ERYTHEMA DOSE (radiation induced erythema) Erythema means reddening of the skin due to inflammation which is usually a result

of accumulation of cells of the immune system and chemicals these cells release. There can be many reasons for the occurrence of erythema: exposure to heat, insect bites, infections, allergy, non-ionizing radiation (sunlight, UV) and ionizing radiation (X-ray, nuclear radiation). A deterministic effect of short term radiation exposure. Exposure of the skin to high doses of ionizing radiation leads to accumulation of lymphocytes in the layers of the skin caused by the effects of cell death and eventually to the development of erythematous skin changes. Patients may not be aware that the radiological procedure he/she has had can lead to erythema and therefore, may not provide a history of recent radiological procedures unless specifically asked. Radiation-induced skin injury may occur on any part of a patients body. Its appearance and severity depends on the circumstances surrounding the radiation event and patient specific factors such as smoking, poor nutrition, disorders of immune system (such as with cancer, or treatment of cancer or chronic infections), obesity and the presence of skin folds. Therefore, the preexisting condition of the patient and the skin prior to irradiation is of great importance. Skin that is previously compromised from previous irradiation, chemotherapy, steroid use, or surgery is more prone to radiation injury. Different parts of the skin also demonstrate different levels of sensitivity to radiation. The skin on the anterior surface of the neck is the most sensitive region. Other sensitive body parts are (in descending order of sensitivity): flexor surfaces (the front of the forearms or upper arms for example) of the extremities, the trunk, the back, the extensor surfaces (back of the forearm or upper arm for example) of the extremities, the nape of the neck, the scalp, the palms of the hands and the soles of the feet. Prompt skin reactions may appear within a few hours after acute exposure to radiation with a skin dose exceeding 2 gray (Gy) for the range of radiation energies encountered in X ray machines used for interventional procedures. In radiation therapy a skin dose of 6 to 8 Gy with 200 kV is required for erythema to occur. Radiation of higher energies requires larger doses to produce the same degree of erythema, since in these cases the maximum dose is received in deeper tissues below the skin. In actual practice the skin dose in interventional procedures varies

over the body, and it is the dose to the area with the highest skin dose (peak skin dose PSD) that determines whether erythema will occur. At skin doses up to approximately 2 Gy, no harmful effects are expected to be observed unless there has been prior irradiation of the skin. In the dose band of 2-5 Gy transient erythema may be a prompt reaction to radiation exposure. Epilation (hair loss) that heals in the midterm may also be observed. Between 5 and 10 Gy epilation appears as an early reaction. For doses at the upper band limit, permanent partial epilation may be observed in the mid-term. Long term dermal atrophy or induration is also possible. At doses between 10 and 15 Gy, dry or moist desquamation (skin loss) may develop as an early symptom. Prolonged erythema and permanent epilation in the midterm may be followed by telangiectasia (an abnormal collection of small blood vessles), dermal atrophy or induration in the long term. For doses exceeding 15 Gy, edema (skin swelling) and acute ulceration may appear as prompt reactions. Epilation and moist desquamation occur early after irradiation. In the midterm, if desquamation does not heal, a secondary ulceration may occur. Dermal necrosis that requires surgical intervention appears at higher doses. In the long term, telangiectasia, dermal atrophy or induration and secondary skin breakdown are probable. Surgical treatment may be required if a persistent wound progresses into a deeper lesion. Very serious reactions may occur for very high skin doses exceeding 80 Gy. However, splitting the delivery of a particular amount of ionizing radiation (also known as fractionation) over multiple sessions can also reduce the possibility erythema occurrence and its severity that would be seen if the entire dose was received at one time. Radiation effects tend to be cumulative, with the possibility of repair in-between two consecutive exposures. If there is a time gap between two interventional procedures, repair processes enable the skin to tolerate higher levels of radiation; the repair processes depend upon the time gap and the number of times the radiological procedure is repeated. However, data from animal studies indicate that increasing the time gap beyond 24 hours has no effect on the total dose for erythema to occur. It may be present few hours after injury or upto 1-2 weeks later. No not every patient needs treatment for this condidion. A systematic follow-up check-up of all patients undergoing an interventional radiology procedure is not necessary. Only patients who are suspected to have received doses high enough to cause skin injuries should be followed-up. This fact makes it most important that each interventional facility keeps accurate records of patient dose and implement a rigorous quality assurance practice at all times. Further, it is of utmost importance that all patients undergoing such procedures be aware of the possibility of skin symptoms, so that they can report any skin symptoms occurring in the relevant areas. Other patients

who require follow-up are those with conditions associated with higher radiosensitivity e.g. ataxia telangiectasia. Moreover, this awareness about the possibility of erythema on the part of doctors performing radiological procedures and also among dermatologists is essential. An understanding of dose and information about the dose delivered to the patient can be helpful in avoiding unnecessary followup or concern. The patient should be advised about the areas on the skin of the back (in cardiac interventions) where erythema might develop. This is best given to the patient in writing in the form of a letter or brochure that will inform the patient of what to look for and remind them to check for possible complications from the irradiation event. The patient should be asked to examine himself or herself until about 2 to 3 weeks after the procedure for any skin changes in those areas. Some facilities place a follow-up call to the patient during this time to ask about skin irritation and this is found to be effective in ensuring that a patient who develops skin irritation does not seek medical help at a place where there may be a chance of missing the correct diagnosis. The Society of Interventional Radiology guidelines for patient radiation dose management recommend a 2 week skin check when the procedure has involved 60 minutes of fluoroscopy, which is considered a rough indicator of high dose procedures

Local management of erythema remains a matter of discussion, with some controversy and on-going scientific investigation. The first (transient) early phase usually does not require any treatment, and frequently subsides before any therapy can be started. The second erythema phase (if correctly recognized) usually requires some prescription medication. One of the most popular therapies is Aloe Vera, given in lotion or ointment form. Although it has not been proven very effective in radiotherapy induced erythema, nor shown to be superior to other ointments or creams through several trials, it remains a frequently prescribed treatment. Biafin cream is also frequently prescribed, particularly by the radiotherapy community. However, there is no randomized trial supporting its use. Its use is actually questioned by some authors. Trolamin has been tested in several trials; no advantage was found for its use in a series of 547 patients irradiated for cancers of the head and neck . One trial showed superiority over Biafin, but another showed inferiority over Calendula. Calendula Officinalis is one of the rare treatments of early phase skin reactions Local steroids (ointments) are also commonly used but a randomized trial has not indicated much success in using this therapy as a prevention of radiation-induced

erythema in radiotherapy. This treatment may however help reduce the inflammatory reaction. Hyaluronic acid may be a possible treatment of early radiation-induced skin reactions; a double-blind, randomized trial has shown that the prophylactic use of a cream with hyaluronic acid was able to reduce the incidence of high-grade radiodermatitis compared to a placebo. When the level of injury reaches moist desquamation, eosin and anti-pain therapies are usually necessary, combined with antibiotics and steroids in selected cases that require them. Management of necrosis exceeds the scope of this document. The management of large areas of radiation-induced necroses is usually difficult and should be managed by experienced teams, and may require skin grafting. Large excisions of the necrotic tissue and surrounding tissue are needed as there is no chance of recovery. Such excisions may be increasingly guided by imaging such as MRI. Reconstruction of the soft tissues in the affected area may require autologous skin grafts, but may necessitate in some cases much more sophisticated approaches (such as grafting of artificial dermis in an intermediate phase, musculo-cutaneous rotational or free flaps, epiploc flaps, etc.). Some rare health conditions related to defects in DNA repair genes render patients highly sensitive to radiation. Patients with the heterozygous form of the ataxia telangiectasia gene have been found to be afflicted by unanticipated serious skin injuries .Other genetically established anomalies such as Fanconi disease, Bloom syndrome, xeroderma pigmentosum, familial polyposis, Gardner syndrome, hereditary malignant melanoma and dysplastic nevus syndrome were found to be associated with increased radiation sensitivity. Diseases such as collagen vascular diseases and diabetes mellitus are also suspected in rendering patients more susceptible to radiation induced skin injury. The reasons why some patients with collagen vascular disease are more sensitive to radiation are unknown. Moreover, having the disease does not systematically predispose patients to heightened sensitivity. Only a few patients with collagen vascular disease have been identified as having greater radiation sensitivity. Diabetes compromises the vascular supply and this leads to a greater risk for longterm complications.