Table 4.

Proposal of a new grading system for bio-radiation dermatitis^a

TERM	G1	G2	G3	G4
Dermatitis Bio-radiation	Faint erythema or dry desquamation; and lesions due to bio-treatment (e.g. xerosis, papules, pustules, and other clinical signs) which may or may not be associated with symptoms of pruritus or tenderness.	Moderate to brisk erythema; patchy moist desquamation in folds and creases; lesions due to bio-treatment (e.g. crusts, papules, pustules, and other clinical signs) mostly confined to less than 50 % of radiated area; bleeding lesions with friction or trauma.	Moist desquamation in areas other than skin folds and creases; extensive (>50 % of involved field) confluent lesions due to bio-treatment (e.g. crusts, papules, pustules, and other clinical signs) associated to bleeding by minor trauma or abrasion.	Life-threatening consequences; skin necrosis or ulceration of full thickness dermis; extensive (>50 % of involved field) confluent lesions due to bio-treatment (e.g. crusts, papules, pustules, and other clinical signs) associated to signs of spontaneous bleeding. Systemic inflammation response syndrome (SIRS)
Activity of Daily living (ADL)	No limiting age-appropriate ADL	Limiting age-appropriate instrumental ADL	Limiting self-care ADL
Action	Topical therapy indicated (moisturizers, corticosteroids, antibiotics)	Topical and oral therapy indicated	Topical and oral therapy indicated; dressing and wound indicated; inpatient therapy may be necessary	Hospitalize the patient
Grade-specific management approaches	Weekly follow-up is adequate, unless rapid progression is noted	Consider twice-weekly assessments to monitor rapid change	Evaluate the need for daily assessment Closely monitor signs of local or systemic infection For grade 3 reactions occurring at <50 Gy, consider brief interruption in treatment	Consider interrupting treatment with both radiotherapy and cetuximab. Cetuximab should be interrupted until the skin reaction has resolved to at least grade 2 In the case of severe superinfection, consider the use of i.v. antibiotics if unresponsive to oral antibiotics

^aAdapted from references 18 and 19