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Radiation dermatitis is most frequently graded using the National Cancer Institute’s Common Terminology Criteria for Adverse Events.4,11 The following grading criteria for radiation dermatitis were proposed for HNSCC patients receiving radiotherapy and cetuximab11:
• Grade 1: Faint erythema or dry desquamation (skin peeling)
• Grade 2: Moderate to brisk erythema; patchy, moist desquamation or nonhemorrhagic crusts largely confined to skin folds and creases; and moderate edema
• Grade 3: Moist desquamation or hemorrhagic crusts; nonhemorrhagic crusts mostly confined to the skin folds and creases, but may also occur outside the skin folds and creases; bleeding caused by minor abrasion or trauma; and infection requiring oral antibiotics
• Grade 4: Life-threatening consequences; skin graft indicated; skin necrosis or ulceration of full-thickness dermis or damage to muscle, bone or supporting structures without full-thickness skin loss; spontaneous bleeding from more than 40% of the affected site; extensive hemorrhagic crust or ulceration of more than 50% of affected site; ulceration associated with extensive infection and intravenous antibiotics indicated.11
Regardless of severity, radiation dermatitis should prompt an effort to exclude the possible role of non-EGFR-blockade dermatotoxic agents.9
Treatment For grade 1 radiation dermatitis in HNSCC patients receiving radiation-concurrent cetuximab, use general measures such as twice-daily skin hygiene using pH-neutral soaps or showering gels designed for sensitive skin and topical hydrogel moisturizers such as RadiaCare.11 Topical antiseptics (eg, chlorhexidine 0.5%-1%) are recommended for grade 2 and 3 radiation dermatitis, with oral antibiotics if infection is suspected.11 If infection is confirmed or severe, systemic antibiotic therapy with clindamycin (Cleocin, generics), doxycycline, or ciprofloxacin (Cipro, generics) are recommended.11 Hydrogels can be used to keep grade 2 nonhemorrhagic crusts flexible or to debride the wound.11 Topical eosin or soft zinc preparations may be applied to the skin folds, but must be removed before radiotherapy sessions.11
Consultation among the oncology nurse, medical oncologist, radiation oncologist, and dermatologist is indicated to consider interrupting radiotherapy and reducing cetuximab dosage for patients who develop grade 3 radiation dermatitis.11 Grade 4 radiation dermatitis demands daily follow-up and patient hospitalization, and in the case of severe infection, IV antibiotic therapy.11 If grade 4 radiation dermatitis develops, radiotherapy should be discontinued to confirm that radiation dose and distribution are correct, and cetuximab should be discontinued until skin toxicity improves to grade 2 or less severe.11 ONA
Bryant Furlow is a medical journalist based in Albuquerque, New Mexico.
REFERENCES
1. Balagula Y, Rosen ST, Lacouture ME. The emergence of supportive oncodermatology: the study of dermatologic adverse events to cancer therapies. J Am Acad Dermatol. 2011;65(3):624-635.
2. Bonner JA, Harari PM, Giralt J, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med. 2006;354(6):567-578.
3. Budach W, Bölke E, Homey B. Severe cutaneous reaction during radiation therapy with concurrent cetuximab. N Engl J Med. 2007;357(5):514-515.
4. Chen AP, Setser A, Anadkat MJ, et al. Grading dermatologic adverse events of cancer treatments: The Common Terminology Criteria for Adverse Events Version 4.0 [published online ahead of print April 11, 2012]. J Am Acad Dermatol. doi:10.1016/j.jaad.2012.02.010.
5. Bonner JA, Harari PM, Giralt J, et al. Radiotherapy plus cetuximab for locoregionally advanced head and neck cancer: 5-year survival data from a phase 3 randomised trial, and relation between cetuximab-induced rash and survival. Lancet Oncol. 2010;11(1):21-28.
6. Berger B, Belka C. Severe skin reaction secondary to concomitant radiotherapy plus cetuximab. Radiat Oncol. 2008;3(5). doi:10.1186/1748-717X-3-5.
7. Pryor DI, Burmeister E, Burmeister BH, et al. Distinct patterns of stomatitis with concurrent cetuximab and radiotherapy for head and neck squamous cell carcinoma. Oral Oncol. 2011;47(10):984-987.
8. Giro C, Berger B, Bölke E, et al. High rate of severe radiation dermatitis during radiation therapy with concurrent cetuximab in head and neck cancer: results of a survey in EORTC institutes. Radiother Oncol. 2009;90(2):166-171.
9. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer. 2011;19(8):1079-1095.
10. Studer G, Brown M, Salgueiro EB, et al. Grade 3/4 dermatitis in head and neck cancer patients treated with concurrent cetuximab and IMRT. Int J Radiat Oncol Biol Phys. 2011;81(1):110-117.
11. Gutiérrez LC, Khosravi-Shahi P, Alvarez YE. Management of dermatitis in patients with locally advanced squamous cell carcinoma of the head and neck receiving cetuximab and radiotherapy. Oral Oncol. 2012;48(4):293-297.
12. Bernier J, Russi EG, Homey B, et al. Management of radiation dermatitis in patients receiving cetuximab and radiotherapy for locally advanced squamous cell carcinoma of the head and neck: proposals for a revised grading system and consensus management guidelines. Ann Oncol. 2011;22(10):2191-2200.
13. Wu PA, Balagula Y, Lacouture ME, Anadkat MJ. Prophylaxis and treatment of dermatologic adverse events from epidermal growth factor receptor inhibitors. Curr Opin Oncol. 2011;23(4):343-351.
14. Revannasiddaiah S, Thakur P, Gupta M. Dermatitis associated with cetuximab and radiotherapy: the potential benefit with recombinant human epidermal growth factor and a concern regarding the use of steroids [published online ahead of print April 23, 2012]. Oral Oncol. doi:10.1016/j.oraloncology.2012.02.008.
