Skin Care During RT Discussion

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Curious as well. Any luck with mometasone? Something else?
 
communitydoc13 said:
What's your go to.

This is an area with very little standardization. Could even be a new thread.
Click to expand...
Isn’t the best level one evidence base for preventing breast skin reaction from radiation to use IMRT 🙂

Also data for daily glass of red wine. Very good data for antibiotic prophylaxis.

einsteinmed.edu

A Simple Antibacterial Treatment Solves a Severe Skin Problem Caused by Radiation Therapy | Albert Einstein College of Medicine

Researchers at Montefiore Einstein Cancer Center discover simple, low-cost treatment to prevent severe cases of acute radiation dermatitis.
einsteinmed.edu einsteinmed.edu
 
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IMRT and mixing in higher energies when appropriate as well as judicious volumes (do you really need to treat the inframam fold in large breasted women with tumor 15 cm away in upper outer quadrant) is the best way to avoid skin reactions.
 
RickyScott said:
IMRT and mixing in higher energies when appropriate as well as judicious volumes (do you really need to treat the inframam fold in large breasted women with tumor 15 cm away in upper outer quadrant) is the best way to avoid skin reactions.
Click to expand...
If it's stage one, and other clinical/age factors too obv, the ASTRO rec is now partial breast vs whole breast anyways for exactly these reasons (studies prove less side effects, equal cancer control, etc). Still surprised at the amount of inappropriate whole breasting going on in the community.
 
communitydoc13 said:
What's your go to.

This is an area with very little standardization. Could even be a new thread.
Click to expand...
*cracks knuckles*

So this is indeed something I've intentionally developed over several years, because I absolutely agree about the chaotic lack of standardization.

For efficiency I won't put in 100 paper links like @TheWallnerus - but I believe the evidence/sources for any of my stuff can be found on either PubMed/Google Scholar, MedNet, or government-backed entities (I remember reading documents from Australia's version of like, the NCCN back in the day).

1) I'm a solo generalist who doesn't do brachy. So dermatitis is something I worry about mostly with breast and head and neck. Obviously, it's something to worry about with gyn/anal, but those are less common disease sites for me and I deploy additional tricks (Tucks pads anyone?). I say this as a disclaimer against accidentally sounding black and white (nothing in medicine is concretely "yes" or "no").

But I'll stick with my breast regimen, which is similar to what I do with head and neck - I just often have to do things earlier with the head and neck cases.

2) It starts with coaching/educating the staff. Boomer therapists are the most difficult because they long ago decided they know what's best and can be reluctant to change. But that's not a tremendous problem - you just need to stop them from contradicting you. Yes, this is a problem I've faced before.

I'm assuming most of us work in clinics with at least one nurse, and that nurse is the first line of defense for "clinic issues". I always try to do three things with my nurses:
- be predictable for them
- explain why I'm doing Intervention XYZ for Common Problem ABC
- encourage them to suggest things/speak up/ask for explanations

I believe in people "practicing at the top of their license". Part of why I have the least dermatitis in my patients that I have ever seen is I have an amazing nurse who is SUPER into skin care. I noticed a big improvement after this nurse came along - I attribute it to consistent reinforcement of the patients.

I've also learned from older staff that the doc I replaced created a culture of "no questions allowed". It sounds like even casual curiosity was met with savage defensiveness. That attitude is a great way to create a culture of apathy in the staff.

3) With the patients, I start discussing skin care at the consult. People naturally want to wait until they see skin issues to do something - you have to break them of that logic.

I tell them that starting the very first day of treatment, I want them to gently wash/exfoliate the area twice a day (morning, night) and explain it's to get dead skin cells and bacteria off. I recommend using a baby shampoo (or equivalent) and a soft washcloth or loofah.

I also tell them to aim for using an oil-based moisturizer three times a day. I explain "oil based" because a common skincare product trick is to put an alcohol base in to make it look like it absorbs, when all it's doing is drying skin out. I recommend calendula oil based products (i.e. Miaderm, but there are cheaper products out there). I then ask if they already use lotion on their hands or elsewhere. Often people will be using lotion anyway. As long as it's gentle (with the litmus test being if it's heavily scented) and oil based, I have patients use it even though it doesn't have calendula. This is often something like coconut oil, Eucerin, etc.

While things like coconut oil are less evidenced-based, I find a much, MUCH higher adherence if patients don't have to go out and get some brand new product they've never heard of, rather, they just keep using what they've always used.

4) I always hypofrac (or 5-fraction) whole breasts, and have a great Dosimetrist (and also EZ-Fluence). Treatment plans are very "by the book".

This gets you 80% of the way there for most patients. Exfoliate twice a day, oil-based lotion three times a day, reinforcement by clinic staff.

5) Even with excellent adherence, the Canadian fraction patients will often experience some level of mild irritation in the last 5-7 days.
- if they complain of more of an itching sensation, instead of burning, I have them go to a local drugstore and get both Benadryl lotion and hydrocortisone cream. They're almost always found side-by-side in store. I tell the patient to experiment with adding them in to their regimen of wash/lotion and use whichever one helps more. Some love the Benadryl, others the hydrocortisone.

6) For patients who complain of "burning", or who experience dermatitis early, I always go with triamcinolone over mometasone. Triamcinolone is waaaay cheaper, has a 12 hour half life, and comes in a 400g version. I have them put the triamcinolone on in the morning and the evening in addition to the base regimen.

7) Finally, if there's actual skin breakdown (desquamation), I immediately go with Silvadene. Interestingly, I've had patients start using Neosporin (or equivalent) on their own without telling me, and I only find out at OTV a week later. They seem happy, and I believe in "if it ain't broke, don't fix it". So if a patient wants to use some OTC antibiotic ointment on the open area and lotion/steroid on the rest, I let them.

8) I warn patients it can take 10-14 days after treatment before they really start to see an improvement, and I encourage them to continue the skin care regimen for at least 2 weeks after completion.

Super long winded, I know...but this saves me a lot of skin trouble.
 
elementaryschooleconomics said:
*cracks knuckles*

So this is indeed something I've intentionally developed over several years, because I absolutely agree about the chaotic lack of standardization.

For efficiency I won't put in 100 paper links like @TheWallnerus - but I believe the evidence/sources for any of my stuff can be found on either PubMed/Google Scholar, MedNet, or government-backed entities (I remember reading documents from Australia's version of like, the NCCN back in the day).

1) I'm a solo generalist who doesn't do brachy. So dermatitis is something I worry about mostly with breast and head and neck. Obviously, it's something to worry about with gyn/anal, but those are less common disease sites for me and I deploy additional tricks (Tucks pads anyone?). I say this as a disclaimer against accidentally sounding black and white (nothing in medicine is concretely "yes" or "no").

But I'll stick with my breast regimen, which is similar to what I do with head and neck - I just often have to do things earlier with the head and neck cases.

2) It starts with coaching/educating the staff. Boomer therapists are the most difficult because they long ago decided they know what's best and can be reluctant to change. But that's not a tremendous problem - you just need to stop them from contradicting you. Yes, this is a problem I've faced before.

I'm assuming most of us work in clinics with at least one nurse, and that nurse is the first line of defense for "clinic issues". I always try to do three things with my nurses:
- be predictable for them
- explain why I'm doing Intervention XYZ for Common Problem ABC
- encourage them to suggest things/speak up/ask for explanations

I believe in people "practicing at the top of their license". Part of why I have the least dermatitis in my patients that I have ever seen is I have an amazing nurse who is SUPER into skin care. I noticed a big improvement after this nurse came along - I attribute it to consistent reinforcement of the patients.

I've also learned from older staff that the doc I replaced created a culture of "no questions allowed". It sounds like even casual curiosity was met with savage defensiveness. That attitude is a great way to create a culture of apathy in the staff.

3) With the patients, I start discussing skin care at the consult. People naturally want to wait until they see skin issues to do something - you have to break them of that logic.

I tell them that starting the very first day of treatment, I want them to gently wash/exfoliate the area twice a day (morning, night) and explain it's to get dead skin cells and bacteria off. I recommend using a baby shampoo (or equivalent) and a soft washcloth or loofah.

I also tell them to aim for using an oil-based moisturizer three times a day. I explain "oil based" because a common skincare product trick is to put an alcohol base in to make it look like it absorbs, when all it's doing is drying skin out. I recommend calendula oil based products (i.e. Miaderm, but there are cheaper products out there). I then ask if they already use lotion on their hands or elsewhere. Often people will be using lotion anyway. As long as it's gentle (with the litmus test being if it's heavily scented) and oil based, I have patients use it even though it doesn't have calendula. This is often something like coconut oil, Eucerin, etc.

While things like coconut oil are less evidenced-based, I find a much, MUCH higher adherence if patients don't have to go out and get some brand new product they've never heard of, rather, they just keep using what they've always used.

4) I always hypofrac (or 5-fraction) whole breasts, and have a great Dosimetrist (and also EZ-Fluence). Treatment plans are very "by the book".

This gets you 80% of the way there for most patients. Exfoliate twice a day, oil-based lotion three times a day, reinforcement by clinic staff.

5) Even with excellent adherence, the Canadian fraction patients will often experience some level of mild irritation in the last 5-7 days.
- if they complain of more of an itching sensation, instead of burning, I have them go to a local drugstore and get both Benadryl lotion and hydrocortisone cream. They're almost always found side-by-side in store. I tell the patient to experiment with adding them in to their regimen of wash/lotion and use whichever one helps more. Some love the Benadryl, others the hydrocortisone.

6) For patients who complain of "burning", or who experience dermatitis early, I always go with triamcinolone over mometasone. Triamcinolone is waaaay cheaper, has a 12 hour half life, and comes in a 400g version. I have them put the triamcinolone on in the morning and the evening in addition to the base regimen.

7) Finally, if there's actual skin breakdown (desquamation), I immediately go with Silvadene. Interestingly, I've had patients start using Neosporin (or equivalent) on their own without telling me, and I only find out at OTV a week later. They seem happy, and I believe in "if it ain't broke, don't fix it". So if a patient wants to use some OTC antibiotic ointment on the open area and lotion/steroid on the rest, I let them.

8) I warn patients it can take 10-14 days after treatment before they really start to see an improvement, and I encourage them to continue the skin care regimen for at least 2 weeks after completion.

Super long winded, I know...but this saves me a lot of skin trouble.
Click to expand...
This is a lot of work. Allow me to provide an alternative & more time efficient process:

1. Inherit patient from another physician in your practice
2. Assume everything is correct, without actually checking anything
3. Get caught, pay the fine, and use your mistake to justify direct supervision nationwide (despite the fact that you actually directly supervised this error)
4. Take home your $1.5M annual paycheck and run for ASTRO president
 
Gfunk6 said:
This is a lot of work. Allow me to provide an alternative & more time efficient process:

1. Inherit patient from another physician in your practice
2. Assume everything is correct, without actually checking anything
3. Get caught, pay the fine, and use your mistake to justify direct supervision nationwide (despite the fact that you actually directly supervised this error)
4. Take home your $1.5M annual paycheck and run for ASTRO president
Click to expand...
IMG_9850.jpeg
 
elementaryschooleconomics said:
*cracks knuckles*

So this is indeed something I've intentionally developed over several years, because I absolutely agree about the chaotic lack of standardization.

For efficiency I won't put in 100 paper links like @TheWallnerus - but I believe the evidence/sources for any of my stuff can be found on either PubMed/Google Scholar, MedNet, or government-backed entities (I remember reading documents from Australia's version of like, the NCCN back in the day).
...
Click to expand...

I am definitely not this aggressive with my patient's skin care routine.

But I am being conditioned to do everything you say. That, and you say things which such conviction that I'm tempted to follow your lead.
 
I have been doing this for head and neck patients, and I haven’t noted any difference so far.
 
CaesarRO said:
I am definitely not this aggressive with my patient's skin care routine.

But I am being conditioned to do everything you say. That, and you say things which such conviction that I'm tempted to follow your lead.
Click to expand...
I made a weird snort/chuckle sound reading this, so thanks.

It's definitely aggressive, but obviously I like to do things at Mach 1...which is a double-edged sword.

I suspect it's somewhat a function of my practice environments. I went to one of the largest residency programs and I didn't observe/experience anyone going this far down the skincare rabbit hole. There was a lot of daily shuffle/turnover.

After residency, I've only been in small departments, either solo or virtually solo (the classic "senior partner works 1.5 days a week" deal).

When it's just me, day in and day out, and elderly staff have been used to doing things a certain way for 30 years...well, let's just say I don't think Grade 1 dermatitis requires a wound care consult like some of the staff I've worked with demand. When there's no one else around to slice up some of their opinions, I find it easier to just prevent situations for anyone to have any opinions on in the first place.

I can save myself a lot of drama if side effects can be avoided....
 
elementaryschooleconomics said:
*cracks knuckles*

So this is indeed something I've intentionally developed over several years, because I absolutely agree about the chaotic lack of standardization.

For efficiency I won't put in 100 paper links like @TheWallnerus - but I believe the evidence/sources for any of my stuff can be found on either PubMed/Google Scholar, MedNet, or government-backed entities (I remember reading documents from Australia's version of like, the NCCN back in the day).

1) I'm a solo generalist who doesn't do brachy. So dermatitis is something I worry about mostly with breast and head and neck. Obviously, it's something to worry about with gyn/anal, but those are less common disease sites for me and I deploy additional tricks (Tucks pads anyone?). I say this as a disclaimer against accidentally sounding black and white (nothing in medicine is concretely "yes" or "no").

But I'll stick with my breast regimen, which is similar to what I do with head and neck - I just often have to do things earlier with the head and neck cases.

2) It starts with coaching/educating the staff. Boomer therapists are the most difficult because they long ago decided they know what's best and can be reluctant to change. But that's not a tremendous problem - you just need to stop them from contradicting you. Yes, this is a problem I've faced before.

I'm assuming most of us work in clinics with at least one nurse, and that nurse is the first line of defense for "clinic issues". I always try to do three things with my nurses:
- be predictable for them
- explain why I'm doing Intervention XYZ for Common Problem ABC
- encourage them to suggest things/speak up/ask for explanations

I believe in people "practicing at the top of their license". Part of why I have the least dermatitis in my patients that I have ever seen is I have an amazing nurse who is SUPER into skin care. I noticed a big improvement after this nurse came along - I attribute it to consistent reinforcement of the patients.

I've also learned from older staff that the doc I replaced created a culture of "no questions allowed". It sounds like even casual curiosity was met with savage defensiveness. That attitude is a great way to create a culture of apathy in the staff.

3) With the patients, I start discussing skin care at the consult. People naturally want to wait until they see skin issues to do something - you have to break them of that logic.

I tell them that starting the very first day of treatment, I want them to gently wash/exfoliate the area twice a day (morning, night) and explain it's to get dead skin cells and bacteria off. I recommend using a baby shampoo (or equivalent) and a soft washcloth or loofah.

I also tell them to aim for using an oil-based moisturizer three times a day. I explain "oil based" because a common skincare product trick is to put an alcohol base in to make it look like it absorbs, when all it's doing is drying skin out. I recommend calendula oil based products (i.e. Miaderm, but there are cheaper products out there). I then ask if they already use lotion on their hands or elsewhere. Often people will be using lotion anyway. As long as it's gentle (with the litmus test being if it's heavily scented) and oil based, I have patients use it even though it doesn't have calendula. This is often something like coconut oil, Eucerin, etc.

While things like coconut oil are less evidenced-based, I find a much, MUCH higher adherence if patients don't have to go out and get some brand new product they've never heard of, rather, they just keep using what they've always used.

4) I always hypofrac (or 5-fraction) whole breasts, and have a great Dosimetrist (and also EZ-Fluence). Treatment plans are very "by the book".

This gets you 80% of the way there for most patients. Exfoliate twice a day, oil-based lotion three times a day, reinforcement by clinic staff.

5) Even with excellent adherence, the Canadian fraction patients will often experience some level of mild irritation in the last 5-7 days.
- if they complain of more of an itching sensation, instead of burning, I have them go to a local drugstore and get both Benadryl lotion and hydrocortisone cream. They're almost always found side-by-side in store. I tell the patient to experiment with adding them in to their regimen of wash/lotion and use whichever one helps more. Some love the Benadryl, others the hydrocortisone.

6) For patients who complain of "burning", or who experience dermatitis early, I always go with triamcinolone over mometasone. Triamcinolone is waaaay cheaper, has a 12 hour half life, and comes in a 400g version. I have them put the triamcinolone on in the morning and the evening in addition to the base regimen.

7) Finally, if there's actual skin breakdown (desquamation), I immediately go with Silvadene. Interestingly, I've had patients start using Neosporin (or equivalent) on their own without telling me, and I only find out at OTV a week later. They seem happy, and I believe in "if it ain't broke, don't fix it". So if a patient wants to use some OTC antibiotic ointment on the open area and lotion/steroid on the rest, I let them.

8) I warn patients it can take 10-14 days after treatment before they really start to see an improvement, and I encourage them to continue the skin care regimen for at least 2 weeks after completion.

Super long winded, I know...but this saves me a lot of skin trouble.
Click to expand...
i literally essentially quoted this today to a breast patient for their 1st OTV. Thanks!
 
It's definitely worth it, once you integrate this whole song and dance into your routine.

Although...it does seem insane that relatively basic skincare can have such a big impact.

Honestly, I find a weird glee in witnessing the magnitude of benefit in both moisturizing for dermatitis, and LDRT for arthritis.

The "glee" comes from still, to this day, being skeptical of...myself, and then seeing this stuff work...again.
 
NotMattSpraker said:
Are you having them exfoliate BID through treatment or does that just naturally stop if they get sore?
Click to expand...
I feel like you're using "exfoliate" in the "spa experience" sense of the word - as in, intentionally more robust than mere washing.

I describe it to the patients as regular, soft washing/cleansing. The intent is exfoliation of dead skin cells/dirt/bacteria etc, but it shouldn't hurt to do it.

I consider this "bargaining" - when I recommend BID washing and TID lotion.

For most patients...that's crazy. But that's my opening offer.

If I can get someone to wash a few times a week and put lotion on at least daily, that's a victory over what they would have done otherwise.

Just like dentists and flossing...it's obvious to me who is actually doing the skincare regimen, vs who is lying about it.

(just kidding - one of the things I love about my rural patient population is they rarely lie to me, they straight up tell me they aren't doing any skincare)
 
For skin cancers (especially poorly vascularized areas like pre-tibial) and some necks in H&N patients, I've had good results with doing wet-to-drys of a mix of betadine and NS up to TID from the beginning of treatment
 
jpace said:
For skin cancers (especially poorly vascularized areas like pre-tibial) and some necks in H&N patients, I've had good results with doing wet-to-drys of a mix of betadine and NS up to TID from the beginning of treatment
Click to expand...
Oh man...do you feel like you get good compliance with that?

Unless patients have visiting nurses or wound care coming to their homes...it's tough for me.
 
jpace said:
For skin cancers (especially poorly vascularized areas like pre-tibial) and some necks in H&N patients, I've had good results with doing wet-to-drys of a mix of betadine and NS up to TID from the beginning of treatment
Click to expand...

That is super intense for a preventative treatment. Can't imagine I would do that on myself knowing what I know.

I usually recommend aloe vera BID and daily showering (the latter if I feel it's a discussion point I need to have based on odor of the patient).

People put OTC aloe vera on sun burns, why not use it to prevent a sunburn?
 
evilbooyaa said:
That is super intense for a preventative treatment. Can't imagine I would do that on myself knowing what I know.

I usually recommend aloe vera BID and daily showering (the latter if I feel it's a discussion point I need to have based on odor of the patient).

People put OTC aloe vera on sun burns, why not use it to prevent a sunburn?
Click to expand...

I like Vitamin E and aloe combinations and I like aloe straight from the plant, but the neon stuff with bubbles you see at every checkout counter in Florida has a drying agent as an ingredient. That makes it feel good if you have a sunburn, but I don't recommend it for RT as a result.
 
elementaryschooleconomics said:
Oh man...do you feel like you get good compliance with that?

Unless patients have visiting nurses or wound care coming to their homes...it's tough for me.
Click to expand...
Even once a day is helpful. Some people do it in the department after treatment. Others put their leg up and watch and the Price is Right at home
 
evilbooyaa said:
That is super intense for a preventative treatment. Can't imagine I would do that on myself knowing what I know.

I usually recommend aloe vera BID and daily showering (the latter if I feel it's a discussion point I need to have based on odor of the patient).

People put OTC aloe vera on sun burns, why not use it to prevent a sunburn?
Click to expand...
I hate aloe vera and actively discourage its use:

journals.lww.com

Radiation dermatitis: An overview : Indian Journal of Burns

n multiple patient and treatment related factors. With the use of megavoltage radiation and implementation of conformal radiotherapy, the incidence of severe radiation dermatitis has reduced significantly. Treatment interruptions due to severe reactions may affect outcome. Prevention and...
journals.lww.com journals.lww.com



I suspect @OTN is correct - many commercial products contain drying agents (alcohol).

They also commonly contain menthol. While technically an analgesic (or, at least, has evidence for influencing analgesic receptors/pathways), I personally consider menthol contraindicated for radiation-induced dermatitis.

*straps on boxing gloves*

I assume saying "I hate aloe vera" is controversial. Maybe not?
 
elementaryschooleconomics said:
I hate aloe vera and actively discourage its use:

journals.lww.com

Radiation dermatitis: An overview : Indian Journal of Burns

n multiple patient and treatment related factors. With the use of megavoltage radiation and implementation of conformal radiotherapy, the incidence of severe radiation dermatitis has reduced significantly. Treatment interruptions due to severe reactions may affect outcome. Prevention and...
journals.lww.com journals.lww.com



I suspect @OTN is correct - many commercial products contain drying agents (alcohol).

They also commonly contain menthol. While technically an analgesic (or, at least, has evidence for influencing analgesic receptors/pathways), I personally consider menthol contraindicated for radiation-induced dermatitis.

*straps on boxing gloves*

I assume saying "I hate aloe vera" is controversial. Maybe not?
Click to expand...
I tell pts to use the plant and that works just fine. Also eucerin/aquaphor if they are interested
 
elementaryschooleconomics said:
I hate aloe vera and actively discourage its use:

journals.lww.com

Radiation dermatitis: An overview : Indian Journal of Burns

n multiple patient and treatment related factors. With the use of megavoltage radiation and implementation of conformal radiotherapy, the incidence of severe radiation dermatitis has reduced significantly. Treatment interruptions due to severe reactions may affect outcome. Prevention and...
journals.lww.com journals.lww.com



I suspect @OTN is correct - many commercial products contain drying agents (alcohol).

They also commonly contain menthol. While technically an analgesic (or, at least, has evidence for influencing analgesic receptors/pathways), I personally consider menthol contraindicated for radiation-induced dermatitis.

*straps on boxing gloves*

I assume saying "I hate aloe vera" is controversial. Maybe not?
Click to expand...

Yes, I recommend avoiding the ones with alcohol as an ingredient

What's your beef with menthol for RT induced dermatitis?

Also, from the updated review you posted: "Aloe vera may be effective when cumulative radiation doses are greater than 2,700 cGy"

Patients don't need skin care if they're getting 2Gy/Fx below 27Gy...

 
Last edited:
RickyScott said:
Just started with s saliverius. I have found high dose neurontin works really well. Will try just abt anythun to avoid that 48% peg use with imrt
Click to expand...
same here with S Salivarius - so far so good, but 1st person I have used it on is only in week 3.

I am instructing prior ENT XRT pts to take it too.
 
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