Cutaneous Radiation Syndrome
Definitions
- Cutaneous Radiation Syndrome (CRS)
- One of the four subsyndromes of Acute Radiation Syndrome (ARS)
- Clinical continuum of pathophysiological reactions of the skin and skin appendages to significant levels of ionizing radiation after:
- Exposure of the skin from whole or partial body radiation which penetrates deeply into tissues (e.g., gamma, neutron)
- Exposure of very large areas of skin from high energy beta radiation, which usually does not penetrate deeply enough in tissue to cause the 3 other subsyndromes of ARS (hematopoietic, gastrointestinal, neurovascular) but can cause major skin effects
- Phases of CRS are the same as for the other 3 ARS subsyndromes
- Prodromal
- Latent
- Manifest Illness
- Recovery (± with chronic or late effects)
- CRS in this context represents Cutaneous Radiation Syndrome, not Chronic Radiation Syndrome, which has also been called CRS.
- Cutaneous Radiation Injury (CRI)
- Clinical continuum of pathophysiological reactions of the skin and skin appendages to significant levels of ionizing radiation
- Differences between CRS and CRI
- CRI need not occur in the context of ARS.
- CRI may occur when radiation injury (from therapeutic or unintentional exposure) is more localized or if radiation dose is insufficient to penetrate to deeper organs and cause ARS.
- CRS and CRI may be confused or used interchangeably (though incorrectly) in the medical literature
- Synonyms of CRI
- Radiodermatitis
- Radiation dermatitis
- Cutaneous radiation effects
- Phases of CRI
- Acute
- Subacute
- Chronic
- Late
- Threshold dose
- Medical literature provides wide range of minimal threshold radiation doses necessary to produce ionizing radiation-induced skin injury (e.g., 350 - 500 cGy).
- Intrinsic biological (i.e., host) and inherent physical (i.e., radiation) factors may raise or lower dose required to cause skin injury, therefore no value or value range is provided by REMM.
- Consult Bibliography for references.
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Clinical information
- This section provides a brief overview.
- Gallery of clinical photographs illustrates "focal" areas of radiation skin injury.
- More extensive skin injury is possible, but not illustrated here.
- Radiation-induced skin injury can result from sufficiently high levels of
- Skin histologic architecture and burns
- Illustration of skin anatomy and levels of burn injury
- Normal skin thickness varies widely (e.g., compare eyelids vs. palms and soles)
- Varies widely (e.g., compare eyelids vs. palms and soles)
- Variables within normal skin architecture include
- Depth/thickness of epidermis and dermis
- Density of blood vessels and lymphatics
- Presence/density of skin appendages (e.g., sweat & sebaceous glands, hair follicles)
- Differences in skin architecture partially explain how/why tissues differ in response to same/similar radiation doses.
- Timing of injuries
- In general, early effects of ionizing radiation-induced skin injury manifest in the epidermis, whereas late effects appear in the dermis.
- Radiation burns differ from thermal or chemical burns in various ways including
- Thermal or chemical burn injuries evolve immediately following insult to skin.
- Ionizing radiation-induced skin injuries carry a small but real potential for malignancy as a late effect.
- Chronic scarring patterns differ.
- See burn information
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Management of cutaneous radiation syndrome
- Management of severe radiation skin injuries must be highly individualized.
- Key management references
- Dainiak N, Gent RN, et al. Literature Review and Global Consensus on Management of Acute Radiation Syndrome Affecting Nonhematopoietic Organ Systems. Disaster Med Public Health Prep. 2011 Oct;5(3):183-201. [PubMed Citation]
- Muller K, Meineke V. Advances in the management of localized radiation injuries. Health Phys. 2010 Jun;98(6):843-50. [PubMed Citation]
- Benderitter M, Gourmelon P, Bey E, Chapel A, Clairand I, Prat M, Lataillade JJ. New emerging concepts in the medical management of local radiation injury. Health Phys. 2010 Jun;98(6):851-7. [PubMed Citation]
- Surgical Management of the Burn Wound and Use of Skin Substitutes - American Burn Association White Paper (PDF - 649 KB) (American Burn Association, 2009)
- Triage, Monitoring and Treatment - Handbook for management of the public in the event of malevolent use of radiation (Registration required for download) See Chapter J, section 7: Local radiation injuries, pages 282-296.
- Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome. (METREPOL) (PDF - 970 KB) (originally published by Oxford: British Institute of Radiology; 2001) Compendium to the main METREPOL document (PDF - 580 KB)
- See also:
- General considerations for acute medical management may include , , , , , ,
- Wound cleanliness and debridement
- Fluid replacement
- Management of pain
- Management of pruritis
- Topical anti-inflammatory therapy, e.g. corticosteroids
- Anti-microbial prophylaxis and therapy
- Inhibitors of proteolysis
- Growth factors to enhance granulation and re-epithelialization
- Stimulation of local blood supply, e.g. pentofylline
- General considerations for management of severe subacute or chronic radiation-induced skin injuries that heal poorly or fail to heal may include
- Medical therapy
- Anti-coagulation to prevent clotting in dermal and subcutaneous vessels
- Anti-inflammatory therapy
- Range of motion exercises for joints and soft tissues after skin injuries than have re-epithelialized
- Surgical Therapy
- Local excision
- ± Grafting for closure
- ± Amputation (e.g., digits, limbs)
- CRS complicates management and recovery from other ARS subsyndromes.
- CRS (and loss of intact skin barrier) can result in
- Major microbial infection
- Bleeding
- Fluid loss
- Pain
- Significant CRS may complicate the radiation-induced multi-organ failure associated with ARS.
- After the Chernobyl nuclear reactor accident in the Ukraine 1986, beta burns were the primary cause of death in a number of patients, increasing the morbidity and mortality of ARS, especially when skin injury exceeded 50% of the body surface area.
- Significant ionizing radiation-induced skin injury will complicate management and impair healing of co-located physical trauma.
- Burn specialists will usually assist the radiation response team in management of severe ionizing radiation-induced skin injury.
- Subsequent trauma to previously irradiated skin is likely to heal slowly/poorly.
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Radiation physics and skin effects
- With some exceptions, radiation dose decreases (attenuates) as it passes through skin and deeper tissues.
- Beta burns
- Represent the effects of beta radiation on the skin.
- Radiation effects on skin may be significant, but effects rarely go deeper, due to the physical properties of the beta radiation.
- Nevertheless, widespread beta burns can increase morbidity and mortality of ARS when ARS develops after significant whole body gamma or neutron radiation in addition to the beta burns.
- Physical properties of radiation associated with increasing injury severity
- Total dose: higher dose → more severe damage
- Dose rate: faster dose delivery rate → more severe damage
- Extent of area affected: larger/wider area → worse effects
- Dose depth: deeper dose → more severe damage
- Radiation with higher RBE → more severe damage
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Manifestations of Acute Skin Injury
- Signs
- Erythema and skin edema
- Similar to sunburn
- Erythema may appear with or without edema.
- Blister
- Epidermal denudation
- Ulceration
- Especially after high dose skin exposure at high dose rate
- Hair and nail changes
- Symptoms
- Pruritis
- Local dysesthesias
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Manifestations of Late/Chronic Skin Injury
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Evaluation of Cutaneous Radiation Syndrome
- Specialized tests may be helpful in managing selected cases with poorly characterized or severe skin injury., , ,
- Sequential color photography: to document skin changes over time
- Ultrasonography and/or MRI: to evaluate injury depth
- Thermography: tissue necrosis lowers skin temperature while inflammation raises skin temperature
- Capillary microscopy: to assess severity of injury by viewing vessels in dermal stratum papillae
- Profilometry: to evaluate changes to skin surface
- Histology/biopsy
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Phases of Cutaneous Radiation Syndrome
Phases of Cutaneous Radiation Syndrome (CRS)*
| Prodromal | Latent | Manifest Illness | Possible Chronic/Late Effects |
- Erythema
- Edema
- Pruritis, increased skin temperature, dysesthesias
|
- Variable time, longer duration with lower dose
- Prodromal symptoms may stabilize or slightly improve
|
Early:
- Second wave of erythema, swelling and edema of skin and subcutaneous tissues, corresponding to the renewal of
epidermal cells
Later:
|
Note: Many of these late/chronic effects can appear years to decades later.
|
*Adapted from references 2, 6, 20, 24
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Prognosis of Cutaneous Radiation Syndrome
Prognosis of Cutaneous Radiation Syndrome (CRS)*
| Syndrome Grade | Severity | Prognosis |
| 1 | Mild | Recovery likely |
|---|
| 2 | Moderate | Recovery likely without significant deficit |
|---|
| 3 | Severe | Recovery likely with deficit |
|---|
| 4 | Critical | Serious deficit, with reconstruction probably needed in appropriate setting |
|---|
*Adapted from references 2, 24
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Gallery of Clinical Photographs
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Clinical photographs of cutaneous radiation syndrome (11 MB, requires Flash Player)
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Normal skin
- Normal skin architecture
- Skin anatomy and levels of burn injury
Acute effects:
- Erythema and skin edema
- Epilation
- Blister
- Dry desquamation
- Moist desquamation
Evolution of skin effects:
- Patient OAF in Goiania incident, 1987 -
blister, evolution to moist desquamation
- Peruvian patient exposed to Iridium-192 -
blister, moist desquamation, ulcer progressing to tissue necrosis
- Wife of the Peruvian patient exposed to Iridium-192 -
Dry desquamation, necrosis, fibrosis, and telangiectasia
- Patient involved in a x-ray diffraction accident, 9-96 days postexposure -
erythema, telangiectasias, blisters, desquamation, cellulitis
Chronic effects:
- Skin atrophy
- Chronic radiation dermatitis
- Fibrosis, contractures, and keratoses
- Keratosis and fibrosis
- Telangiectases and epidermal atrophy
- Telangiectases and xerosis
- Telangiectases
- Telangiectases and muscle contractures/fibrosis
- Lentiginous changes in skin
- Hyperpigmentation, keratoses, and telangiectases
- Hyperpigmentation and onychodystrophy
- Onycholysis (Onychodystrophy)
- Ulcer
- Chronic radiation ulcer
- Tissue necrosis
- Skin cancer
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Bibliography
- Barabanova A, Baranov A, Bushmanov A, Guskova A, Radiation injuries in humans, Slovo Publishers, Moscow, Russia, 2007. (Russian language)
- Barabanova AJ: Local Radiation Injury. In: Gusev IA, Guskova AK, Mettler FA Jr, eds.: Medical Management of Radiation Accidents, 2nd ed. Boca Raton, Fl: CRC Press, 2001, pp. 223-240.
- Charles MW. The skin in radiological protection--recent advances and residual unresolved issues. Radiat Prot Dosimetry. 2004;109(4):323-30. [PubMed Citation]
- Cutaneous Radiation Injury: Fact Sheet for Physicians (HHS/CDC, 5/10/2006)
- Diagnosis and Treatment of Radiation Injuries (PDF - 202 KB) (IAEA Safety Reports Series No. 2, Vienna 1998)
- Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome, pp.27-32. (METREPOL) (PDF - 970 KB) (originally published by Oxford: British Institute of Radiology; 2001) Compendium to the main METREPOL document (PDF - 580 KB)
- Gottlöber P, Bezold G, Weber L, Gourmelon P, Cosset JM, Bahren W, Hald HJ, Fliedner TM, Peter RU. The radiation accident in Georgia: clinical appearance and diagnosis of cutaneous radiation syndrome. J Am Acad Dermatol. 2000 Mar;42(3):453-8. [PubMed Citation]
- Gottlöber P, Steinert M, Weiss M, Bebeshko V, Belyi D, Nadejina N, Stefani FH, Wagemaker G, Fliedner TM, Peter RU. The outcome of local radiation injuries: 14 years of follow-up after the Chernobyl accident. Radiat Res. 2001 Mar;155(3):409-16. [PubMed Citation]
- Hall EJ, Giaccia AJ, Radiobiology for the Radiologist, 6th Edition, Lippincott Williams & Wilkins, Philadelphia, PA, 2006, pp.333-6.
- Hopewell JW. The skin: its structure and response to ionizing radiation. Int J Radiat Biol. 1990 Apr;57(4):751-73. [PubMed Citation]
- How to recognize and initially respond to an accidental radiation injury - images of radiation skin effects and injury (poster, PDF - 436 KB) (pamphlet, PDF - 322 KB) (Radiation dermatological injuries, IAEA, WHO)
- Meineke V. The role of damage to the cutaneous system in radiation-induced multi-organ failure. BJR Suppl. 2005;27:85-99. [PubMed Citation]
- Mettler FA Jr, Guskova AK, Gusev I. Health effects in those with acute radiation sickness from the Chernobyl accident. Health Phys. 2007 Nov;93(5):462-9. [PubMed Citation]
- Müller K, Meineke V. Radiation-induced alterations in cytokine production by skin cells. Exp Hematol. 2007 Apr;35(4 Suppl 1):96-104. [PubMed Citation]
- Oliveira AR, et al., Skin lesions associated with the Goiania accident, in The Medical Basis for Radiation Accident Preparedness II, 173-181, Ricks RC, Fry SA (eds.), 1990.
- Peter RU, Braun-Falco O, Birioukov A, Hacker N, Kerscher M, Peterseim U, Ruzicka T, Konz B, Plewig G. Chronic cutaneous damage after accidental exposure to ionizing radiation: The Chernobyl experience. J Am Acad Dermatol. 1994 May;30(5 Pt 1):719-23. [PubMed Citation]
- Peter RU, The Cutaneous radiation syndrome, in Advances in the Treatment of Radiation Injuries/Advances in the Biosciences , MacVittie TJ, Weiss JF, Browne D (eds.), 94:237-40, 1994.
- Peter RU, Cutaneous radiation syndrome: clinical and therapeutic aspects, Radiological Protection Bulletin, 183: 19-25, 1996
- Peter RU, Gottlöber P. Management of cutaneous radiation injuries: diagnostic and therapeutic principles of the cutaneous radiation syndrome. Mil Med. 2002 Feb;167(2 Suppl):110-2. [PubMed Citation]
- Peter RU. Cutaneous radiation syndrome in multi-organ failure. BJR Suppl. 2005;27:180-4. [PubMed Citation]
- Peter RU, Management of skin injuries in radiation accidents: The cutaneous radiation syndrome, in The Medical Basis for Radiation-accident Preparedness, the Clinical Care of Victims, Proceedings of the Fourth International Radiation Emergency Assistance Center/Training Site (REAC/TS) Conference, March 2001, Parthenon Publishing Group, New York, NY, 2002.
- Radiation Emergency Assistance Center/Training Site, Oak Ridge Institute for Science and Education, Oak Ridge, TN, Advanced Radiation Medicine Course, September 17-21, 2007.
- Rubin P, Casarett GH, Clinical Radiation Pathology. Saunders, Philadelphia, PA, 1968.
- Steinert M, Weiss M, Gottlöber P, Belyi D, Gergel O, Bebeshko V, Nadejina N, Galstian I, Wagemaker G, Fliedner TM, Peter RU. Delayed effects of accidental cutaneous radiation exposure: fifteen years of follow-up after the Chernobyl accident. J Am Acad Dermatol. 2003 Sep;49(3):417-23. [PubMed Citation]
- The biological basis for dose limitation in the skin (International Commission on Radiological Protection, ICRP Publication 59, 1992)
- The radiological accident in Yanango (PDF - 3.30 MB) (IAEA, 2000)
- Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Radiology. 2010 Feb;254(2):326-41. [PubMed Citation]
Additional References:
- Dainiak N, Gent RN, et al. Literature Review and Global Consensus on Management of Acute Radiation Syndrome Affecting Nonhematopoietic Organ Systems. Disaster Med Public Health Prep. 2011 Oct;5(3):183-201. [PubMed Citation]
- Muller K, Meineke V. Advances in the management of localized radiation injuries. Health Phys. 2010 Jun;98(6):843-50. [PubMed Citation]
- Benderitter M, Gourmelon P, Bey E, Chapel A, Clairand I, Prat M, Lataillade JJ. New emerging concepts in the medical management of local radiation injury. Health Phys. 2010 Jun;98(6):851-7. [PubMed Citation]
- Surgical Management of the Burn Wound and Use of Skin Substitutes - American Burn Association White Paper (PDF - 649 KB) (American Burn Association, 2009)
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