1. Keep skin clean & dry: several studies have looked at washing and demonstrated that washing skin is beneficial. A mild unperfumed soap and shampoo should be used (Roy 2001, Westbury 2000, Campbell 1992) and the skin allowed to evaporate dry, or use a cool hairdryer or pat dry. Do not rub. A quick bath is OK provided the water is not too hot and carefully dried after.
2. Antiperspirants can be used (Thebberge 2009, Gee 2000, Bennett 2009)
3. Wear loose fitting cotton clothing in treatment area to reduce sweating.
4. Keep treatment area covered from the sun. Do not apply suntan lotion to the treatment area during the radiotherapy.
5. Do not apply any topical agents without prior recommendation. Do not use:
   • talcum powder.
   • aqueous cream as some people are allergic to the preservatives (Cork, 2003)
   • aloe vera as causes drying (Williams 1996, Olsen 2001, Heggie 2002.)
   • sudacream or other barrier creams e.g, zinc oxide cream.
   • petroleum gel e.g. Vaseline.
6. In the treatment area reduce shaving and use an electric shaver.
7. Do not wax hairs in the treatment area or apply hair removal creams.
8. Do not use a hot water bottle or ice pack on the treated region.
9. Where possible adhesive dressings should be avoided in treatment area.
10. Swimming should be avoided for patients at high risk of skin reaction, others should ensure the skin is well rinsed after swimming.

Obviously where possible planning techniques should be used to keep skin doses as low as possible.
There is no evidence for using topical NSAIDS (e.g. trolamine (Biofine) –not licensed in UK anyway), hyaluronic acid, sucralfate, calendula or silver leaf dressings.

Low risk

Dose less than 30Gy BED.
No specific measures needed. If develops skin reaction a consultant should be informed to investigate (consult Planning and check family history).

Medium risk

Dose 30-45Gy BED to skin: dry desquamation possible.
The main issue with dry desquamation is the itch. Though most radiotherapy departments use emollients there is actually little research to actually support their routine use however, patients like to feel they are doing something and it is important to try and reduce itch and scratching. In this group 50g tube of Diprobase/Zerobase will be provided at the end of treatment to apply to any dry areas. Diprobase / Zerobase is chosen as on the Lothian Formulary. The alternative is Aveeno (without shea) but this is considerably more expensive so Diprobase /Zerobase has been selected, but should patients chose to purchase this, there is no reason to not use it.

High risk

Dose >45Gy BED to skin: High risk of moist desquamation or ulceration.
The best evidence is for the prophylactic use of potent steroid creams.
The seven randomised studies looking at the impact of prophylactic medium or potent steroids all show reduced grade 2 or higher skin reactions. This group of patients will be provided with 100g betamethasone valerate 0.1% (Betnovate) steroid cream to apply sparingly to the treated area each evening from the start of treatment till two weeks after. They will also be provided with a 500ml pump pack of Diprobase/Zerobase to apply to dry areas. Betamethasone was chosen as it is a third the cost of mometasone but of equivalent potency. Provided the use is <100g per week the risk of adrenal suppression is low.

• Keep clean and dry.
• If not already on steroids, start on betamethasone valerate 0.1% and continue for one-two weeks after completion of treatment.
• Though there is no research data to support the use, anecdotally over the years patients have found profavine liquid and aqua-cool packs soothing so can be used for symptomatic benefit. (Proflavine topical solution is an unlicensed medicine).
• Observe carefully for signs of supra-added infection resulting in cellultis. If this occurs take swab for MC&S and start flucloxacillin or clarithromycyn (if penicillin allergy).
• On completion of treatment there are two options in case of moist desquamation
  • Silver sulfadiazine cream (Flamazine) –contains a sulphonamide antibiotic and can be used if the skin is broken and superficially infected. A 3-5mm layer should be applied once a day.
  • Hydrocolloid dressings can be used though the trial data is inconsistent (methodological issues with trials)

There is insufficient evidence to support honey, sucralfate, 1% hydrocortisone or trolamine.

All patients should be advised to either cover up or apply high factor sun cream to the previously irradiated skin.

Telangiectasia

Long pulsed dye LASER (LPDL) has been successfully used in a few small (<20 patients) studies.

Fibrosis

Pentoxifylline and Vitamin E was studied in a phase 2 trial and regression of the fibrosis was noted however, there are no randomised trials, principally because in intensity modulated radiotherapy (IMRT) era this is relatively rare.