Fluoroscopy-Induced Chronic Radiation Dermatitis

Alison Spiker, BAb,*, Zachary Zinn, MDa, William H. Carter, MDc, Roxann Powers, MDa, and
Rodney Kovach, MDa
A 62-year-old man with a history of 2 previous cardiac catheterizations presented with an
itchy, nontender skin lesion over his right scapula. The skin lesion had been present for >5
years. Review of the medical records found evidence of a prolonged and complicated
cardiac catheterization 8 years previously. Physical examination revealed an 8 6 cm,
well-demarcated, erythematous reticulated atrophic plaque with telangiectasias and ulcer-
ation. Biopsy confirmed histologic changes consistent with radiation dermatitis. In conclu-
sion, the characteristic histologic findings of radiation dermatitis, along with the location
over the right scapula and the history of prolonged fluoroscopic exposure during cardiac
catheterization, led to the clinical diagnosis of fluoroscopy-induced chronic radiation
dermatitis. 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;110:18611863)

The advent of therapeutic interventions such as atrial
fibrillation ablation, biventricular pacing, and even complex
coronary intervention has resulted in increased radiation
exposure in the catheterization laboratory. Skin exposed to
fluoroscopy can be injured by the radiation and is often the
tissue most at risk because it receives the highest dose.1 We
present a case of a patient found to have fluoroscopy-
induced chronic radiation dermatitis and review the current
research surrounding the diagnosis and management of
these patients.
Case Description
A 62-year-old man presented with a history of an itchy,
nontender skin lesion over his right scapula, which he re-
ported had been present for 5 years. His medical history
included hypertension, hyperlipidemia, heart failure, coro-
nary artery disease, and extensive smoking. He reported no
history of excessive sun exposure or radiation therapy. The
patient had 2 cardiac catheterizations with stent placement 8
and 9 years before presentation. Later review of his medical
records revealed that the patients second cardiac catheter-
ization involved stent breakage in the ostial right coronary
artery requiring prolonged fluoroscopic exposure to retrieve
the broken stent. The total fluoroscopy time and total dose
of radiation delivered during the catheterization are un-
known; there were no reporting requirements for total grays
at that time.
On physical examination, the lesion was an 8 6 cm,
well-demarcated, erythematous reticulated atrophic plaque
with telangiectasias and ulceration located over the right
scapula (Figure 1). Histopathology of the lesion demon-
strated dilated superficial vessels; thickened, sclerotic col-
lagen bundles with loss of adnexal structures; and sparsely
a
Section of Dermatology, Department of Medicine, bWest Virginia
University School of Medicine, Morgantown, West Virginia; and cDepart-
ment of Medicine, Charleston Area Medical Center, Charleston, West
Virginia. Manuscript received May 23, 2012; revised manuscript received
and accepted August 8, 2012.
*Corresponding author: Tel: 304-532-3141; fax: 304-347-1251.
E-mail address: alison.spiker@gmail.com (A. Spiker).
scattered atypical fibroblasts (Figure 2). These findings
were consistent with radiation dermatitis. The patients his-
tory of prolonged fluoroscopic exposure during cardiac
catheterization combined with the location of the lesion and
the characteristic histologic findings of radiation dermatitis
led to the clinical diagnosis of fluoroscopy-induced chronic
radiation dermatitis. Since presentation to clinic, the patient
has been followed regularly for skin cancer screening and
symptomatic management of his lesion.
Comments
Radiation dermatitis is well documented and common,
occurring in about 90% of patients receiving radiotherapy
for cancer.2,3 Fluoroscopy-induced radiation dermatitis is
uncommon, because radiation doses delivered during fluo-
roscopic procedures are typically low and do not reach the
threshold needed for skin injury.4 Radiation dermatitis can
develop after fluoroscopy-guided interventional procedures
such as coronary angiography, percutaneous transluminal
coronary angioplasty, and radiofrequency cardiac catheter
ablation.5 The location of skin injury correlates with the site
of radiation beam entry and varies depending on the proce-
dure.6 Radiation dermatitis from coronary procedures is
commonly found on the midback, scapular areas, right an-
terolateral chest, and below the right axilla.6
Clinical presentation of fluoroscopy-induced radiation
dermatitis can vary from early reactions of erythema, epil-
ation, and dermal atrophy to chronic changes such as telan-
giectasia, ulceration, and necrosis.57 Signs of acute radia-
tion dermatitis are usually present but are not necessary for
the development of chronic radiation dermatitis. Histologic
features characteristic of radiation dermatitis include epi-
dermal atrophy, dermal sclerosis, dilated superficial blood
vessels, and atypical stellate fibroblasts.8 Fluoroscopy-in-
duced radiation dermatitis is diagnosed by correlating the
patients history of a fluoroscopy-guided procedure with the
location of the skin lesion and the characteristic histologic
findings.5 A biopsy is generally not recommended for
chronic radiation dermatitis if the history and clinical pre-
sentation are classic given poor wound healing of skin
damaged by radiation.

0002-9149/12/$ see front matter 2012 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2012.08.023
1862 The American Journal of Cardiology (www.ajconline.org)
Figure 1. Appearance of the skin lesion. The lesion was found over the
patients right scapula, which was the site of radiation beam entry during
the cardiac catheterization. The lesion was described as an 8 6 cm,
well-demarcated, erythematous reticulated atrophic plaque with telangiec-
tasias and ulceration.
Figure 2. Histology of the skin lesion. Histologic examination revealed
characteristic findings of radiation dermatitis. The lesion was described
as having dilated superficial blood vessels; thickened, sclerotic collagen
bundles with loss of adnexal structures; and sparsely scattered atypical
fibroblasts.
Treatment options for radiation dermatitis consist mostly
of symptomatic management and monitoring for progres-
sion of the lesion. There is currently no definitive treatment
for radiation dermatitis.2,3 Review of the existing therapies
demonstrates that topical corticosteroids, such as mometa-
sone furoate and beclomethasone dipropionate, reduce skin
reactions after radiation.3 Evidence for the use of topical
nonsteroidal creams is conflicting and does not show a clear
benefit.3 Surgical excision and skin grafting may be re-
quired for severe injuries, such as nonhealing ulcers.5,6
Malignant transformation of the skin into squamous cell
carcinoma in the area exposed to ionizing radiation has been
documented.9 There have been reports of superficial basal
cell carcinomas developing 20 to 30 years after multiple
diagnostic fluoroscopic procedures in patients exposed to
large cumulative doses of ionizing radiation.10,11 Cancer is
an example of a stochastic effect of radiation.1,4 Stochastic
effects lack a threshold dose required for injury, whereas
deterministic effects of radiation are injuries to the skin and
subcutaneous tissues that occur once a threshold dose is
exceeded.1,4
Patients who undergo fluoroscopy-guided procedures
should be made aware of the possibility of radiation derma-
titis, especially if they will be exposed to 4 Gy.4 In most
patients, the threshold dose for clinically significant skin
and hair changes is 5 Gy.7 If a patient received an estimated
total radiation dose 10 Gy, medical follow-up is appro-
priate.7 After fluoroscopic procedures, patients should be
advised to monitor for any skin changes in the area exposed
under fluoroscopy and should receive direct skin evaluation
if exposed to higher doses.
Fluoroscopic procedures are increasing in younger pa-
tients, particularly radiofrequency cardiac catheter ablation
as a treatment for atrial fibrillation, many of whom require
2 procedures.12 Physicians must know thresholds of ex-
posure mandating follow-up and published guidelines for
reducing exposure.1,4,13 As outlined in a recent publication
by the American College of Cardiology Foundation and the
Society for Cardiovascular Angiography and Interventions,
cardiac catheterization reports must include fluoroscopy
time and radiation dose as minimum requirements, and
patients should be informed if they received significant
exposure.14 Because there is no definitive treatment for
fluoroscopy-induced radiation dermatitis, prevention is crit-
ical to reducing injuries. Radiation dermatitis should be
considered in any patient at late follow-up presenting with a
well-demarcated, atrophic, telangiectatic ulcerated lesion
arising in an area exposed to substantial fluoroscopy.
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