Table 2.

Radiation dermatitis: grading and general management recommendations

Grade of radiation dermatitis	Grade 1	Grade 2	Grade 3	Grade 4
Definition of radiation dermatitis (NCI CTCAE, v3.0)	Faint erythema or dry desquamation	Moderate to brisk erythema; patchy, moist desquamation, mostly confined to skin folds and creases; moderate oedema	Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion	Skin necrosis or ulceration of full thickness of dermis; spontaneous bleeding from involved site
General management approaches	See General management
	Maintain hygiene and gently clean and dry skin in the radiation field shortly before radiotherapy
	Topical moisturisers, gels, emulsions and dressings should not be applied shortly before radiation treatment as they can cause a bolus effect, thereby artificially increasing the radiation dose to the epidermis
Grade-specific management approaches	Use of a moisturiser is optional	Keep the irradiated area clean, even when ulcerated		Verify that radiation dose and distribution are correct
	If anti-infective measures are desired, antibacterial moisturisers (e.g. triclosan or chlorhexidine-based cream) may be used occasionally	In the absence of clinical signs of infection, one or combinations of the following topical approaches may be used:		Requires specialised wound care with the assistance of the radiation oncologist, dermatologist and nurse, and should be treated on a case by case basis
		•- Drying gels, possibly with the addition of antiseptics (e.g. chlorhexidine-based creams)
		•- An anti-inflammatory emulsion, such as trolamine
		•- Hyaluronic acid cream
		•- Hydrophilic dressings, applied after radiotherapy to the cleaned, irradiated area, which may provide symptomatic relief
		•- Zinc oxide paste, if easy to remove prior to radiotherapy
		•- When used, silver sulfadiazine or beta glucan cream should be applied after radiotherapy (possibly in the evening) after cleaning the irradiated area
		•- Where infection is suspected:
		•- The treating physician should use best clinical judgement for identifying infection, including the consideration of swabbing the area for identification of the infectious agent
		•- Topical antibiotics (should not be used prophylactically)
		•- Doxycycline is not recommended at this stage
		•- Blood granulocyte counts should be checked, particularly if the patient is receiving concomitant chemotherapy
		•- Blood cultures should be carried out if there are additional signs of sepsis and/or fever
Management team	Can be managed primarily by nursing staff	Can be managed by an integrated management team comprising the radiation oncologist, nurse, medical oncologist (where appropriate) and dermatologist, as required	Should be managed primarily by a wound specialist, with the assistance of the radiation oncologist, medical oncologist (where appropriate), dermatologist and nurse, as required
		Skin reactions should be assessed at least once a week