INTRODUCTION

In recent years, innovations in medical physics and computer technology have made radiotherapy a core treatment modality for malignant tumors. Despite advancements in modern radiation therapy techniques, it is inevitable that normal tissues are exposed to radiation.1 The skin is the largest organ in the human body, constantly renewing itself with the rapid proliferation and maturation of cells. As a result, the skin system is sensitive to radiation.2,3 As radiation kills tumor cells, it also causes substantial damage to normal tissue cells in the irradiated area, and the resulting skin toxicity remains a serious problem.1,4

Acute radiation dermatitis refers to the progression of mild erythema to dry or moist desquamation and ulceration of the skin within the irradiated field.2,5 It typically occurs within the first 90 days after the start of radiation therapy.6 Radiation dermatitis can cause symptoms such as skin itching, burning, and pain. In severe cases, it may lead to skin ulcers, bleeding, and necrosis, resulting in the interruption of radiation therapy, which affects treatment efficacy and the radiation treatment plan. Radiation dermatitis also increases psychological distress and financial burden for patients while diminishing aesthetic attractiveness.7 It markedly impairs the patient’s quality of life.7–9

Currently, there is no unified standard for skin management during cancer radiation therapy, either domestically and internationally.10–12 Further, there is no strong evidence to suggest that any specific product can prevent or treat radiation dermatitis.13 One clinical study found an incidence of moist desquamation requiring wound dressing treatment of 15% among patients undergoing radiation therapy.14 In patients with head and neck cancer who are undergoing concurrent radiation therapy and cetuximab treatment, the incidence of grade 3 or 4 radiation dermatitis is as high as 43.1%.15 Thus, there is an urgent need to explore effective treatment methods for radiation dermatitis.

Ethical Approval

The patient provided written informed consent for the publication of his case details and photographs.

CASE REPORT

The following is a summary of the treatment experience of a patient with grade 4 acute radiation dermatitis. The patient was a 55-year-old man diagnosed with nonkeratinizing undifferentiated carcinoma of the nasopharynx with bilateral cervical lymph node metastasis staged as T1 N2 MO, stage III. The patient underwent six cycles of induction chemotherapy followed by concurrent chemoradiotherapy. A palpable mass measuring 6.0 × 3.0 cm was felt in the right upper neck. The mass was firm in consistency, nontender, with poorly defined borders and limited mobility. The patient underwent helical computed tomography radiation therapy. The planned radiation dose for the primary site of the nasopharyngeal tumor was 70.95 Gy, delivered in fractions of 2.15 Gy each. A total of 33 radiation treatments were administered. Tissue compensators were employed for radiation treatment in the right cervical lymph node area. Skin ulceration and necrotic tissue were observed in the right neck area after the completion of radiation therapy. There was a considerable increase in local skin temperature, with the patient perceiving a burning sensation. According to the grading criteria for acute radiation dermatitis by the Radiation Therapy Oncology Group,16 the patient developed grade 4 acute radiation dermatitis. Subsequently, the patient was referred to the wound care clinic for wound management.

Steps for Wound Treatment

The wound was managed using a three-step approach. First, the wound was cleansed by irrigating it with 0.9% sodium chloride (normal saline) to remove debris and necrotic tissue. Subsequently, the residual normal saline at the wound site was gently patted dry using sterile dry gauze and allowed to air dry slightly. Next, a thin layer of hydrogel was applied to the wound. Finally, the wound was covered with a low-adherent alginate dressing, and gauze was used to secure it appropriately around the neck area.

During the initial visit, the patient’s wound was covered with black necrotic tissue on the surface. The patient reported difficulty in neck movement accompanied by pain, itching, and a burning sensation. The patient experienced limited range of motion in the neck and stiffness, which affected his sleep and greatly impacted his quality of life.

The therapist advised the patient to adopt a comfortable left-sided lying position and to relax his entire body. First, sterile gauze was moistened with saline solution and used to cover the surface of the necrotic tissue for approximately 5 to 10 minutes. Once the black necrotic material softened, it was removed. Afterward, a substantial amount of yellow necrotic tissue was observed, along with excessive exudate and multiple bleeding points (Figure 1A). The area measured approximately 10 × 12 cm. The provider continued to cautiously clean the wound by gently wiping the wound bed with moist cotton balls and using forceps to remove the yellow necrotic tissue.

Figure 1.:

TREATMENT PROGRESSIONA, Initial diagnosis of the wound revealed a grade 4 acute radiation skin injury with extensive yellow necrotic tissue on the skin within the radiation field on the right side of the patient’s neck. B, On the fifth day of treatment, partial epithelial tissue migration and the formation of new granulation tissue were observed, accompanied by scattered small bleeding points. C, On the eighth day of treatment, the wound was mostly covered with epithelial tissue, with a small portion of healthy granulation tissue. D, On the 11th day of treatment, only the creased area of the wound remained as granulation tissue; the remaining area had completely healed and showed repaired skin. E, On the 13th day of treatment, epithelialization was observed in the creased area of the skin within the radiation field on the right side of the neck, and the remaining area showed complete skin repair. F, On the 18th day of treatment, the skin within the radiation field on the right side of the neck was essentially similar to the skin on the opposite side.

After cleaning the wound, the provider evenly spread a hydrogel on the wound using a moist and smooth cotton swab. Using a moist cotton swab prevented the hydrogel from adhering to the cotton or leaving cotton fibers on the wound surface, thus enhancing the adhesion and stability of the outer dressing and promoting wound healing. This method is straightforward to execute, offers comfort and convenience, and substantially improves the patient’s usage experience and adherence. Finally, an appropriately sized alginate dressing was trimmed and applied to the surface of the wound as the outer layer of the dual-layer dressing. This creates a moist healing environment, preventing the wound from being exposed and promoting overall wound healing. Due to the large wound area and excessive exudate, the patient underwent dressing changes once daily at the outpatient clinic.

By the fifth day of treatment, there was a substantial reduction in necrotic tissue in the wound, partial epithelialization, and formation of granulation tissue. However, there were still scattered minor bleeding points (Figure 1B). After 8 days of treatment, most of the wound was covered with epithelial tissue (Figure 1C). The patient reported no notable pain or burning sensation, and the muscles in the neck appeared relaxed. On the 11th day of treatment, only the creased area of the wound showed granulation tissue, whereas the remaining skin had fully healed (Figure 1D). On the 13th day of treatment, epithelialization occurred in the creased area of the skin within the radiation field on the right side of the neck; the remaining skin was completely healed (Figure 1E). After approximately 20 days, the wound had completely healed (Figure 1F). The patient reported no wound recurrence or discomfort within 3 months of completing the treatment.

DISCUSSION Key Steps in Wound Debridement

Wound debridement is a critical step in wound management. During the initial wound cleansing stage, thoroughly moisten the wound with normal saline solution and then gently remove necrotic tissue once it has completely loosened. This method can decrease pain caused by pulling during wound debridement. As the wound continues to heal, carefully differentiate between necrotic tissue and newly formed epithelial tissue during subsequent dressing changes. It is important to avoid damaging the delicate pink epithelial tissue, which could impede wound healing. When managing a wound, it is advisable to preserve less viable epithelial tissue, especially when it is adhered to newly formed tissue. Excessive cleansing can cause the wound to bleed and further damage the wound, thereby affecting the healing process.

Hydrogel and Its Usage

Hydrogel and hydrocolloid dressings have been used to treat moderate to severe radiation dermatitis involving moist desquamation. These dressings help maintain a moist environment on the skin surface after the epidermis has peeled off, promoting autolytic debridement of necrotic tissue. They also effectively prevent wound exudate from adhering to the outer dressing, thereby avoiding secondary damage to new tissue and accelerating wound healing.10 In this process, maintaining a moist environment for the wound is crucial for facilitating the dissolution of necrotic tissue and enhancing the phagocytic removal of dead debris and bacteria.17

Usage of Alginate Dressings in Promoting Wound Healing

Studies have shown that alginate has high absorbency.18 Moreover, alginate dressings are as soft, easy to fold, and easy to apply as gauze. They remove excessive exudate while maintaining sufficient moisture in the affected tissue, providing an optimally moist environment for wound healing. They are easy to remove, aid in blood clotting, and promote wound healing.15,18 Therefore, this dressing can help shorten wound healing time, alleviate pain, and reduce the risk of infection. Alginate dressings have been widely used in various types of wounds due to their effective barrier properties against external bacteria. Alginate dressings not only demonstrate excellent effectiveness in moist wound healing but are also user-friendly, making them a preferable choice as a bioactive dressing.

However, the effectiveness of alginate dressings in the prevention or treatment of radiation dermatitis has not been fully substantiated.10 In a retrospective study investigating the application of calcium alginate dressings in patients undergoing head and neck cancer radiotherapy, Bonomo et al15 found that early application of calcium alginate dressings effectively treated moist desquamation. Its effective adherence prevents displacement of the dressing, thereby avoiding direct contact with thermoplastic masks and ulcerated skin, which helps prevent treatment interruptions caused by this contact.15 Although there is a lack of high-quality evidence regarding the effectiveness of alginate dressings in the treatment of radiation dermatitis both domestically and internationally, their efficacy is demonstrated in this particular case.

Wound healing rates vary among patients, and providers should determine the frequency of dressing changes based on observations of the wound healing progress and the amount of exudate produced on a daily basis. When there is a substantial amount of wound exudate, it is important to promptly change the dressing. In contrast, as epithelial tissue growth begins and wound exudate decreases, the frequency of dressing changes should be reduced to avoid excessive disturbance to the newly formed epithelium. Based on the size and shape of the wound, it is recommended to trim the dressing to a suitable size and shape that corresponds to and extends at least 1 cm beyond the wound boundaries. This guarantees optimal adherence and stability of the dressing. As the wound heals, the dressing will naturally fall off, and the wound will gradually become dry.

Combined Hydrogel and Alginate Dressing Usage

In the present case, the combined use of hydrogels and alginate dressings was effective in treating acute radiation dermatitis occurring in the head and neck region. Neck skin is thin and highly active, containing sweat and sebaceous glands as well as an abundance of skin wrinkles; with large dosages of radiation therapy, the likelihood of severe acute radiation dermatitis occurring in the neck region is increased.19 The head and neck region also has a high degree of mobility, making it difficult to directly secure dressings when treating acute radiation dermatitis in this area. Observational results from the practice of covering hydrogel with alginate dressings have shown that the dressings are less likely to detach and can remain in place for an extended period on the neck. This approach also avoids potential tension damage around the wound that may result from using adhesive tape. Patient satisfaction in terms of pain relief and wound size reduction indicates that this approach has considerable efficacy in the treatment of radiation dermatitis.

Previous studies have indicated that the use of dressings containing metals can result in radiation scatter and increase the surface dose to the skin. Hence, dressings with metal components must be removed prior to radiation therapy.20 This not only increases the frequency of dressing changes and resultant patient discomfort but also imposes an economic burden during the treatment process. In contrast, alginate dressings do not contain any metallic components and thus do not interfere with patients’ ability to continue their radiation therapy. This is particularly advantageous for patients who experience severe acute radiation dermatitis before the completion of their radiation treatment.

Psychological Care and Dietary Guidance

For patients with severe acute radiation dermatitis and large wounds, the cycle of dressing changes and length of wound healing may be longer. In the initial stages of treatment, there may be a substantial amount of exudate, requiring daily dressing changes. During this process, wound care providers need to provide patients with patient-centered education and psychological support to gain their trust and improve their adherence. During dressing changes, it is important to compare the current wound with its previous state and inform the patient about the gradual reduction in wound size. This helps relieve anxiety and boosts patients’ confidence by showing them positive progress in their healing process. Providers should also inform patients that adequate nutrition and a high-protein diet can enhance their immune system and facilitate wound healing.

CONCLUSIONS

In the present case, the combination of hydrogel and low-adherence alginate dressings was successful in treating acute radiation dermatitis. Together, these components create a moist environment that accelerates re-epithelialization and is conducive to wound healing.

Although the use of alginate dressings can effectively treat moist desquamation,21 there is currently little consensus on the optimal dressings or barrier films for preventing or treating acute radiation dermatitis.22 Research is particularly limited regarding the treatment of grades 3 and 4 radiation dermatitis. Moreover, because of the high mobility of the neck, it is challenging to secure dressings effectively in this location. Further investigation is needed to identify the most effective dressing methods by anatomic area.

The success of this case provides a foundation for clinical practice and suggests further application of hydrogels combined with alginate dressings in the treatment of grades 3 and 4 radiation dermatitis as well as future directions for high-quality research.

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