Skin Hygiene and Care
Skin Hygiene and Care
Skin hygiene and care refers to consistent skin cleaning with mild soaps and skin care, usually including moisturizers. Good skin hygiene and moisturizers are important for patients with lymphedema for prevention of skin breakdown or infection. In the past, in patients receiving radiotherapy, washing the skin and continuation of use of moisturizers or lotions on the skin in the radiation field was controversial. Effects of skin hygiene and care, such as moisturizers, was evaluated in patients with cancer related to lymphedema and radiodermatitis.
Recommended for Practice
Bolderston, A., Lloyd, N.S., Wong, R.K.S., Holden, L., Robb-Blenderman, L., & Supportive Care Guidelines Group. (2005). The prevention and management of acute skin reactions related to radiation therapy: A clinical practice guideline (Practice Guidelines Report #13-7). Toronto, Canada: Cancer Care Ontario. Retrieved from https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=34406.
Purpose & Patient Population:
To develop practice guidelines answering two questions:
- What are the optimal methods to prevent acute skin reactions related to radiation therapy (RT) within the first six months of irradiation?
- What are the optimal methods to manage acute skin reactions related to RT?
Type of Resource/Evidence-Based Process:
Databases searched were PreMEDLINE, MEDLINE, CANCERLIT, and Cochrane Library between January 1980 and April 2004. The name of the initiative was the Cancer Care Ontario’s Program in Evidence-Based Care. The method used was the practice guidelines development cycle. Articles were included based on rigorous inclusion criteria (meta-analysis, systematic reviews, evidence-based practice guidelines, comparative studies, prospectively collected data in at least one trial arm, studies with reported outcomes—degree of skin reaction [using a validated skin reaction tool] and other outcomes reported and articles available as published articles or abstract reports). Exclusion criteria were also identified.
The systematic review included interprofessional members from the Supportive Care Guidelines Group of Cancer Care Ontario and the Program in Evidence-Based Care, an internationally recognized program at McMaster University, Hamilton, Ontario, Canada.
No conflict of interest was identified.
A systematic review of 28 clinical trials was included in analyses; 23 pertained to prevention and 5 addressed management of skin reactions. Two practice guides were reviewed: Oncology Nursing Society and British Columbia Cancer Agency (expert opinion and consensus).
Results Provided in the Reference:
A table of clinical studies presented study descriptions and outcomes of the trials on prevention and management of skin reactions, pain, and itching.
The largest randomized trial compared calendula versus Biafine and was significant (p = 0.03) in reducing the severity of RT dermatitis.
Guidelines & Recommendations:
- Gentle skin washing with water alone or mild soap (unscented, lanolin-free) and water
- Gentle shampooing of the scalp with mild shampoo if receiving RT to the head
- Encourage personal hygiene habits to avoid psychosocial distress. Limiting personal hygiene practices is not recommended.
- Patients who received breast irradiation may use calendula ointment to decrease the occurrence of a grade 2 or higher skin reaction.
Insufficient evidence existed to support or refute the use of
•Topical agents (corticosteroids, sucralfate cream, Biafine® (Ortho Dermatologics), ascorbic acid, aloe vera, chamomile cream, almond ointment, or polymer adhesive skin sealant)
•Oral agents (enzymes, sucralfate)
•Intravenous agents (amifostine)
Gentle skin and hair washing should be unrestricted in patients receiving RT. No barrier exists to using mild soap.
No trials answered the question on management.
- Outcome assessment tools are required, including quality of life tools.
- Trials to assess oral enzymes are needed to confirm studies showing potential for prevention benefit.
- Randomized trials are needed (double-blinded, randomized, controlled trials) about the benefits of moisturizing cream as a preventive measure.
- Randomized trials are needed that address moist desquamation management with the use of dressings as an intervention.
- Trials are needed that explore sites with different risk factors and possible differing management.
Opinions of This Group:
- Use plain, unscented, lanolin-free hydrophilic cream, but discontinue with skin breakdown.
- Low-dose corticosteroid cream may be helpful with itching and irritation, but caution patients about overuse. More evidence is required to make firm recommendations.
Research Evidence Summaries
Campbell, I.R., & Illingworth, M.H. (1992). Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial. Clinical Oncology, 4, 78–82.
To examine the controversy regarding washing the skin during or after a course of radiation therapy (RT)
Intervention Characteristics/Basic Study Process:
Participants were randomized to one of three washing policies: (a) not washing, (b) washing with water alone, or (c) washing with soap and water. Assessment of skin reactions was weekly during treatment and at two and four weeks after treatment was completed.
- The study sample (N = 95) was comprised of female patients.
- Age ranged from 33–75 years.
- All patients were receiving postoperative RT following breast local excision or mastectomy.
- Prescribed doses were 4,500 cGy or 4,700 cGy in 20 fractions in 28 days.
The study took place at Mercy Clatterbridge Hospital in Bebington, Mercyside, United Kingdom.
The study used a randomized controlled trial design.
- Patients graded their symptoms or itching and pain in the treated skin as none (0) to severe (3).
- Skin was graded according to the European Organization for Research and Treatment of Cancer/Radiation Therapy Oncology Group (EORTC/RTOG) Scale from 0 (none) to 3 (severe).
- Desquamation was scored as none (0), dryness of the skin (1), moderate flaking (2), severe flaking (3) or patchy moist desquamation (4).
Itching was the main local symptom experienced; it was present at some point in 77% of the patients. In all groups the average itching score rose progressively during treatment, with a maximum at four weeks after starting treatment. Participants randomized to washing had itching scores either similar to or less than those not washing. Several of the comparisons showed a statistically significant reduction in itching at p < 0.05 with washing. Pain in the treated skin was reported by 31% of participants during the observation period. No clear trends were observed in the different washing policy groups. The average scores for erythema rose progressively during observation with a maximum at four to six weeks. There was little difference between washing groups, and a small trend for the non-washing groups to have the highest reactions. Several comparisons showed a statistically significant reduction in erythema associated with washing (p < 0.05). Average scores for desquamation showed maximum reactions at six to eight weeks after starting treatment. Patients who were washing had markedly lower scores than patients who were not washing, with some comparisons reaching statistical significance (p < 0.05 washing compared with p < 0.01 not washing).
Findings support allowing patients to wash during RT with either soap and water or water alone.
- Generalization of findings is not completely clear.
- Approximately half of the participants were prescribed a topical cream for their skin reaction (n = 45), and whether the cream had any effect on study findings is not clear.
- No restriction was placed on the frequency of washing in any of the groups.
Meegan, M.A., & Haycocks, T.R. (1997). An investigation into the management of acute skin reactions from tangential breast irradiation. Canadian Journal of Medical Radiation, 28, 169–173.
To determine if there is an adverse effect to irradiated skin when patients use their normal skin care regimens
Intervention Characteristics/Basic Study Process:
Two consecutive groups of patients received tangential breast irradiation. The first group (group A) used the traditional skin care advice of using warm water only, avoiding the use of all lotion, soaps, and deodorants in the treatment field. The second group (group B) continued with their normal skin care regimen with no product restriction. Patients and therapists scored the skin reaction weekly and three weeks after treatment.
- The study sample was comprised of 156 patients with breast cancer who received treatment in group A (n = 94) or group B (n = 64).
- Twenty-two percent of patients were also receiving tamoxifen.
- Patients were treated on cobalt units or a 6 MV linear accelerator.
The study used a prospective trial design.
- Erythema, dry desquamation, patchy desquamation, and moist desquamation were scored weekly using a numerical scale from the researchers' institution.
- Level of discomfort, interference with normal activities, and use of analgesics for skin reactions was self-scored by patients weekly using a numerical scale.
- Treatment parameters, breast size, medical history, concurrent medications, nursing or medical interventions, and skin products used were documented.
- T-test statistical analysis method was used to establish if there was a significant difference in the mean score for the reactions in each group.
There were no significant differences found in skin assessment scores between groups. Reactions peaked at 7–10 days from completion of radiation. There was no difference in the skin scores between the two groups at that point. Patient self-scoring of the severity of the skin reaction revealed that group A consistently scored higher than group B, indicating greater level of problems.
There is no difference between the severity of skin reactions of patients using no products and those using their usual skin care products.
- The study had a risk of bias due to no random assignment.
- Skin scoring and patient self-report did not use standard scales.
- No testing was completed for validity and reliability of rating scale.
- No data were provided on the specific products patients used.
Roy, I., Fortin, A., & Larochelle, M. (2001). The impact of skin washing with water and soap during breast irradiation: A randomized study. Radiotherapy and Oncology, 58, 333–339.doi: 10.1016/S0167-8140(00)00322-4
To evaluate the impact of washing breast skin with soap and water during radiation therapy on the intensity of acute skin toxicity
Intervention Characteristics/Basic Study Process:
Patients were randomized prior to receiving radiation into two groups. In group 1, skin within the treatment field was not allowed to be washed. In group 2, skin within the treatment field could be washed with Dove® or Ivory® soap and water. Patients were not to apply any other materials unless prescribed by a physician. Topical treatment was prescribed for 87% of non-wash patients and 80% of wash patients for a mean duration of 18.2 and 17.6 days, respectively. The topical agents prescribed were topical corticosteroids, eosin, Burow’s solution, and Biafine®. Patients were requested not to tell physicians if they were washing the irradiated area or not. Skin toxicity was independently scored by the author and radiation oncologist.
- The study sample was comprised of 99 patients with breast cancer who received treatment in group 1 (n = 49) or and group 2 (n = 50).
- Mean patient age was 56 years in group 1, with a range of 33.2–78 years, and 58.4 years in group 2, with a range of 27.6–84.2 years.
- Sixty-nine percent of group 1 and 72% of group 2 were postmenopausal.
- Total prescribed dose was more than 40 Gy.
The study took place at an institution in Quebec, Canada.
The study used a randomized, blinded, controlled trial design.
- Acute skin toxicity was recorded according to the Radiation Therapy Oncology Group (RTOG) scale before radiation therapy, weekly during radiation therapy, and one month after end of radiation therapy.
- Subjective assessment for pain, itching, and burning was scored by visual analog scales at the same time intervals.
- Other data included type of washing, frequency of washing, radiation technique, necessity for second simulation, and interruptions of treatment.
- Analysis was performed on an intent-to-treat basis, and no patients were excluded.
In group 1, 57% had grade 2 or higher skin toxicity. In group 2, 36% had grade 2 or higher skin toxicity (p = 0.04). Mean time to maximal toxicity score achieved was not different between the groups. Maximal erythema score was not significantly different between the two groups. Incidence of moist desquamation was significantly higher in group 1 (p = 0.03). Dry desquamation (one month after treatment) was experienced by 74% of patients in group 1 compared with 56% of patients in group 2. The difference was not significant. Variables in univariate model significantly associated with acute skin toxicity included group 1, chemotherapy as part of treatment regimen, concomitant chemotherapy, presence of hot spots on dosimetry, and increased patient weight.
Allowing patients to wash irradiated skin did not result in any increased skin toxicity.
- Patients were treated with a combination of cobalt and megavoltage equipment.
- Fifteen percent of group washed during the study.
- Soap used was not consistent, as advised in group 2.
- Not clear how use of topical agents may have also affected results.
Westbury, C., Hines, F., Hawkes, E., Ashley, S., & Brada, M. (2000). Advice on hair and scalp care during cranial radiotherapy: A prospective randomized trial. Radiotherapy and Oncology, 54, 109–116.doi: 10.1016/S0167-8140(99)00146-2
To establish whether standard scalp care, as usually practiced by the patient, affects severity and course of acute skin radiation side effects, and to what extent advice on changing normal routine of hygiene causes distress
Intervention Characteristics/Basic Study Process:
Patients receiving cranial radiation therapy were randomized to two groups. Group 1 patients were advised to continue normal scalp care. Group 2 patients were advised to avoid washing the irradiated area. Hair washing was not prohibited, but patients were advised to avoid it. Patients were assessed weekly over 10 weeks from the start of treatment, with recording of symptoms by patients and clinical assessment by an observer.
- The study sample was comprised of 59 male and 48 female patients (N = 107) who were randomized to group 1 (normal scalp care [n = 55]) or group 2 (no washing [n = 52]).
- Median age was 52 years in group 1 and 48 years in group 2.
- All patients had primary brain tumors or were receiving prophylactic cranial irradiation
- Patients received high (more than 30 Gy [n = 23]) or low-dose (less than 30 Gy [n = 84]) radiation therapy.
The study took place at The Royal Marsden NHS Trust in London, England.
The study used a randomized controlled trial design.
- Pain and itching were recorded by patients using a modified RTOG/EORTC acute skin reaction scoring on a scale of 0–3.
- Skin reaction was assessed using RTOG/EORTC scale for erythema/desquamation, on a scale of 0–4.
- Frequency of hair washing and distress of changing practice of normal hygiene were recorded on a self-completed diary card.
- Degree of distress was assessed on a four-point scale by group 2.
- Differences between area under the curve of male and female patients were assessed by t-test.
- Use of topical applications for treatment of skin reactions was recorded.
- Mann-Whitney Test was used to investigate differences between treatment groups at each time points.
No differences were reported between scores of skin reaction in the two groups. Itching was the main local symptom experienced by both groups, with no significant differences. A marginal difference occurred between patient groups at six weeks, with the patients in group 2 having more severe symptoms.
The practice of normal hair washing is not associated with increased severity of adverse skin reaction caused by megavoltage cranial radiation therapy. The time course of skin reaction was also not affected by the different practice of hair washing. Mild-to-moderate skin reaction is not exacerbated in patients continuing their usually regimen of hair care.
- After six weeks, completion of skin reaction assessments declined, and interpretation of results became more difficult.
- Patients did not stop hair washing completely and, therefore, the study assessed acute skin reaction for different hair-washing frequencies.
- The small trial size meant that statistical power of results was limited, particularly when stratifying by dose of radiation therapy.
- There is no discussion of validity and reliability symptom scoring used.
- Patients were not instructed to use any creams or lotions unless prescribed by their physician.
Koukourakis, G.V., Kelekis, N., Kouvaris, J., Beli, I.K., & Kouloulias, V.E. (2010). Therapeutics interventions with anti-inflammatory creams in post radiation acute skin reactions: A systematic review of most important clinical trials. Recent Patents on Inflammation & Allergy Drug Discovery, 4(2), 149–158.doi: 10.2174/187221310791163099
To investigate through a systematic review what topical treatments are currently advocated to manage acute skin reactions, including creams, ointments, and dressings, and what evidence there is to support the use of these treatments
Databases used were MEDLINE and Cochrane Central Register of Controlled Trials. Keywords searched radiation therapy, epidermis, acute skin reactions, and therapy. Studies were included if they
- Were written in the English language
- Were controlled trials
- Provided information about the post-radiation acute skin reactions
- Had patients who were eligible for treatment.
No exclusion criteria were identified in the article.
Total references retrieved, evaluation method, and comments on the literature used were not reported.
- The final number of studies included in the review was 17, 15 studies in which an agent was used and 2 studies with washing only.
- The total sample size across studies was 1,968 participants, with a range of 10–194 participants in one arm and 39–366 participants in an entire study.
- Radiation sites included breast, head and neck, pelvic, chest, and abdomen.
Phase of Care and Clinical Applications:
Patients were undergoing active treatment.
- Washing: Significant decrease in itching, erythema, and desquamation was found in the group that washed with soap and water. A higher incidence of moist desquamation was found in the no washing group (33%) as compared to the washing with soap and water group (14%).
- Aloe vera: One study showed a benefit at higher cumulative doses. Another showed no difference in maximum severity or time to onset of grade 2 radiodermatitis. Still another showed a detriment in that dry desquamation was higher in the aloe vera arm (70%) as compared to topical aqueous cream (41%).
- Biafine (trolamine): Two studies showed no significant decrease in skin reaction when comparing no treatment, Aquaphor, Lipiderm, and Biafine. A third study showed a decrease in less than grade 2 skin reaction, pain, and treatment interruptions.
- Hyaluronic acid: Two studies showed a significant benefit (i.e., decreased severity and delayed onset of radiodermatitis) among patients receiving hyaluronic acid as compared to a placebo or unidentified control.
- Corticosteroids: Of two randomized, double-blinded studies using corticosteroid cream as a prophylaxis, the study by Bostrom et al. found a 25% compared to 60% incidence of grade IV radiation dermatitis (corticosteroid vs. emollient). The second study did not find significant results in favor of corticosteroid. Another study showed no significant difference between a corticosteroid cream and a placebo. Still another study showed a significant difference between a corticosteroid cream and clobetasone, but most of the patients in both arms experienced moderate-to-maximum skin reactions.
- Sulcrafate: A randomized study in head and neck cancer found no difference in erythema, but found a higher incidence of moist desquamation in the topical sulcrafate prophylaxis group. A large (N = 357) randomized study in head and neck (n = 107), breast (n = 229), and anorectal (n = 30) cancer by found no significant difference among the topical sulcrafate, topical aqueous cream, and no cream groups. Another study (N = 44) found a significant reduction in grade 2 radiodermatitis and more rapid healing in the topical sulcrafate group among patients with breast cancer. A different study (N = 39) compared topical sorbolene and sorbolene plus sulcrafate to manage higher than grade 3 skin toxicity and found no differences between the two groups. Another study showed no benefit of using oral sulcrafate as a prophylactic agent for late reaction in prostate cancer. A final study showed no benefit of using oral sulcrafate as a prophylactic agent in preventing skin reactions in head and neck cancer.
- Barrier film: A study compared No-Sting barrier film to topical sorbolene as prophylaxis for moist desquamation among patients with breast cancer, showed a significant benefit. Another study (N = 50 ) examined the use of Dermofilm in reducing pain and irritation. “Favorable” results were reported, but a larger study was recommended.
- Anti-microbials: No study results were found. The authors cautioned against using antimicrobials as a prophylactic agent related to our knowledge of drug resistance.
- Dressings: One study examined healing after radiation treatment among 18 patients and found the mean healing time was 13 days. There was no comparison arm. Another study compared the use of sliver leaf nylon dressings applied to the perineum of 15 patients with anal or gynecologic cancers to historic controls. Patients who received the silver leaf nylon dressings had significantly reduced incidence of grade 3 and 4 reactions. A different study (N = 60) showed a higher incidence of radiodermatitis in the sulcrafate arm among patients with head and neck cancer. Another study (N = 44) showed a significant benefit to breast cancer patients. One very small study (N = 15) showed a benefit of using sliver leaf nylon dressings to reduce grade 3 and 4 radiodermatitis of the perineum among anal and gynecologic cancers.
Washing with soap and water consistently demonstrated a benefit. The evidence for the use of aloe vera is mixed with one study showing harm. Biafine did not demonstrate a benefit nor a harm. Hyaluronic acid showed a benefit. Corticosteroid showed mixed results, with one study showing favorable results, two showing no increased benefit, and one study showing mixed results. Most of the evidence on topical sulcrafate shows no increased benefit in preventing and managing radiodermatitis. Dermofilm, a barrier film, showed a significant benefit in reducing moist desquamation among patients with breast cancer in one small study.
Additional studies with a larger sample and a blinded randomized controlled design are needed.