Radiography 18 (2012) 21e27

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Radiography
journal homepage: www.elsevier.com/locate/radi

Radiotherapy skin care: A survey of practice in the UK

Rachel Harris a, *,1, Heidi Probst b,1, Charlotte Beardmore c,1, Sarah James c,1, Claire Dumbleton c,1,
Amanda Bolderston d,1, Sara Faithfull e,1, Mary Wells f,1, Elizabeth Southgate g,1
a
The Society and College of Radiographers, 207 Providence Square, Mill Street, London SE1 2EW, UK
b
Faculty of Health and Wellbeing, Shefeld Hallam University, UK
c
The Society and College of Radiographers, UK
d
Fraser Valley Cancer Centre, British Colombia, Canada
e
Faculty of Health and Medical Sciences, University of Surrey, UK
f
School of Nursing and Midwifery, University of Dundee, UK
g
Birmingham Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK

a r t i c l e i n f o a b s t r a c t

Article history: Aim: The primary objective of the survey was to evaluate clinical skin care practice in radiotherapy
Received 27 May 2011 departments across the United Kingdom.
Received in revised form Methods and sample: A questionnaire containing sixty-one questions grouped into eight themed sections
11 October 2011
was developed and a link to an on-line survey, using the Survey Monkey tool, was e-mailed to all
Accepted 20 October 2011
Available online 13 November 2011
radiotherapy department managers in the United Kingdom (N 67). Each recipient was invited to
provide one response per department.
Key results: Fifty-four departments responded within the allocated timeframe giving a nal response rate
Keywords:
Radiotherapy
of 81%. Products and their use for skin conditions varied and some outdated and unfounded practices
Radiation therapy were still being used which did not always reect the current evidence base. The amount of data
Skin care routinely collected on skin toxicity was limited making it difcult to quantify the extent of skin morbidity
Radiation dermatitis following radiotherapy.
Skin reactions Conclusion: The survey demonstrated variability in skin care practice in radiotherapy departments across
Evidence based practice the UK, with limited practice based on evidence or on skin toxicity measurement and monitoring.
2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction intensity modulated radiotherapy (IMRT) has been shown to offer

The Society and College of Radiographers (SCoR) last reviewed
UK radiotherapy centre skin care practice in 2000 and produced
guidelines for radiotherapy departments.1 A decade later it was
timely to re-assess what was actually happening in clinical practice
with the aim of assessing current practices and subsequently
updating the information.
Skin reactions from external beam radiotherapy are one of the
most common side-effects from treatment and a factor which can
limit radiation dose. Megavoltage linear accelerators with skin
sparing capabilities have signicantly reduced the severity of
reactions from radiotherapy,2 however accelerated dose schedules
with combined radiation chemotherapy regimens3 have increased
the condition. The most severe reactions tend to be in seen in those
patients receiving high doses to large elds. Recently the use of
* Corresponding author. Tel.: 44 020 77407 250; fax: 44 020 7740 7204.
E-mail address: rachelh@sor.org (R. Harris).
1
In collaboration with the Department of Psychology, University of Exeter.
the opportunity to reduce skin toxicity in some cases, especially the
rates of dry and moist desquamation when treating cancers in the
head and neck region.4e10
Despite changes in practice and published guidelines1,11,12
radiotherapy skin care appears to have changed little over the
years, with departments caring for their patients skin in different
ways. Consequently, a plethora of agents is being used on the skin
in a non-standardised fashion.13,14
Faithfull et al15 note a growing awareness of the need for
evidence based practice in radiotherapy but that there are well
documented disparities between clinical practice and research
ndings which could underpin care; reecting that supportive care
is often based on no, little, or poor evidence. Comparing data across
radiotherapy skin care studies is difcult as often the methods used
are unclear, patient allocations differ, different skin assessment
scales are used, and follow-up data is inconsistent.16
Although it is unlikely that radiation reactions can be
completely prevented, the current driver in clinical practice is to
minimise and delay the onset of symptoms.

1078-8174/$ e see front matter 2011 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.radi.2011.10.040
22 R. Harris et al. / Radiography 18 (2012) 21e27

The extent of skin reaction is often dependent upon the clinical existing scales52) are helpful indicators of how appropriate
site being treated. For example, patients undergoing radiotherapy a product will be for future use.
for head and neck cancer require immobilisation and often receive
combination chemotherapy. This can make these patients very
The survey
vulnerable to intensied skin reactions and it is known that inter-
ruptions in radiotherapy for this category can have a detrimental
A panel of experts was consulted for the issues they felt required
effect on treatment outcome.17
investigation in a survey of skin care practice. The panel consisted of
The use of an effective evidence-based skin care protocol and
a team from the Society and College of Radiographers, two leading
monitoring system18,19 would assist in a researched approach to
nursing professionals, the Chair of the SCoR Research Group, and the
radiation skin care management, aiding product evaluation and
authors of the recent systematic reviews. Initially the survey was
justication of practice.
large and unfocussed as panel members had different aspects of care
they felt required exploration. Two previous surveys53,54 into
Background
radiotherapy skin care practice aided this survey construction and
focus, as did an examination of the relevant literature.
In Barkhams 1993 assessment of radiotherapy skin reactions
Dhaese et al53 evaluated skin care during radiotherapy practice
and associated treatments,13 52% of UK radiotherapy departments
by nurses in Flanders. They designed a 58 item questionnaire
reported dry desquamation as a common event and 85% of
structured into 4 main sections: preventative advice, advice for
departments reported moist desquamation as an occasional event.
erythema, dry desquamation and moist desquamation. Dividing
However, as Glean et al20 noted, the incidence of skin reactions has
the questionnaire into these key sections seemed a logical easy to
not been accurately quantied in departments and practices have
follow format which the project team adapted.
changed since Barkhams survey.
Swamy et al54 developed a questionnaire to explore variations in
Turesson et al21 demonstrated that the number of basal cells in
radiation oncologist practice across the USA in managing breast
the epidermis declines during fractionated radiotherapy due to
cancer, specically related to skin reactions. Their main questions
increased cell cycle arrest and reduced mitosis. The reduction in the
focussed on prophylactic skin care, risk factors, topical products
basal cells causes a thinning of the epidermis and an inammatory
used, and percentages of patients with skin reactions. These themes
reaction. The variation in the reaction appears to be a genetic
were also built into the survey tool.
predisposition due to individual DNA repair capacity,22e27 genetic
This nal survey comprised of 61 questions, grouped into 8
radiosensitivity,28e30 and/or intravascular thrombin generation.31
sections (Table 1).
Specic genetic tests could therefore be used to predict those
An advanced draft of the survey tool was reviewed by the SCoR
patients most likely to develop a severe radiotherapy reaction.32,33
Public and Patient Liaison Group and was also piloted at one radio-
Certain clinical factors can also help to predict the possibility of
therapy department. Comments returned were minor and around
a radiation reaction.34,35 Extrinsic factors are treatment related, i.e.
clarity. These were incorporated and the survey tool nalised.
dose; volume; fractionation; adjuvant treatment; treatment in a skin
The nal survey is a comprehensive tool which is relevant to UK
fold area (e.g. inframammary fold or rectal cleft); use of bolus mate-
radiotherapy practice.
rial; type of immobilisation; treatment technique.36 These factors
need to be under constant review with changing work practices; for
example, with the introduction of IMRT. Intrinsic factors are indi- Sample
vidual patient related, e.g. larger breast size2,36; higher body mass
index (BMI)25,37,38; pre-existing conditions (e.g. psoriasis).21,39 Such A link to an on-line survey, using the Survey Monkey tool, was
intrinsic factors may enhance a skin reaction and therefore should be e-mailed to all radiotherapy department managers in the United
recorded as a baseline and closely monitored.12,40e42 Kingdom (N 67) and they were invited to provide one response
Gosselin43 notes that some skin care products did show prom- per department. A back-up pdf le was also provided which could
ising results but comparing data across studies is difcult because be printed off and a hard copy returned if required (2 departments
of the wide variety of differing assessment tools. By utilising skin used this option). Anonymity was maintained for all respondents.
assessment tools on at least a weekly review basis, it would be Fifty-four departments responded within the allocated time-
possible to monitor and record a patients skin reaction throughout frame with a nal response rate of 81%.
the treatment stage.
Naylor and Mallet44 undertook a literature review to investigate Main results
the products being used for radiotherapy skin reactions and the
evidence base behind their use. They identied certain products Not all departments responded to all questions, therefore n
where evidence contraindicated use: values stated for each result are associated with the number of
responses to each particular question, as opposed to the number of
 Petroleum jelly45e47 as it may create a build up effect and is returned responses.
difcult to remove;
 Topical antibiotics unless there is a proven infection18,46,47; Table 1
 Topical steroids on broken skin due to the adverse effect on the Distribution of survey questions.
wound healing process45,48e50;
Section Number of questions
 Gentian Violet due to potential carcinogenic side-effects.18,49,51
Pre-treatment e assessment 14
Pre-treatment e prophylactic skin care 6
Another important aspect of skin care during radiotherapy is During treatment e assessment 7
that of patient well being. It may not be possible to stop or even During treatment skin care e erythema 8
reduce the rates of skin reaction from occurring, but there may be During treatment skin care - dry desquamation 8
comfort and psychosocial benets that skin care products provide, During treatment skin care e moist desquamation 9
Post-treatment e assessment and skin care 5
such as empowerment and control.43 Recording of patient accept- Review of guidelines 4
ability/satisfaction and compliance (as incorporated into some
 R. Harris et al. / Radiography 18 (2012) 21e27 23

Table 2
Prophylactic skin care products.

Question 16 If yes, which prophylactic skin care product(s) does your

department recommend? (please tick all that apply)

Answer options Response percent Response count

None 0.0% 0
Aqueous cream 68.4% 26
Chamomile and Almond oil 0.0% 0
Aloe vera 13.2% 5
Calendula 2.6% 1
Biane 0.0% 0
Hyaluronic acid 0.0% 0
Sucralfate cream 0.0% 0
Diprobase cream 7.9% 3
Skin sealant or barrier product i.e. Cavilon 5.3% 2
Other 7.9% 3
N/A 31.6% 12
If other, please specify 9
answered question 38
Graph 1. Which guideline does your department follow. skipped question 16

Pre-treatment: assessment
All departments (n 54) stated they provide verbal and written
information to patients on how they should care for their skin
during their course of radiotherapy. Forty six (n 52 88%)
departments stated they had skin care guidelines and protocols.
Twenty seven (n 52 52%) departments use their own locally
developed guidelines or adaptations of existing national guidelines
(Graph 1).
Skin assessment
Thirty eight (70%) departments stated that skin assessment
prior to radiotherapy would be conducted by a radiographer.
Only thirteen (24%) use a skin assessment tool on all patients
prior to radiotherapy; with 30 departments (55%) using no
assessment tool at all (Graph 2).
The Radiotherapy Oncology Group (RTOG) skin assessment
tool55 is the most commonly used by 20 departments
(n 30 66%); 24 departments chose not to answer this question.
Thirty six respondents (67%) reported no formal documentation
and 22 (41%) do not review skin care products that a patient
currently uses.
Forty two departments (77%) stated they knew their hospital
had a tissue viability nurse (TVN), or equivalent, but liaison with
this person was not commonplace.
Pre-treatment: prophylactic skin care
Twenty six (n 38 68%) departments use aqueous cream as
a prophylactic treatment (Table 2).
Five (n 38 13%) departments recommend aloe vera for
prophylactic skin care.
Nine (n 38 23%) use a range of other products, for example:
calendula; diprobase; sucralfate; skin sealant.
Sixteen (29%) departments chose not to answer this question.
During treatment: assessment
The range of responses to the questions on assessment of
patients skin during treatment was varied, demonstrating no
single clear practice was followed by the majority of departments.
The one area where it was possible to identity practice that was
comparable in several departments was the advice on using soap
and deodorant, as shown below.
Forty-two (77%) departments specify the type of soap to use:
simple, dove or none being the most common answers.
Nine (16%) specify the type of deodorant to use: Pitrok56 or
a non-metallic being the most common answers.
Thirteen (24%) state no deodorant to be used.

During treatment: erythema

Aqueous cream is used by 49 (n 50 98%) departments as

a product to alleviate erythema (Table 3).
Aloe vera is used by 8 (n 50 16%) departments.
A variety of other products are also used to a lesser extent.

Evaluation and cost effectiveness

Only 1 (n 49) department is conducting a randomised
controlled trial into the clinical effectiveness of a topical agent for
erythema.
There were no assessments into the cost effectiveness of using
creams and topical agents for erythema.

During treatment: dry desquamation

Twenty four (n 44 54%) departments are using hydrocor-

tisone 1% for dry desquamation (Table 4).
A variety of other products are used to a lesser extent.
Graph 2. Use of a skin assessment tool. Ten (18%) departments chose not to answer this question.
24 R. Harris et al. / Radiography 18 (2012) 21e27

Table 3 Table 5
Skin care products for erythema. Skin care products for moist desquamation.

Question 29 If yes, which skin care product(s) does your department Question 45 If yes, which skin care product(s) does your department
recommend for erythema? (please tick all that apply) recommend for moist desquamation? (please tick all that apply)

Answer options Response percent Response count Answer options Response percent Response count
None 0.0% 0 None 0.0% 0
Aqueous cream 98.0% 49 Parafn or Lanolin Gauze 6.7% 3
Chamomile and Almond oil 0.0% 0 Hydrocolloid dressing 40.0% 18
Aloe vera 16.0% 8 Silicone dressing e.g. Mepitel 46.7% 21
Calendula 0.0% 0 Gentian violet 4.4% 2
Biane 0.0% 0 Dermolm 0.0% 0
Hyaluronic acid 0.0% 0 Second skin 2.2% 1
Sucralfate cream 0.0% 0 Hydrogel 73.3% 33
Diprobase cream 14.0% 7 Lyofoam 15.6% 7
Skin sealant or barrier product i.e. Cavilon 8.0% 4 Other 28.9% 13
Other 16.0% 8 N/A 0.0% 0
N/A 0.0% 0 If other, please specify 20
If other, please specify 12 answered question 45
answered question 50 skipped question 9
skipped question 4

Limitations of the survey

During treatment: moist desquamation
A variety of products and dressings are used for moist desqua-
mation but hydrogels were the most popular with 33
(n 45 73%) departments using them (Table 5).
The various other products used included: 18 departments use
hydrocolloid dressings (n 45 40%); 21 silicone dressings
(n 45 46%); 7 lyofoam (n 45 15%).
Three departments (n 45 6%) use lanolin and 2 (n 45 4%)
gentian violet.
Nine (16%) departments chose not to answer this question.
Twenty nine (n 47 61%) departments stated that those
undertaking care of moist desquamation have received additional
training in wound care management (Graph 3).
Only 3 (n 46 6%) departments are conducting randomised
controlled trials into the clinical effectiveness of a topical agent for
moist desquamation.
There is one on-going assessment into the cost effectiveness of
a product.
Post-treatment: assessment and skin care
37 (n 47 78%) departments stated they supplied post
radiotherapy moist desquamation skin care products for up to two
weeks (2e3 days being the most common answer) after which they
would expect the community nurse to continue supply and care.
There are certain limitations to the survey that need to be rec-
ognised and which may have affected results.
As the survey was sent to each radiotherapy departmental
manager and they selected who completed the survey and anon-
ymously returned data, it is unknown who and what department
answered. Therefore, it is also unknown if the responses expressed
are individual views or departmental policy.
It is not possible to know if each question was fully understood
in the manner intended as there was no face to face follow up. The
disparity in results could be owing to misinterpretation of a ques-
tion, although the authors believe this reects the unknown
statistics as many departments do not routinely record this data.
It is unknown if all questions were answered honestly or if the
survey was given the answer the respondent felt was correct. For
example, do more departments use gentian violet in reality but felt
this was an incorrect response to declare?
Discussion
The survey highlights the need for departments to undertake
a baseline assessment of the patients current skin condition.
Despite papers emphasising the potential risk factors35,36 which

Table 4
Skin care products for dry desquamation.

Question 37 If yes, which skin care product(s) does your department

recommend for dry desquamation? (please tick all that apply)

Answer options Response percent Response count

None 0.0% 0
Aqueous cream 79.5% 35
Hydrocortisone 1% 54.5% 24
Mometasone Furoate cream 0.0% 0
Biane 0.0% 0
Sucralfate cream 0.0% 0
Hyaluronic acid 0.0% 0
Other 18.2% 8
N/A 2.3% 1
If other, please specify 17
answered question 44
skipped question 10
Graph 3. Training in wound care management.
 R. Harris et al. / Radiography 18 (2012) 21e27
may exacerbate a skin reaction these are not routinely recorded.
Over two thirds of the respondents to this survey did not routinely
assess and formally record the patients skin prior to radiotherapy.
Without the collection of such data it is difcult to attain
a complete picture of the extent of radiotherapy induced reactions,
which will be essential for improved research and skin care studies.
Furthermore, over a third of respondents failed to assess and record
skin care products currently being used by patients, hence it is
possible that unsuitable skin care practices may be being used
unmonitored by the health care team; potentially exacerbating
radiotherapy skin reactions.
The importance of linking with other sectors of care, especially
a Tissue Viability Nurse (TVN), or equivalent, would strengthen
improved communication, understanding and consistency of
radiotherapy skin care across the care pathway thereby avoiding
patient and staff confusion.57,58 It is disheartening that many
departments did not know if their hospital had a TVN and did not
collaborate on skin care with this person.
A main area of variation across departments relates to washing
instructions and the use of soap and deodorant (also conrmed by
other studies13,53,59). The traditional patient advice of not to wash the
affected area with soap and water, or even use water alone is still
given, despite updated evidence that this is unnecessary36,60e62 and
there should be no restriction to using a specic type of
soap.60,61,63e67 Over two thirds of respondents in this survey reported
washing restrictions (i.e. either no soap, or limited to specic brands
such as simple and dove), this has the potential to unnecessarily
control choices and preferences an individual may have.
Still referencing traditional practice may be a factor affecting
patient social well being. For example, breast cancer patients who
are advised not to use a deodorant often cite this as one less area of
control they have in their life.68 Additionally, we need to consider
whether or not patients actually comply with these instructions.43
The survey illustrates that there are numerous products for
radiotherapy skin care available and there is no consensus as to the
best practice, causing an inconsistency of care.57
As noted by Russell34 if the underlying cause of a radiation
reaction is physiological and the extent is genetically predisposed
topical agents are unlikely to realistically have any signicant effect.
Currently the quality and quantity of studies evaluating topical
agents appears to be insufcient to support or refute any specic
product62,69 and the survey indicated there were minimal on-going
assessments into skin care products; therefore it would appear
progress into understanding what actually may work will be slow.
Aqueous cream is commonly recommended by most depart-
ments and is a relatively cheap readily available moisturising agent,
and recommended by the recently withdrawn College of Radiog-
raphers 2000 guidelines.1 However, the evidence base indicates
that type of regime applied preventatively and to erythema appears
to have no inuence in a skin reaction occurring70e72. Therefore,
there needs to be further debate about this aspect of care and the
evidence base supporting actions. Furthermore, 16% of responding
departments reportedly advise patients to use topical aloe vera
which may incur a substantial cost either to the institution or to the
individual, yet there is limited evidence73 as to any benet obtained
using this agent over another and therefore no justication without
further detailed studies for this recommendation to patients.42,74
Hydrocortisone 1% is frequently used (over 50% of respondents
reported using this cream) for dry desquamation reactions, in line
with the College of Radiographers 2000 guidelines.1 This is despite
current contradictory evidence,47,75e77 further illustrating how
clinical practice has not kept pace with emerging research evidence.
Product use varies considerably, hydrogels are the most
commonly used (over 70% of respondents) but there is conicting
evidence as to their effect on wound healing.78,79
25
Gentian violet and lanolin are still used (10% of respondents
reported using these products) despite contraindications for
use.18,80 In a small randomised controlled trial (n 30) comparing
gentian violet and hydrogel dressings for moist desquamation80 the
gentian violet was signicantly less effective (p 0.0003) and also
less well tolerated by patients.
This again demonstrates our propensity to continue with
familiar traditional practice rather than an openness to test the
effectiveness of products.
There were no assessments into the cost effectiveness of using
creams and topical agents for erythema or dry desquamation and
only one assessment of a product for moist desquamation.
With the introduction of more expensive skin care treatments to
a vulnerable clientele market, health care professionals need to
consider if such products are more effective than their cheaper
comparators and why centres choose one product over
another.40,54,81,82 This is an important facet of modern health care
with the necessity for justication for actions and seems to have
been almost totally overlooked.
There may be problems with product supply and continuity of
care after treatment. Not all departments routinely supplied skin
care products for moist desquamation post-treatment. For those
that did, the majority provided products for up to 2e3 days post
radiotherapy, with an expectation that community care
providers would then take over skin care following this period.
This means that about 20% of responding departments did not
provide skin care products post radiotherapy. Therefore, in the
period when most skin reactions build up to their maximum
there may be variability and inconsistency in product
availability.
An evaluation into the treatment after care requires review to
ensure local continuity of care across the pathway; a general need
highlighted by a recent Department of Health cancer patient
experience survey.83 It is essential that the whole health care
pathway of a patient is considered and reviewed to ensure best
practice.
Conclusion
The survey appears to indicate that skin care advice to patients
undergoing radiotherapy in the UK is varied. Currently, some of the
skin care provided may not alleviate the problem and indeed may
even compound the effect. This area of patient care is time
consuming and expensive, therefore it is important to understand
what is being done and why.2
As Kedge16 noted, and as the results of this survey show, the
College of Radiographers (CoR) guidelines1 need updating, paying
particular attention to advice about deodorant use, aqueous
cream for erythema, use of hydrocortisone 1% for dry desqua-
mation, and the use of hydrogels and hydrocolloids for moist
desquamation. Given that the survey shows that the CoR 2000
guidelines1 were followed by the majority of departments, it is
reasonable to assume that revised guidelines would be followed
and so provide an appropriate base for future evaluation of skin
care practices.
The results indicate that not all radiotherapy departments are
monitoring and documenting skin morbidity in a systematic way.
Departments need to routinely monitor, assess and document skin
reactions using standard grading systems, and noting intrinsic and
extrinsic related factors. Although the majority of skin reactions
tend to subside after a few weeks, some can be prolonged,
uncomfortable and distressing, thereby affecting a patients quality
of life.84 As Gosselin et al noted, patients prefer to take action
rather than do nothing72 so the focus for skin care should be on
alleviating symptoms and providing comfort.
26 R. Harris et al. / Radiography 18 (2012) 21e27
Recommendations
 All radiotherapy departments should implement pre-
treatment assessment and baseline, and weekly reviews of
skin condition using a validated tool and process. Skin care
practice should also be agreed across the cancer network, in
line with the requirement for agreed radiotherapy protocols as
recommended within the Cancer Peer Review Measures for
Radiotherapy (England).85
 New high quality trials to investigate interventions for dry or
moist desquamation are urgently required; enabling a more
consistent approach for patients receiving radiotherapy and to
inform guidelines.
 The College of Radiographers skin care guidelines1 must be
revised as the evidence on which they were based is no longer
valid.
 Evaluation of treatment after care requires review to ensure
local continuity and consistency of care across the patient
pathway.
 Research into patient preferences and compliance with skin
care information and products should be undertaken in order
to inform future national guidelines.
Conict of interest
None.
Acknowledgements
All the departments who responded to the survey
Professor Audrey Paterson, The Society and College of Radiog-
raphers Dr Ian Frampton, University of Exeter
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