of radiation injury.
What else can Radiation-Induced Skin Ulcer be?
Here is a list of some conditions that may appear similar to a particular type of skin lesion:
- Buruli ulcer
- Chronic herpes ulcers
- Cutaneous tuberculosis
- Deep fungal infection
- Drepanocytosis
- Ecthyma
- Leishmaniasis
- Leprosy
- Phagedenic ulcers
- Skin cancers
- Tropical ulcer
- Vascular or diabetic ulcers
- Yaws
What to expect with Radiation-Induced Skin Ulcer
Generally speaking, how well a patient recovers depends on several factors. These factors mainly include the severity of the radiation injury, which can be graded from 1 to 4, and any other existing health issues the patient may have.
