Introduction

• Askincareworkingpartywassetuptoproduceevidencebasedpracticeskincareguidelines,includingrecommendationsforthetreatmentandpreventionofmoistdesquamation.Anauditof259patientsin2008revealedthat7%ofpatientsdevelopedmoistdesquamation.

• Aliteraturesearchbymembersoftheskincareworkingpartyfoundseveralstudieslookingatthepreventionofskinreactions1-6.Oneofthesestudieslookedintotheuseofcavilonnostingbarrierfilm(CNSBF)inpostmastectomytreatments6.TheresultsfromthestudysuggestedthattheuseofCNSBFcouldreducetheincidenceofmoistdesquamationinthisgroupofpatients.Anin-houseauditwasdevisedtoassesstheeffectivenessofCNSBFinotherpatientgroups.

• Numerousstudieshavepreviouslylookedatthetreatmentofmoistdesquamation7-11.Noonetreatmentinterventionhasbeenprovensuperiortoanyother9.

• Howeverourexistingclinicalpracticeneededupdatingtofollowbestpracticemoistwoundhealingprinciples.

• PolyMemdressingwaschosenandassessedforitsefficacyinthetreatmentofmoistdesquamation.Itsappealingpropertiesincludedodourreduction,nonadherence,absorbency,woundcleansingaswellashealingandpainrelief.

Methods and Materials

• 40patientswereidentifiedathighriskofdevelopingfrictionrelatedmoistdesquamation(RTOGscore2bandabove)usingtheresultsgainedfromthepreviousaudit(seetable1).

• These40patientsweregivenCNSBFtoapplyduringtheirtreatment.Theapplicationstartedtwiceweekly.OnceRTOG2bwasreached,theapplicationswereincreasedtoeveryotherday.TheirRTOGscorewasinitiallyrecordedweekly,thenincreasedtotwiceweeklyonce2bwasreached.Eachpatientwasissuedwitha28mLspraybottleandgivenverbalinstructionsforuse.

• 20patientswhodevelopedRTOG2bweregivenPolyMemdressingsappliedasperthemanufacturersinstructionsandtheirRTOGscorerecordedtwiceweekly.TheirpainscorewasrecordedbeforeandafterapplicationusingthefollowingadaptedpainmeasurementscalebyMcCaffreyandBeebe(1989)assuppliedbyActivaHealthcareLtd.

Table 1: Patient groups identified as being at high risk of developing RTOG 2b skin reactions

Results - CNSBF

• Ofthe40patientsidentifiedasbeingathighrisk,17(42.5%)patientsdevelopedstage2borgreaterskinreactions,3oftheselaterdevelopedstage3andnoneofthepatientsinthestudydevelopedstage4(Graph1).

• Stage2bwasnotobservedinanyofthecasesuntilweek3.Table2showsasummaryoftheweeklyskinreactionsover2bobservedindifferentpatientgroupsincludingriskfactorsassociatedwiththesepatients.8ofthesepatientswentfrom0to2binthespaceofaweek,3from1to2band2from2ato3.

• TheRadiographersobservedamarkedimprovementintheskinreactionsgenerallyandinparticularforpatientstreatedforanalcarcinomathatusedCNSBFwherethe2bareatendedtobelimitedtotheperinealregion.Intwoanalcarcinomapatientstheirgroinandgenitalareasweremissedintheapplicationprocess,stage2bwasreachedatweek3intheseareas,comparedtoweek5fortheperineum.

• Someskinreactionsdidnotfollowtheusualgradualprogressionthroughstage1,2a,2b,andinsteadwentstraightto2aor2b.

• TwopatientsreportedasensitivitytoCNSBF-amilderythematousrashdevelopedintheapplicationareaearlyoninthestudy-thereforeallpatientsweretestedforsensitivityoutsidethetreatmentarea24hoursbeforeCNSBFwasapplied,afurther2patientssubsequentlyshowedsensitivityreactionsandwereexcludedfromthestudy.

Table 2:- RTOG weekly score

PolyMem

• Ofthe17patientsreachingstage2b+intheCNSBFaudit,11weregivenPolyMemtouse(onepatientwasnoncompliantandasecondpatientdidnotlikethedressingandthereforedidnotuseit.TheremainingpatientsweregivengentianviolettoapplybytheclinicianbeforePolyMemcouldbeused).

• Atotalof20patientsweregiventhedressing.Table3showsatwhichRTOGscorePolyMemdressingswereinstigatedandtowhichsites.

• PolyMemwasgenerallyusedafterthepatienthadreceivedaminimumof20Gy.

• PolyMemwasfoundtohavereducedpainscoresbetween1and4pointsin14ofthe19patientsstudied.WilcoxonSignedRanksTestshowedthatthisisasignificantreduction(p<0.001).

Table 3:- RTOG score and number of patients* issued withnPolyMem dressing(*NBsomepatientsusedthedressinginmultiplesites)

Discussion

• Fromtheresultsofthestudythereappearstobeadelayinthepresentationofacuteskinreactions.Thisishighlightedintwoanalcarcinomapatientswherestage2bwasreachedinareasmissedbytheCNSBFapplication2weeksbeforetheareasthathadCNSBFapplied.

• 57.5%ofhighriskpatientsdidnotreachtheexpected2bskinreactionsnegatingtheneedforfurtherinterventions,overallthismayreducethecostintreatingthesepatientsskinreactionslongtermaswellasimprovingoverallcosmeticresultsandthepatientsexperienceoftreatment.

• Weareunabletoofferanexplanationastowhytheskinreactionsappearedtomissstagesofreactions.

• InitiallypatientswereaskedtoapplytheCNSBFthemselves,howeverRadiographersnotedabettercoverageandconsequentlyabetterreactioniftheCNSBFwasappliedbyRadiographers,thisalsoencouragedRadiographerstoassesstheskinreactionmorefrequentlyandinterveneearlierwithPolyMem.

• Theapplicationprocesstakes30secondsandduetothesmallnumberofpatientsrequiringapplication,thishasnooverallimpactontreatmentunitthroughput.

• InsomepatientstherewasabuildupofCNSBFwhenthepatientwasunabletoadequatelywashthetreatmentareaalthoughthisdidnotappeartoeffecttheoverallresults.OnebreastpatientstoppedusingCNSBFasherperfusesweatingcausedabuildupoffluidbeneaththefilmcausingdiscomfort.

PolyMem

• Thereisasignificantpainreductionformanypatients.Thisisduetoaninhibitionbythepolymericmembraneofthedressingonthenociceptorreaction,whichhasalsobeenproventoreduceinflammation,bruisingandoedema13,14onbothbrokenandintactskin.

• Thewoundcleansingpropertiesofthedressingensuredthattheriskofinfectionwasreducedwhilethedressingwasinplaceaswellasensuringeaseofdressingchangesandthetimerequiredwasminimised.

• Woundhealingcommencedinsomepatientsevenwhilstcontinuingwithradiotherapytreatment.

• PolyMemalsoactedasananti-inflammatorywhenitwasinstigatedatstage2a,particularlyintheanal/perinealregion.

• Feedbackfrompatientswaspositive,fromeaseofusetopainandodourrelievingproperties.Nopatientsshowedsignsofsensitivity.

• Someareasstillremaindifficulttodressandensurethedressingissecuree.g.scrotal,vulvalregions.Oftenthiswaseffectivelymanagedbyencouragingpatientstousescrotalsupportsandnettolastpants.

Cost implications

(asperOctober2009NHSsuppliescatalogueprices)

• 1bottleofspray(£8.26)lastedfor4weeksofapplication(18patients).22patientsrequiredanotherbottle.

• Ofthese40patients,11receivedPolyMemdressings.Twosizeswereordered(10x61cmroll(£12.21perroll)and13x13cmdressings(£4.21perdressing)),bothdressingswerecuttosizeasrequiredandchangeddaily.Totalcostperpatientwasdependantonwhenthedressingwasissuedthemaximumcostforasinglepatientwasfor5rolls(£61.05).AsthedressingisfreelyavailableinthecommunityG.P.swereabletoprescribethedressingforthepatientsonceitseffectivenesswasestablishedwithonly1dressingneedingtobeissuedbythedepartment.

Conclusion

• DuetotheeffectivenessoftheCNSBFitisnowroutinelyappliedbyRadiographerstopre-identifiedhighriskpatients,howeverallpatientsaretestedforsensitivitypriortoitsapplication.

• CNSBFisalsousedtopreserveskinmarksrequiredforsuperficialx-rayandelectrontreatments.

• PolyMemisnowissuedbyRadiographerstoallpatientspresentingwith2bskinreaction.

• Inpatientsbeingtreatedforlowerrectal/analcancerstheauthorswouldrecommendtheinstigationofPolyMemat2askinreactions,particularlywhenthepatienthasaheavymucosaldischargeandthereforetheskinislikelytomacerateandbreakdown.

• FuturestudiesarewarrantedintheuseofCNSBFwherepatientsareusedastheirowncontroltofullyestablishCNSBFeffectivenessinthepreventionofacuteradiotherapyinducedmoistdesquamation.

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Treatmentsiteisintheanal-genitalareae.g.vulva,vagina,penis,scrotum,anus,groins

Radicallimbs

Obeseradicalpelvispatients(withskinfoldsintreatmentarea)

Breastpatientsneedingorfitimmobilisationbras

Radicalfaceandneckhavingconcurrentchemotherapyorbolus

Week Number

RTOG Score Diagnosis Risk factors

3 2b3xBreast2xAnus

Largecupsize,tangentialpair,ParallelPair,bolus,concurrentchemo

4 2b2xAnus1xRectum1xVulva

AsAbove(samepts)Concurrentchemo,Parallelpair,bolus,concurrentchemo

5

2b

5xAnus3xRectum1xPenis1xGroin

AsaboveConcurrentchemo,Parallelpair,concurrentchemoHightotaldose,bolus,vacbag

31xVulva1xGroin/scrotum

Parallelpair,bolus,concurrentchemoHighdose,electrons

6

2b4xAnus1xGroin

AsaboveSameptaswk5

31xVulva1xGroin/scrotum1xAnus

Sameptaswk5Sameptaswk5

7 2b1xGroin1xFemur/groin

Sameptaswk5+6Hightotaldose,vacbag

RTOG Score No. of Patients Site

0 0

1 21–Inframammaryfold

1–Genitalarea

2a 61–Inframammaryfold5–Anal/perinealarea

2b 13

1–Axilla1–Inframammaryfold1–Scrotum2–Underabdominalfold4–Groin4–Anal/perinealarea

3 1 1–Anteriorcommisure

Two Novel Treatments for the Prevention and Treatment of Radiation Induced Moist Desquamation Authors: Claire Bode1 Helen Woodman2, Radiotherapy Department, Queen Elizabeth Hospital, Birmingham, B15 2TH 1 – Training and education Facilitator, 2 – Macmillan Paediatric Liaison Radiographer