Barbara Fowble · Sue S Yom Florence Yuen · Sarah Arron Editors Skin Care in Radiation Oncology A Practical Guide 123 Skin Care in Radiation Oncology Barbara Fowble • Sue S Yom Florence Yuen • Sarah Arron Editors Keith Sharee • Abhishek Jairam Associate Editors Skin Care in Radiation Oncology A Practical Guide Editors Barbara Fowble, MD, FACR, FASTRO Department of Radiation Oncology University of California San Francisco San Francisco, CA, USA Sue S Yom, MD, PhD Department of Radiation Oncology University of California San Francisco San Francisco, CA, USA Florence Yuen, RN, MSN, AOCNP Department of Radiation Oncology University of California San Francisco San Francisco, CA, USA Sarah Arron, MD, PhD Department of Dermatology University of California San Francisco San Francisco, CA, USA Associate Editors Keith Sharee, BA Department of Radiation Oncology University of California San Francisco San Francisco, CA, USA Abhishek Jairam, BA Department of Radiation Oncology University of California San Francisco San Francisco, CA, USA ISBN 978-3-319-31458-7 ISBN 978-3-319-31460-0 DOI 10.1007/978-3-319-31460-0 (eBook) Library of Congress Control Number: 2016947072 © Springer International Publishing Switzerland 2016 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG Switzerland Preface On any given day, thousands of patients will receive radiation for cancer or other conditions Most of these patients will experience some degree of skin reaction that may affect quality of life and, if severe enough, result in treatment interruptions Minimizing the frequency and severity of these reactions is important not only for improving quality of life but to avoid interruptions that could compromise local-regional control Intervention strategies are divided into those with the goal of preventing a skin reaction and those with the goal of managing a skin reaction Ideally these strategies are evidence based However, despite many systematic reviews and meta-analyses, no single best practice has been identified and practice guidelines are lacking While the armamentarium of available products is rapidly expanding, their use and acceptance in radiation oncology has been slow For many radiation oncologists, skin care is limited to the use of aloe or an aqueous cream and Domeboro’s solution This guide documents our clinical experience and observations with radiation skin changes at the University of California, San Francisco We present the range and frequency of expected reactions, the factors that influence the reactions, and the interventions we employ We provide evidence where it exists for the intervention We have included photographs to illustrate the various reactions and their response to our intervention(s) The photographs facilitate identification of the skin changes in the clinic or inpatient unit Our goal is to provide a framework for patient care in an era of advancing technology and systemic and targeted therapies and to highlight the importance of preventing and managing the side effects of our treatment San Francisco, CA, USA Editors Barbara Fowble Sue S Yom Florence Yuen Sarah Arron Associate Editors Keith Sharee Abhishek Jairam v Acknowledgments We would like to acknowledge the significant contributions of Patrick MartinTuite in the preparation and organization of all the chapters His assistance has been paramount to the completion of this project We would also like to acknowledge the incredible cooperation of our patients who have allowed us to photograph them on multiple occasions during and after their treatment and document their experience Many individuals have participated in the care of our patients, and we would like to thank them for their meticulous and compassionate care vii Contents Scope of the Problem Barbara Fowble Part I Background Anatomy of the Skin and Pathophysiology of Radiation Dermatitis Sarah Arron Types of Radiation-Related Skin Reactions Barbara Fowble, Sue S Yom, and Florence Yuen 15 Skin Care Products Used During Radiation Therapy Florence Yuen and Sarah Arron 31 Part II Site-Specific Recommendations Head and Neck Cancer Sue S Yom, Florence Yuen, and Joyce Tang 49 Thoracic Cancers Sue S Yom and Florence Yuen 79 Breast Cancer Barbara Fowble, Catherine Park, and Florence Yuen 93 Gastrointestinal Cancer 123 Mekhail Anwar and Jennifer Bohm Genitourinary Cancer 139 Kaveh Maghsoudi, Steve E Braunstein, and Florence Yuen 10 Gynecologic Cancer 145 Tracy Sherertz and Jennifer Bohm 11 Central Nervous System 159 Steve E Braunstein and Florence Yuen 12 Pediatrics 167 Daphne Adele Haas-Kogan, Steve E Braunstein, Florence Yuen, and Lisa Tsang ix Appendix: Skin Care Products Commonly Used in Radiation Oncology Mepilex Lite (small) Mepilex Lite (large, cut to fit) 223 224 Mepilex Ag Mepilex Transfer Ag Appendix: Skin Care Products Commonly Used in Radiation Oncology Appendix: Skin Care Products Commonly Used in Radiation Oncology Mepilex Lite with Silvasorb Gel Mepilex Lite with Therahoney 225 226 Appendix: Skin Care Products Commonly Used in Radiation Oncology Aquacel Extra Ag and Algicell Ag with Mepilex Lite Aquacel Extra Ag, Algicell Ag, Mepitel Ag, and Silvasorb gel Appendix: Skin Care Products Commonly Used in Radiation Oncology Silvasorb Gel Hydrocolloidal Dressings with and without medical-grade honey 227 228 Medical-grade honey products Tubifast Appendix: Skin Care Products Commonly Used in Radiation Oncology Appendix: Skin Care Products Commonly Used in Radiation Oncology Kendall Abdominal Binder Surgilast 229 230 Appendix: Skin Care Products Commonly Used in Radiation Oncology Silicone tape Miscellaneous Detachol and Adhesive Tape Remover Pad Appendix: Skin Care Products Commonly Used in Radiation Oncology Lidocaine % cream 231 Index A Abdominal perineal resection (APR), 123 Acute radiation dermatitis, 1, 10–11 Acute skin toxicity concurrent chemotherapy, 83 reirradiation, 84 tamoxifen/aromatase inhibitor, 96 targeted therapies, 83 trastuzumab, 96 Alginate, 41 hydrofiber dressings, 64, 65 Kaltostat, 65 Sorbsan, 65 Aloe vera, 2, 3, 37 Alopecia, 54, 62 Anal cancer chemotherapy, 123, 124 HIV-positive patients, 123, 124 low CD4 counts, 124 radiation therapy, 123, 124 skin reactions, 132 skin toxicity, 124 treatments, 126 Anti-EGFR-1 targeted therapies, 124 Antifungal agents, 37 Anti-inflammatory emu oil, 34 and healing properties, 32 inhibiting gamma interferon, 34 interleukin-2, 34 Antioxidants, 59 Antiperspirants, APR See Abdominal perineal resection (APR) Aquacel Ag, 65, 100 Aromatase inhibitors, 96 Avocado oil, 35 B Bacitracin, 37 Bactroban See Mupirocin Basal vacuolar change, 11 Biafine, 33 Bolus, 1, 63, 64 axilla and inframammary fold region, 95 moist desquamation, 96 postmastectomy, 94 BRAF-inhibitor therapy, 160 Brain tumor, 159 Breast cancer, 1, 2, 23, 95 acute skin toxicity, 94–96 autologous reconstruction, 100, 103, 104 axillary dissection vs sentinel node biopsy, 94 cases and reactions, 100, 110–115 erythema, 93 fibrosis, 97–98 implant-based reconstruction, 100, 104–107 mastectomy, 100, 107–108 morphea, 97 postmastectomy radiation, 93, 100, 104–107 principles, skin care, 100 radiation dermatitis, 98–100 recall dermatitis, 96 tamoxifen, 95 telangiectasias, 96–97 Breast edema chemotherapy, 95 radiation, 94 Burow’s solution, 37 C Calendula, 2, 32, 33, 99 Candidiasis, 110 Capecitabine and oxaliplatin, 126 Cavilon No Sting Barrier Film, 39, 99 Cellulitis, 110 Central nervous system (CNS) alopecia, 160 altered mental status, 160 bolus, 165 brain metastases, 159, 160 desquamation, 159, 160 erythema, 160–162 highly conformal, 159 impaired immunity, 160 © Springer International Publishing Switzerland 2016 B Fowble et al (eds.), Skin Care in Radiation Oncology, DOI 10.1007/978-3-319-31460-0 233 Index 234 Central nervous system (CNS) (cont.) mask, 160, 165 metastatic lesion, 159 minimally conformal, 159 skin dose, 159, 160 spine tumors, 159 stereotactic radiosurgery, 160 steroid, 160 systemic therapy, 160 UV-exposure, 160 wound care protocols, 160 Cetuximab, 61, 62 Chlorhexidine gluconate See Hibiclens™ Chronic non-healing malignant wounds, 199 Chronic radiation dermatitis, 11, 12 Cleansers See also Antiseptics chlorhexidine gluconate, 36 Hibiclens™, 36 manual debridement, 37 Skintegrity Wound Cleanser™, 37 soaps and synthetic detergents, 36 Coconut oil, 34 Collagen dressings/gels, 39–40 Common Terminology Criteria for Adverse Event (CTCAE), 93, 96, 98, 99 Cornstarch, Corticosteroids mometasone, 62 topical prophylactic, 54 Cost-effectiveness of dressing supplies, 200 Craniospinal axis radiotherapy, 159 CTCAE See Common Terminology Criteria for Adverse Event (CTCAE) Cushing’s syndrome, 160 Cutaneous candidiasis, 17 Cyclophosphamide, 96 D 3D conformal radiation therapy (3DCRT), 177 Debridement, 64, 65, 72 Dermis, 10 Diabetes, 59, 66 Domeboro See Burow’s solution Domeboro Otic See Burow’s solution Dose-limiting toxicity, 50 Dry desquamation, 1, 2, 10, 17, 20 erythema, 53, 93 fibroblast and keratinocyte activity, 64 Medihoney, 99 treatment, 64, 99 Drying agents aloe vera, 37 Burow’s solution, 37 Dyskeratosis, 11 E EBRT See External beam radiotherapy (EBRT) Edema, 17 chemotherapy, 95 tamoxifen, 95 EGFR See Epidermal growth factor receptor (EGFR) Electron beam radiation therapy, 189 Emollients See Moisturizers Emu oil, 34 EpiCeram, 33 Epidermal growth factor receptor (EGFR), 61 Erlotinib, 83 Erythema, 1–3, 10, 16–18 dry desquamation/peeling, 53 follicular reaction/itching, 93 hypopigmented, 97 neck treatments, 82 radiation dermatitis, 93 thorax, 80 Ethnicity, 59 External beam radiotherapy (EBRT), 145 F Fibrosis, 12, 23–24 ATM heterozygosity, 97 parenchymal cells, 97 scleroderma and lupus erythematosus, 97 subcutaneous, 98 tamoxifen, 98 5-Fluorouracil (5-FU), 96, 123, 124 Folliculitis, 17, 23, 110 G Gastrointestinal cancer, 123 acute toxicity, 125 diarrhea, 127 film dosimeters, 127 radiation sensitizer, 123 skin care, 127, 128 Gemcitabine, 83 Genitourinary cancer circumcision, 141 dry desquamation, 141 erythema, 140, 142 fibrosis, 141 hypo/hyperpigmentation, 141 moist desquamation, 141 radiation treatment, 140 skin toxicity, 139–141 telangiectasias, 141 ulceration and necrosis, 141 Gentian violet, Glancing beams, 81 Grading scales EGFR inhibitor-specific, 61 RTOG, 53 skin toxicity, 50 Graft vs host disease (GVHD), 13 Gynecologic cancer, 146–151 alopecia, 148 atrophy, 148 bleeding/painful tumors, 145 body mass index, 150 brachytherapy, 148 cancer death, 145 Index cell turnover kinetics, 146 diabetes, 150, 151 edema, 146 external genitalia, 146, 151 fungal and bacterial infection, 151 high-risk cervical cancer, 145 hypertension, 150 radiation field, 152–153 radiotherapy, 146 sitz baths, 151–154 skin reactions chemotherapy, 146 hyperpigmentation, 146 pelvic radiotherapy, 146 radiation treatment, 146 skin toxicity age, 150–151 appositional skin, 148 body habitus, 148–150 cervical cancer trials, 147 chemotherapy, 150 external genitalia, 148, 150 radiation field, 148 vulvar and vaginal cancer, 149 H HDR-BT See High dose rate brachytherapy (HDR-BT) Head and neck cancer (HNC), 54, 59–61 applications, 62 barrier ointment, 63 chronic management, 66 corticosteroids, 62 dry desquamation, 63–64 external beam radiation, 54–59 gastric acid leakage, 63 geographic region, 49 IMRT, 54 moist desquamation, 64 moisturization, 62 patient-related factors age, 54 antioxidants, 59–60 ethnicity, 59 nutrition, 54 obesity, 59 rheumatologic disorders, 59 UV skin damage/reirradiation, 59 post-treatment, 66 radiation/chemoradiation, 49 skin reactions, 50, 53, 54 special cases and reactions, 66–72 treatment-related factors dose and fraction size, 60 irradiated tissue, 60 radiation therapy, 61 surgical procedures, 60 systemic therapy, 60, 61 wound dressings, 64–66 Hibiclens™, 36, 37, 100 High dose rate brachytherapy (HDR-BT), 177 235 HPV See Human papillomavirus (HPV) Human papillomavirus (HPV), 123 Hyaluronic acid cream, 33 Hydrocortisone, 61, 62 Hydrofiber alginate, 64 Aquacel and Versiva, 65 dressings, 64 Hydrogels, 40–41 amorphous, 64 hydrated polymer dressings, 65 SilvaSorb, 66 Hydrophilic dressings hydrocolloids, 40 radiation-induced moist desquamation, 40 Hyperkeratosis, 11 Hyperpigmentation, 11, 17, 19, 53 inframammary fold, 101 mild residual, 108 Hypertension, 59, 66 Hypofractionated treatments, 82 Hypopigmentation, 11, 59, 62 I Immunocompromised/actively smoking patients, 150 IMRT See Intensity-modulated radiation therapy (IMRT) Inflammatory cells, 12 Intact breast antiperspirants and deodorants, 95 axilla and inframammary fold region, 95 Fitzpatrick skin type, 95 IMRT, 95 single nucleotide polymorphisms, 95 Intensity-modulated radiation therapy (IMRT), 54, 60, 126, 129–131, 177 fibrosis, 98 higher energy photons, 95 telangiectasia, 97 wedge-based radiation, 95 Intraoperative radiation therapy (IORT), 177, 183 Ionizing radiation, 10 IORT See Intraoperative radiation therapy (IORT) K Kaltostat, 65 Kerlix, 201, 202 L Locally advanced cancers activities of daily living, 199 alginate dressing, 200, 206 bleeding, 201 Cavilon No Sting, 201 cleansing, 200 drainage, 200, 201 fungating malignant wound, 199, 201 infection, 199, 201–202 neosporin and polysporin, 200 Index 236 Locally advanced cancers (cont.) occlusive dressings, 200 odor, 201 necrotic tissue, 199 pain, 202 palliative radiation therapy, 200 prevention of healthy skin maceration, 200 quality of life, 199, 200 radiation therapy, 199, 204–207 silvadene, 200, 202 skin and tissue, 199, 203 ulceration, 199 wound and securing dressings, 202–203 Long-term toxicity, 127 Lotion Soft™, 32 Lung cancer, 79 M Macrophages, 12 Maculopapular lesions, 13 Manual debridement, 37 Mānuka honey, 38 Meatal-urethral strictures and stenosis, 141 Mepilex Lite, 41, 84, 88, 99, 100, 200, 202, 204–206, 208 Mepitel Film, 99 Methicillin-resistant Staphylococcus aureus (MRSA), 36 Methotrexate, 96 Mitomycin C (MMC), 123, 124 Moist desquamation, 1, 2, 17, 21–23, 64 alginate dressings, 41 ATM mutations, 95 bolus, 96 dry, 39 erythema, 93 vs extensive, 94 hydrogel dressing, 99 management, 40 Mepitel Film, 39 postmastectomy radiation, 96 pruritus, 39 radiation-induced, 40 small/moderate, 93 Staphylococcus aureus infections, 99 thin-skinned sites, 35 Moisturization, 62 avocado oil, 35 Biafine, 33 calendula, 32 coconut oil, 34 efficacy, 32 emu oil, 34 EpiCeram, 33 hyaluronic acid cream, 33 lotion soft, 32 olive oil, 34 petroleum-based bland emollients, 33 Remedy Lotion, 32 sucralfate, 34 tea tree oil, 35 Mometasone furoate, 99 Morphea, 13, 24, 97 MRSA See Methicillin-resistant Staphylococcus aureus (MRSA) My Girls Breast Cream™, 36 Myofibroblast, 12, 13 N Necrosis skin/flap, 60 ulceration/hemorrhagic, 53 Non-small cell lung cancers (NSCLC), 79 NSCLC See Non-small cell lung cancers (NSCLC) Nutrition consult, 127 O Obesity, 59, 82 Olive oil, 34 P Parakeratosis, 11 Particle therapy, 83 Pediatric cancer, 167, 169 acute skin reactions, 170 Ewing’s sarcoma, 167 external beam radiation, 169–173 neuroblastoma, 167 neurocutaneous syndromes, 167 neutropenia, 171 osteosarcoma, 167 radiation dermatitis, 168 radiotherapy, 168 rhabdomyosarcoma, 167 skin toxicity, 168 stratum corneum, 168 surface to body mass ratio, 168 toxic therapies, 167 Wilm’s tumor (WT), 167 Pemetrexed, 83 Penile cancer, 139, 141 Perfume, Perianal skin, 123 Petroleum-based bland emollients, 33 Poikiloderma, 12 Postmastectomy, 96 Prostate cancer, 139–141 R RadiaGel™, 36 RadiaPlex™ gel, 36 Radiation dermatitis, 1–3, 81–83, 98, 99 acute radiation, 10, 11 chronic radiation, 11 macrophages, 12 pathophysiology, 12–13 prevention, 99, 100 barrier-forming products, 99 topical agents, 98 topical prophylactic steroid creams, 98 Index dressings, 99 dry desquamation, 99 moist desquamation, 99 silver ion dressings, 100 soft silicone dressing (Mepilex), 99 skin eruptions, 13 Radiation fibroblasts, 11 Radiation-induced erythema, 33 Radiation necrosis, 11 Radiation-related skin reactions, 13, 15–17, 23–24, 27 acute radiation dermatitis, 10–11 acute reactions cutaneous candidiasis, 17 dry desquamation, 17 erythema, 16–17 folliculitis, 17 hyperpigmentation, 17 moist desquamation, 17 chronic radiation dermatitis, 11, 12 late reactions aging of skin, 61 edema, 17 fibrosis, 23–24 morphea, 24 pigmentation changes, 17, 62 recall skin reactions, 27 telangiectasia, 17 ulceration, 27 scoring systems, 15–16 Radiation therapy alginate dressings, 41 cleansers/antiseptics, 36–37 collagen dressings/gels, 39–40 drying agents, 37 hydrophilic dressings/hydrogels, 40–41 moisturizers and emollients, 32–35 prophylactic topical steroid creams, 31 silicone dressings, 41 silver ion dressings, 41–42 skin barriers, 39 skin reactions, 31 topical anti-infective agents, 37–38 topical steroids, 35–36 Radiation Therapy Oncology Group (RTOG), 50, 66, 93, 97, 98 Radiation treatment Mepitel Film, 99 NSCLC, 79 SCLC, 80 SRT, 79 subcutaneous fibrosis, 98 topical/oral antioxidant, 59 Radiosensitizers, 13 Recall dermatitis, 96 Recall skin reactions, 26, 83 Rectal cancer, 126 Re-epithelization, 66 Reirradiation, 84 Remedy Lotions, 32 Rheumatologic disorders, 59 RTOG See Radiation Therapy Oncology Group (RTOG) 237 S Sarcoma abscess, 178 bolus, 179 chemotherapy, 177–179 fibrosis, 178–180 hyperpigmentation, 179, 181, 182 joint stiffness, 178, 179 lymphedema, 179 postoperative radiation therapy, 178 radiation dermatitis, 178, 179 radiation treatment, 177–180, 183 seroma, 178 systemic agents, 179 wound complication, 178, 179 SCLC See Small cell lung cancers (SCLC) Scoring systems acute and late radiation skin toxicity, 16 CTCAE, 15 LENT/SOMA, 15 RTOG/EORTC system, 15 treatment-related factors, 16 Silicone, 3, 41 Silver-containing amorphous hydrogel (Silvasorb), 41, 66, 192 Silver ion dressings, 42 Silver-impregnated dressings hydrofiber/alginate, 192 ionic silver, 65 sheet-based dressings, 66 Silver leaf dressing, Silver sulfadiazine, 2, 38 Skin anatomy dermis, 10 epidermis, spinous/squamous layer, stratum basale and granulosum/granular layer, stratum corneum, 10 Skin barriers Cavilon No Sting Barrier Film, 39 mechanical friction, 39 Mepitel Film, 39 Skin cancer alopecia, 189 area of targeted skin, 189 atrophy/contraction, 189 bone necrosis, 189 cataracts, 189 conjunctival scarring, 189 dosimetric/physical shielding, 190 dry eye, 189 epiphora, 189 erlotinib and antibiotics, 190 eyelid deformity, 189 fibrosis/scar, 189 fractionation, 189, 190 lymphatic and perineural channels, 188 mepilex, 192–195 orthovoltage/electron treatments, 189 pigmentation change, 189 pinna, 189 Index 238 Skin cancer (cont.) prior surgery and/or reconstruction, 191 prior UV damage, 191 radiation therapy, 188 skin reaction, 189 soft tissue necrosis, 189 surgery/cryotherapy, 189 systemic therapy, 191 telangiectasia, 189 total dose, 190 treatment, radiation, 192, 194 wet desquamation, 190, 192 X-ray therapy, 189 Skin care, 80, 84 Skin reactions antiperspirants, 54 hyperfractionation, 50 hyperpigmentation (“tanning”), 53 mucositis and dysphagia, 50 RTOG grading scale, 53 RTOG radiation therapy, 50–52 toxicity and heterogeneity, 50 Skin-sparing effects, 81 Skintegrity, 99, 100 Skintegrity Wound Cleanser™, 37 Skin toxicity, 82 acute (see Acute skin toxicity) SRT, 81 superficial, 82 Skin washing, Small cell lung cancers (SCLC), 80 Smoking, 59, 66 Soaps and synthetic detergents, 36 Soft tissue sarcomas (STS), 177 Sorbsan, 65 SRT See Stereotactic radiation therapy (SRT) Stereotactic radiation therapy (SRT) erlotinib, 84 hypofractionation, 81 RTOG 0618, 82 Steroids, STS See Soft tissue sarcomas (STS) Sucralfate, 34, 54, 62 Superficial fibrosis, 62 Superficially directed electron therapy, 82 Systemic therapy cetuximab, 61 EGFR inhibitor, 61 radiation therapy, 61 T Tamoxifen, 95, 96 Tea tree oil, 35 Telangiectasias, 10, 11, 17, 54, 62 dilated superficial blood vessels, 96 IMRT, 97 Thoracic cancers, 80–81, 84 acute skin toxicity, 83, 84 beam arrangement, 81 chemoradiation, 79 chest wall toxicitie, 82 hypofractionated treatments, 82 lung cancer, 79 lung parenchymal/mediastinal regions, 81 proton therapy, 83 radiation-related skin/chest wall reaction, 82 radiation treatment, 79–80 skin reaction management, 84 types and frequency, 80–81 SRT lung cancer, 82 thoracic inlet/supraclavicular region, 81 thorax, 79, 84–86 Topical anti-infective agents antifungal agents, 37 bacitracin, 37 Bactroban, 37 cellulitis, 37 Mānuka honey, 38 mupirocin, 38 silver sulfadiazine cream, 38 Topical steroids cutaneous side effects, 35 hydrocortisone cream, 36 inflammatory response, 35 mometasone furoate, 35 Transforming growth factor beta (TGFβ), 12 Trastuzumab, 96 Trolamine, 2, 98 See also Biafine U Ulceration, 27 Urethral cancer, 140, 143 UV damage/reirradiation, 59 V Vaginal cancer, 145 Vancomycin-resistant enterococci (VRE), 36 Versiva, 65 VRE See Vancomycin-resistant enterococci (VRE) Vulvar cancer, 145 W WBRT See Whole-brain radiation therapy (WBRT) Wet desquamation, 82, 84 Whole-brain radiation therapy (WBRT), 81, 159, 160, 164 Wound care, 54, 65, 66 Wound cleansing, 64 Z Zoster, 113 ... the RISRAS (radiationinduced skin reaction assessment scale) [9], the Catterall Skin Scoring Profile [10], the Skindex-16, the Skin Cancer Index, and the Dermatology Life Quality Index [11–14].. .Skin Care in Radiation Oncology Barbara Fowble • Sue S Yom Florence Yuen • Sarah Arron Editors Keith Sharee • Abhishek Jairam Associate Editors Skin Care in Radiation Oncology A Practical... Baudelin C, Sache A, et al Pravastatin limits radiation- induced vascular dysfunction in the skin J Invest Dermatol 2009;129:1280–91 doi:10.1038/jid.2008.360 16 Muller K, Meineke V Radiation- induced