Lacey Meyer

More than half of people with cancer will receive radiation therapy at some point during their cancer treatment. Radiation therapy is often delivered from a machine outside the body. One of the most common side effects is a skin condition called radiation 

, which can range from a mild, red rash (erythema) and itchy, peeling or flaking skin (dry desquamation) to a more severe reaction with blisters and wet, peeling skin (moist desquamation).

Unfortunately, radiation injures or kills healthy cells as well as cancer cells in the treated area. Repeated radiation exposure causes an imbalance in tissue damage and repair so that exposed skin is damaged faster than it can repair itself. Treatment-related factors that increase the risk and severity of skin reactions include high daily and cumulative radiation doses, the type of beam used to deliver the radiation, a large treatment field, treatment to areas with skin folds (such as the head and neck, the groin or under the breast), and whether it was delivered with certain chemotherapies.

Moderate to severe reactions, such as moist desquamation and blistering, can occur toward the end of treatment, four to six weeks after treatment, or with a cumulative radiation dose of 45 to 60 Gray (Gy); a Gray is a measure of radiation dose.

Radiation burns and skin irritation can interrupt treatment if not managed early and properly. Patients are advised to wear loose-fitting clothing, avoid fabrics that can cause itchiness and check with a healthcare provider before using lotions, perfumes or deodorants.

Gently washing the affected skin with lukewarm water and a mild soap is recommended as a practical step to prevent infection.

Calendula ointment and silver sulfadiazine cream are considered effective topical treatments. An herbal extract from the marigold plant, calendula has anti-inflammatory properties. A large, phase 3 study showed that topical calendula cream reduced pain, treatment interruptions and incidence of moderate skin reactions, such as severe redness and pain, during radiation therapy.

Silver sulfadiazine cream, an antibacterial agent, can be used for moist desquamation to reduce the risk of infection. Studies have also shown that, compared with no treatment at all, it helps to reduce the severity of radiation dermatitis.

Low-dose topical corticosteroids might help reduce irritation and itching, but they should be discontinued if moist desquamation occurs. Some studies have shown that they significantly reduce the severity of skin reactions, but no specific agent was shown to be superior.

In a small study of women receiving breast radiation, a commercially available barrier film reduced skin toxicities and itching. Hyaluronic acid is another topical cream that has shown some evidence of reducing the severity of skin reactions.

For moist desquamation, special dressings, including hydrocolloid and hydrogel dressings, could be used to maintain a moist healing environment.

Small studies have shown that silver leaf nylon dressings can also help to reduce pain and slightly lessen the severity of reactions as well as accelerate healing. A meta-analysis published in 

, however, determined that there wasn’t enough evidence to recommend any particular type of dressing.

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One of the most common side effects of radiation therapy is a skin condition called radiation dermatitis.


What to Do When Radiation Causes Skin Damage

Photosensitivity is a skin reaction in which certain medications and medical conditions can make the skin more sensitive, especially to sunlight, resulting in a rash or easy sunburn.

There are three main types of photosensitivity: phototoxic reactions, photoallergic reactions and radiation recall.

 Many different medications can cause photosensitivity, including antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), diuretics, retinoids and some chemotherapy drugs. 

In phototoxic reactions, the drug is activated by exposure to sunlight and causes damage to the skin. Phototoxic reactions may cause a burning, stinging sensation and appear as exaggerated sunburns within minutes or up to 24 hours after sun exposure. Symptoms are limited to the area of sun-exposed skin and include redness, inflammation, blistering, seeping and peeling. A phototoxic reaction typically clears up (even after re-exposure to light) once the drug is discontinued and has been cleared from the body.

Many different medications can cause photosensitivity, including antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), diuretics, retinoids and some chemotherapy drugs.

In photoallergic reactions, ultraviolet radiation (UV) exposure modifies the structure of the drug so that it is seen by the body’s immune system as an invader, which causes an allergic response. Photoallergic reactions might not occur for one to three days following sun exposure. This type of reaction usually resembles eczema, is generally long-lasting and can spread to other areas of the skin not exposed to sunlight. Photoallergic reactions may initially cause itching, followed by redness, swelling and eruption of the involved area. Some sunscreens, fragrances and occasionally antibacterial soaps can also cause photoallergic reactions when applied to the skin.

Radiation recall is a rare but severe skin reaction that occurs when certain chemotherapy drugs are administered during or soon after radiation treatment, even without exposure to sunlight. Radiation recall is characterized by one or more of the following symptoms in irradiated skin: redness, tenderness, swelling, wet sores and peeling skin. The rash usually appears a few weeks to months following radiation treatment, but it can also manifest years after therapy. Symptoms can last a couple of hours or several days and can make skin sunburn more easily. The skin may be discolored even after it has healed.

Photosensitivity can mimic infections or rashes that are due to drugs but not to photosensitivity, so sometimes a referral to a dermatologist is important to make the correct diagnosis and treatment recommendations.

Treatments for photosensitivity are aimed at treating and minimizing the symptoms. 

Topical corticosteroid creams reduce inflammation, itching and burning of the affected area. The use of systemic corticosteroids should be reserved for the most severe cases. Applying cool, wet dressings or moisturizing lotion may also help.

Over-the-counter analgesics, such as acetaminophen, aspirin or ibuprofen, can ease the pain of photosensitivity rashes and blisters. 

Over-the-counter oral antihistamines, such as loratadine and diphenhydramine, may also be used. More severe photoallergic reactions may require a prescription oral antihistamine. 

For radiation recall, topical or systemic corticosteroids or NSAIDs help to reduce inflammation so that chemotherapy may be continued without delay. Patients should inform their doctor, so the sensitizing chemotherapy can be delayed or withdrawn to allow the skin to heal to prevent infection. Reactions often resolve within one to two weeks.

Patients can minimize symptoms and protect themselves against photosensitivity by avoiding sun exposure, wearing a wide-brimmed hat and clothing that has a tight weave, wearing broad-spectrum sunscreen on all exposed areas, applying skin moisturizers and avoiding tanning beds.

Some cancer treatments can result in skin sensitivity, sunburn and rash.

Light Bright: Awareness of Skin Sensitivity

Breakthrough cancer pain (BTCP) is pain that “breaks through” persistent pain that may be otherwise controlled with a long-acting analgesic. Often of sudden onset, short duration and more moderate to severe, BTCP affects about 65 percent of cancer patients.

BTCP can generally be divided into two categories: spontaneous pain with no evident precipitating event and incident pain with an evident precipitating cause or event, such as walking, sneezing or coughing.

But just because it breaks through the barrier medication for persistent pain doesn’t mean that BTCP can’t be managed. Background pain management consists of around-the-clock medication, usually with long-acting opioids, such as morphine, oxycodone, methadone and fentanyl products; whereas short-acting or rapid-acting oral opioids can effectively treat BTCP episodes.

 Patients can manage BTCP with short-acting formulations of opioids, such as morphine, oxycodone, hydromorphone, buprenorphine and methadone. A rescue dose is an as-needed administered medication for BTCP and generally consists of an immediate-release preparation of the same drug used on an around-the-clock basis for background pain. According to the National Cancer Institute (NCI), the rescue dose is 10 to 20 percent of the total amount of the scheduled background pain medication.

The characteristics of an individual’s pain determine the optimal use of opioid treatment for BTCP. Optimizing pain control means matching the characteristics of the pain (onset, duration, type) with the characteristics of the medication (onset, duration, type), according to the American Pain Foundation.

 The recent development and FDA-approval of new rapid-onset opioid pain medications offers patients the possibility of faster and better management of BTCP. Rapid-onset pain medications are delivered transmucosally, meaning the medication is absorbed through the mucus membrane. Transmucosal fentanyl is a rapid-onset opioid that can be administered inside the cheek (buccal), under the tongue (sublingual) or inside the nose (nasal). Other opioids are not suited for buccal or sublingual administration.

Because pain usually starts and intensifies quickly (in approximately three minutes) and lasts 30 to 60 minutes, the faster-acting and shorter duration forms of transmucosal fentanyl fit better with peak pain periods of BTCP. The newer quick-acting fentanyl products peak in 30 minutes whereas most immediate release pain medications peak in one hour. And the onset of analgesia (pain relief) with transmucosal fentanyl has been shown to occur 5 to 15 minutes after administration.

According to the NCI, side effects of fentanyl are similar to other opioid therapies, including sedation, constipation, stomatitis (inflammation and sores in the mouth) and nausea.

 A number of physical interventions, such as using heating pads or ice packs, light massage or acupuncture, may be used in addition to pharmacological treatments. Cognitive interventions may include distraction techniques, focusing one’s attention on something else to help temporarily relieve pain, especially while waiting for medications to take effect. Meditation, imagery and other integrative approaches can also complement medications.

Patients can take short-acting medications to minimize incident BTCP or prevent it by taking the drugs before a situation known to trigger BTCP. Because oral opioids often have slow analgesic peaks, patients might want to take these medications 15 to 30 minutes prior to an activity known to cause incident pain.

What to do when cancer pain becomes sudden and severe.

Dealing with Breakthrough Cancer Pain

Bettye Davis admits she has never had very good teeth. But when she received a diagnosis of salivary gland cancer, she was surprised that her oncologist recommended she visit a dentist before beginning radiation treatments to her jaw.

“When we first saw her, she still had quite a few teeth, but she had severe periodontal disease and severe bone loss,” says Dennis Abbott, DDS, Davis’ dentist. Knowing radiation would do more damage, he recommended removing the remainder of her teeth and allowing time to heal before she began 33 radiation treatments. 

“We knew that if we took the teeth out after radiation, we risked the bone not healing well, which would have meant osteonecrosis, dead bone in her mouth, and lots of systemic problems.” 

According to the National Cancer Institute, eliminating pre-existing dental and mucosal infections and instituting a comprehensive oral hygiene protocol before and throughout therapy can reduce the severity and frequency of oral complications from cancer therapy. Abbott says the NCI recommendations, as well as an increasing number of studies, are bringing more recognition to the importance of dental issues before, during and after cancer treatment.

Abbott’s goal is to help patients maintain healthy teeth and reduce the risk of future infection with an oral care plan that eliminates or stabilizes disease that could produce complications during or following therapy. These complications can range from irradiated bone and gums not healing properly to an oral bacterial infection spreading throughout the body due to chemotherapy-induced immunosuppression. 

Radiation to the head and neck area can also cause severe dry mouth (xerostomia) and loss of the protective effects of saliva, which accelerates existing tooth decay and can damage tiny blood vessels in the bone that deliver nutrients and oxygen that allow the bone to grow. So any tooth extractions or invasive dental procedures in irradiated bone are likely to result in slow healing, leading to pain and infection.

Oral complications may be acute (developing during therapy) or chronic (developing or continuing long after therapy), with the most common and significant being oral mucositis (inflammation and ulcers in the lining of the mouth), salivary gland dysfunction, taste dysfunction, pain and dry mouth. Limited or no saliva can lead to increased risk of infections in the mouth, gum disease and dental disease, which can progress rapidly and be difficult to control. 

Available medications to stimulate saliva production rely on residual salivary gland function, if enough function remains. Mouth gels, rinses and sprays can moisturize the mouth, but unlike natural saliva, they don’t contain antibodies; growth and repair factors; fluoride; and calcium phosphates that help keep teeth healthy and strong. 

Abbott says this means patients must be proactive in caring for their teeth to prevent cavities. Topical antimicrobials or antiseptics can also help control infections, including dental decay related to acid-producing bacteria.

With radiation therapy directed at her salivary glands, Davis, 73, experienced extreme dry mouth, especially at night. But, she says, a mint-flavored antioxidant topical gel Abbott prescribed, AO ProVantage, effectively relieved this symptom. “It has really helped because it keeps your mouth refreshed, plus it helps you have more moisture in your mouth,” Davis says.

The decision to extract teeth prior to radiation, Abbott says, is based on the health of the tooth, the condition of the gums and bone around the tooth, the amount of radiation the bone around the tooth is scheduled to receive and the area that will be radiated. Gum disease is a cause for tooth extraction prior to therapy. Other causes include problems with previous root canals, tooth fractures and broken fillings that can’t be adequately restored. 

“You can’t dismiss oral health because it affects systemic health,” Abbott says. “The mouth has a huge amount of bacteria, and if it’s not taken care of, there is the risk of that bacteria getting into the bloodstream.”

The American Dental Association recommends all cancer patients schedule a dental exam at least two weeks before beginning treatment. This should involve a full comprehensive exam, gum probing around every tooth and X-rays. It may also include removal of local sites of irritation, such as broken teeth, or identifying chronic infections, such as gum disease. 

“Those conditions need to be managed up front because we are very limited after treatment and the complication risk is so significant that not doing it before can lead to significant difficulties after,” says Joel Epstein, DMD, MSD, director of oral medicine services at City of Hope Cancer Center in Duarte, Calif.

Appropriate healing time for dental care prior to treatment is imperative, Epstein adds, because a surgically treated area in the mouth becomes vulnerable to bacteria. Patients with suppressed immune systems can develop infection, which could result in a treatment delay or dose reduction, ultimately affecting the treatment outcome and survival.

Epstein says two weeks of healing time is ideal, but the overall goal is to have the right dental treatment coordinated with medical therapy to avoid those types of risks. Therefore communication between the dentist and oncology team is key.

Treating dental issues during cancer therapy is possible but can be difficult and can also lead to complications, such as infection in patients on immunosuppressing chemotherapy and delayed healing of affected oral tissue in patients receiving high-dose radiation. 

If dental treatment is needed during a cycled chemotherapy, it must be coordinated between cycles and at a time when white cell counts are high, Epstein says. 

For patients receiving radiation for head and neck cancers, the dentist needs to understand the risks for healing and communicate with the oncologist to understand which regions are involved in the radiation fields, Epstein says. The dentist should also be aware of any previous or ongoing bisphosphonate use and understand the associated risks.

 “We function as a part of the oncology team for all of our patients,” Abbott says. “I understand the blood work that I get back, and I understand what it is that I need to look for in order to keep the patient safe and then develop my treatment plan around that.”

A less common but significant oral complication involves bone healing, or lack thereof. Because radiation can damage bone cells, limiting their ability to heal, any future trauma or surgery to irradiated bone can cause osteonecrosis, or bone death. 

Bisphosphonates and the RANK ligand inhibitor Xgeva (denosumab)—used to maintain bone density and prevent fractures in people with bone metastases&mdash;have also been associated with increased risk for osteonecrosis of the jaw (ONJ), which can occur in 1 to 2 percent of patients on these therapies, according to a 2010 study published in the J

 showed that preventive dental measures can significantly decrease the risk of developing ONJ. In 2003 and 2004, the FDA updated inserts for the intravenous bisphosphonates Aredia (pamidronate) and Zometa (zoledronic acid) recommending a dental exam with preventive dentistry prior to cancer treatment. 

“The main prevention is treatment of the at-risk dental conditions before you’ve had a long-term effect on the bone,” Epstein says. The FDA also warns against invasive dental procedures if possible during or following bisphosphonate use, noting that the majority of reported cases of ONJ have been associated with dental procedures, such as tooth extraction, and many had signs of local infection.

Whether a tooth is extracted from an irradiated area or following bisphosphonate use, Epstein says it must be done carefully. “You want a specialist surgeon to do that with coordination with the cancer center and with people who have supported this need before.”

After her diagnosis of metastatic renal cell carcinoma in 2009, Linda Morris had two extractions before starting Zometa. When an exposed jaw area wouldn’t heal, she developed osteonecrosis. After visiting six dentists over two years, the 67-year-old saw Abbott.  

To prevent infection, Abbott had her apply AO ProVantage twice daily and rinse her mouth with non-alcoholic antibacterial chlorhexidine, as well as clean her teeth with a water flosser. To promote healing, Abbott removed necrotic tissue and performed a comprehensive cleaning every two weeks. For the first time, Morris began to see progress.

“The biggest problem I had was not being able to find the dental care I needed,” Morris says. 

“The topically applied gel has made a huge difference in how we can treat this problem,” Abbott says. “We’ve had two cases where the necrotic bone has been totally resolved.”

Those conditions need to be managed up front because we are very limited after treatment and the complication risk is so significant that not doing it before can lead to significant difficulties after.

Dentists advise resolving tooth and gum issues before starting cancer treatment.

Lacey Meyer

What to Do When Radiation Causes Skin Damage

Light Bright: Awareness of Skin Sensitivity

Dealing with Breakthrough Cancer Pain

Consider Dental Issues Before Beginning Cancer Treatment

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