Managing Radiotherapy Induced Skin Reactions A Toolkit for Healthcare Professionals

Radiotherapy Induced
Skin Reactions
A Toolkit for Healthcare Professionals
The Princess Royal Radiotherapy Review Team
Supported by:
This Toolkit has been developed as an educational resource supporting the assessment and
management of radiotherapy induced skin reactions. The toolkit can be adapted to suit the
clinical needs of your patients and the healthcare setting in which they are being treated. We
hope that you will find it useful.
Princess Royal Radiotherapy Review Team
St James’s Institute of Oncology, The Leeds Teaching Hospitals NHS Trust
A Joint Working initiative
NHS organisations and staff are encouraged to consider the opportunities for joint working with the pharmaceutical industry,
where the benefits that this could bring to patient care and the difference it can make to their health and well-being are clearly
advantageous. A philosophy of developing appropriate partnerships to help achieve high quality patient care could further
enhance the objectives of a patient-centred NHS. The development of effective and clinically appropriate joint working with
external stakeholders can contribute to building an NHS that is truly a beacon to the world.
The learning from a number of partnership projects has confirmed that joint working can provide real benefits to patients whilst
supporting the strategic objectives of the delivery partners. Accordingly, NHS organisations and staff are encouraged to consider
joint working as a realistic option for the delivery of high-quality healthcare. Joint working between the pharmaceutical industry
and the NHS must be for the benefit of patients or the NHS, preserve patient care and should be of mutual benefit, with the
principal beneficiary being the patient.
All content and clinical guidance is drawn from current clinical practice and a review of evidence by the Princess Royal
Radiotherapy Review Clinic. Under a joint working initiative, Aspen Medical Europe Ltd, Molnlycke Healthcare Ltd and Smith and
Nephew Ltd are supporting the production and wider awareness of this Toolkit.
(Excerpts from Best Practice Guidance on joint working between the NHS and pharmaceutical industry and other commercial organistions, DoH, 2008)
This toolkit aims to provide Healthcare Professionals with:
1. An understanding of the mechanism of skin damage specific to radiotherapy and factors
that can exacerbate the reaction.
2. A guide to care goals and objectives.
3.An assessment framework and the treatment options, with rationale for each stage,
including information about the best use of suitable products. .
4.A resources section containing:
• M
aterials for use when advising patients and other health professionals involved in
patients’ continuing care
• A short post-training assessment
• Links to information and further advice
Radiotherapy Induced Skin Reactions
•Radiotherapy is a major modality in the management of cancer treatment,
along with chemotherapy and surgery.
•One of the most common side effects of radiation is acute skin reaction which can range
from mild erythema to confluent moist desquamation and occasionally, ulceration.
•All patients receiving external beam radiotherapy are at potential risk of developing
a reaction within the treatment field with approximately 85 – 87% of these patients
experiencing a moderate to severe skin reaction1,2,3 of which 10-15% will progress to moist
•Radiation skin reactions are not ‘burns’; they occur as a result of damage to the basal cell
layer of the skin and the resultant imbalance between the normal production of cells in this
layer and the destruction of cells at the skin surface.
•It is essential that any damage is minimised, as far as possible, by ensuring that interventions
are based upon best practice and supported by evidence based guidelines5.
•There is a lack of randomised controlled trials to evaluate prophylactic skin care
interventions and treatment of radiotherapy skin reactions. Therefore this guidance has
been drawn from available published evidence, expert opinion from specialists within
the field of radiotherapy and the Leeds Teaching Hospitals Trust Radiotherapy Skin Care
1. Radiotherapy and the skin
Structure of normal skin
Epithelial cells in
basal membrane
damaged by radiation
Damaged cells from
basal membrane
migrating upwards
New epithelial cells
generated in basal
Effect of radiotherapy
•Radiotherapy causes biochemical changes within cells, as the DNA molecules are susceptible
to radiation damage during mitosis. Radiobiological damage affects regeneration of the skin
by the process of repair, redistribution, repopulation and reoxygenation. Damaged cells are
replaced by cells moving from the resting phase into the active cycle (repopulation).
•Skin damage occurs when the rate of repopulation of the basal cell layer (Stratum
Germinativum) cannot match the rate of cell destruction by treatment6. The inflammatory
response activated is a normal physiological reaction to radiotherapy.
•Radiotherapy induced skin damage is seen approximately 10-14 days following the first
fraction of radiation, corresponding with the time it takes for the damaged basal cells to
migrate to the skin surface. Initially the skin will become warm, and reddened (erythema),
and in some patients the area may also feel itchy.
•As the skin is damaged through further exposure to radiation it tries to compensate by
increasing mitotic activity in order to replace the damaged cells. However, if the new cells
reproduce faster than the old cells are shed then the skin will become dry and flaky (dry
•As radiotherapy continues the basal layer cannot produce enough new cells to replace the
old ones and therefore the outer layer of the epidermis will become broken, oedematous
with exudate (moist desquamation). The exudate is normal and rich in nutrients which
helps the growth of new skin cells. Skin necrosis is rarely seen primarily due to the advanced
techniques used in the delivery of radiotherapy.
•The severity of skin reactions may increase for 7-10 days after radiotherapy has finished.
It can take this amount of time for the cells that have been affected by radiotherapy to
reach the outer epidermis. This is often referred to as the ‘peak’, when the side effects
can be at their worse. After this time side effects will gradually start to settle down and
the condition of the skin will slowly improve.
•4 - 6 weeks after treatment has been completed, skin should be healing well and may
even be fully healed with the exception that the area may still look hyperpigmented
(darker). It takes this amount of time for the basal cells of the epidermis to recover and
for new skin to start to grow and heal7,8.
Radiotherapy cycle
Treatment completed. Takes 10-21 days for
basal cells to recover & new skin to grow.
Radiotherapy commences.
Activates inflammatory response.
No new cells to replace dead
cells = moist desquamation.
10 - 14 days from 1st treatment.
Damaged basal cells migrate to skin
surface. Erythema develops.
Further skin damage
New cells reproduce
before old dead cells shed
= dry desquamation.
How are radiotherapy skin reactions different to burns?
The assessment and management of burns is different to that of radiotherapy-induced skin reactions. They differ in
terms of cause mechanisms, extent, duration and trajectory.
• Inaccurate assessment can lead to inappropriate treatment
• Understanding the differences is pivotal in implementing correct interventions.
Radiotherapy Skin Reaction
Absorption of energy from ionising radiation affecting the process of
Delayed - days
Time to
Skin Layers Epidermal layers only
Sequence Damaged basal cells migrate upwards to the surface of the skin
of Damage
Burn Injury
Trauma - e.g. fire, hot liquids, hot objects, freezing objects, corrosive chemicals,
electric current, UV light, etc.
Immediate - minutes
Potentially all layers from epidermis down to muscle / tendon / bone.
(Superficial - full thickness depths)
Damage occurs downwards through skin layers in relation to degree of burn
2. Intrinsic & Extrinsic Predisposing Factors
for Radiotherapy-induced skin reactions
The natural ageing process affects the epidermal cell cycle which can result in extended healing times.
Adequate nutritional intake is necessary for optimum repair of tissue damage.
The skin of undernourished patients may be at increased risk of damage.6,9,10,11
Can decrease capillary blood flow and oxygen levels thus increasing the severity of the skin reaction and impairing the body’s
ability to heal damaged tissues and fight infection.
Other illnesses and some medications can increase the risk and intensity of skin reactions and impact upon the healing process
e.g. diabetes12,steroids.
There is a suggestion that patients with long term UV exposure will experience a more severe radiation-induced skin reaction
and impaired healing. Patients from BME groups have reported more severe post-treatment skin reactions compared to white
Smoking and Alcohol
UV exposure / ethnic origin:
Extra adipose tissue can compromise healing and exacerbate skin toxicity due to the extra skin folds or areas where there is a
natural skin fold e.g. natal cleft and inframammary fold.
The presence of bacterial and/or fungal infection can damage the cells in the basal layer resulting in delayed healing14.
Higher doses; larger fields; increased volume and presence of bolus can all lead to increased skin reactions
Energy of radiotherapy:
The higher the energy the lesser the skin reaction. Megavoltage beams (energies above 1MV) deliver maximum dose
underneath the surface of the skin (skin sparing effect) whilst kilovoltage beams (energies below 1 MV) deliver maximum dose
to the surface of the skin therefore increasing the skin reaction.
Some chemotherapy agents are radiosensitisers (e.g. 5-Fluorouracil, Mitomycin C, Cisplatin) and therefore increase the severity
of skin reaction.
Chemicals such as deodorants, perfume, talcum powder and aftershave, metal-containing dressings and creams.
Extremes in temperature e.g. hot water bottles, ice packs.
irritants can exacerbate the skin
reaction and delay the healing process. Friction by rubbing skin or wearing tight fitting clothing.
3. Goals of Care for Skin Reactions
During Radiotherapy
•Initially, maintaining integrity and hydration of the skin
•Reducing potential for further exacerbation of the skin reaction
•Promotion of comfort and compliance
•Reduction of pain
• Protection from trauma
•Prevention of infection
•Promotion of a moist wound healing environment, in the stages where skin is broken
•Control of bleeding, odour and excessive exudate, where radiotherapy is being given for symptom
management of a fungating lesion
• The severity of skin reactions can increase and ‘peak’ around 7 - 10 days after treatment has finished.
- Within this 7-10 day period there is a continuing lack of new cells being produced to replace the old cells.
•Within 4 – 6 weeks of completing radiotherapy treatment, skin should be improving significantly, if
not fully healed.
- It takes this amount of time for the basal cells of the epidermis to recover and for these new cells to reach
the surface enabling new skin to grow and heal.7,8
•The rationales for interventions post radiotherapy are the same as during radiotherapy
- Comfort, reduce the risk of infection and further trauma and ultimately, promotion of healing.
- Interventions should be matched to the skin reaction based on continuous assessment of the skin and
RTOG score.
•As part of the expected radiotherapy skin reaction the body produces a greenish/yellow exudate
within areas of moist desquamation.
- T his should not be cleaned off (unless there are excessive amounts) as it assists with the healing process
post treatment and provides pain relief by bathing the exposed nerve endings within the area of moist
4. Assessment of Skin Reactions
Skin Assessment
•Assessment of the skin forms an integral part of the patient’s holistic care and starts with asking the right questions:
WHAT - are we assessing? What do we see? What does the skin look like? What other structures are within the treatment field? What lies beneath the skin reaction? What does the patient report? What has changed? What is the cause?
WHY - has it happened? Why are things changing - cause and effect?
HOW - do we treat it? How do we make the right choices about appropriate actions and interventions?
•Predicting the severity of skin reactions can be difficult due to the varying radio-sensitivity of skin and a number
of contributing factors15. Intrinsic and extrinsic factors may significantly increase the severity of radiotherapy skin
reactions which may delay the healing process16.
•Individuals with darker skin may notice that the skin in the treatment field becomes darker initially before going
through the other stages of the reaction. A study by Ryan et al (2007) reported that patients with dark/black skin
reported more severe skin reactions at the treatment site than white skinned patients13.
•A consistent approach to skin assessment is essential to ensure that the ‘right interventions’ are implemented at
the ‘right time’ in response to ongoing assessment and evaluation. Without accurate assessment and relevant
knowledge interventions may be inappropriate, dressing selection is likely to be arbitrary and ineffective, as well as
wasteful both in terms of time and resources.
•Most importantly, inaccurate assessment and inappropriate interventions may cause harm and distress to the patient
and ultimately, compromise the healing process.
•The use of an acute radiation scoring assessment tool is recommended to promote consistency and continuity of
appropriate management and interventions during, and after, radiotherapy, until the reaction has settled.
•The most commonly used framework for objective evaluation of skin reactions is the Radiation Therapy Oncology
Group (RTOG) grading system17.
•The RTOG scoring criteria does not take account of the subjective aspects of skin damage such as pain and
discomfort18. If the skin reaction is causing pain or discomfort, our Trust guidelines recommend that the WHO
analgesic ladder is used as a framework for appropriate pain management.
RTOG Grading System:
Faint or dull erythema. Mild
tightness of skin and itching
may occur
Bright erythema / dry
desquamation. Sore, itchy and
tight skin
RTOG 2.5
Patchy moist desquamation
Yellow/pale green exudate.
Soreness with oedema
Confluent moist desquamation.
Yellow/pale green exudate.
Soreness with oedema
Ulceration, bleeding, necrosis
(rarely seen)
Effects of Radiotherapy on Skin Cells
Step 3
Opioid for moderate to
Severe pain
+/- adjuvant analgesia
Morphine, fentanyl etc
Step 2
Opioid for mild to moderate pain
Plus non opioid.
+/- adjuvant analgesia
Codeine, tramadol etc
Step 1
Non opioid
+/-adjuvant analgesia
Paracetamol, aspirin or NSAID
Adapted from World Health Organisation (WHO) analgesic
Pain persisting, move up one step
No visible change to skin
Side effects reduce or signs of
toxicity move down one step
Assessment / Observation
WHO Analgesic Ladder:
5. Management of Radiotherapy
Skin Reactions
• G
eneral advice given to all patients receiving radiotherapy treatment
(in relation to the treatment field):
-Continue washing/bathing as normal using non-perfumed soap and toiletries
- Pat skin dry using a soft towel to avoid friction
-Do not use perfumes, deodorants, talcum powder, creams or gels in the treatment field (other than ones
recommended / prescribed by the Clinical Oncologist / Radiotherapy treatment centre)
-The use of a plain, un-perfumed emollient (e.g. aqueous cream), recommended by the Radiotherapy
treatment centre, to cleanse, soothe and soften the skin in the radiotherapy treatment field can help
maintain skin moisture levels, skin integrity and patient comfort19,20,21
-Advise to wear loose fitting clothing
-Avoid exposure of skin to sun until healed then use a high factor suncream of SPF30 or above23 as irradiated
skin will always be more sensitive and at increased risk of sun damage. Sunscreens should be used in
addition to clothing and shade to offer maximum protection
-Swimming in chlorinated water can have a drying effect on the skin therefore it is advised that swimming is
avoided until the skin reaction has completely settled and the skin is fully intact21,24
-Avoid applying extremes of temperature e.g. hot water bottle/ice pack (specialist cooling dressings as
recommended by the radiotherapy treatment centre can be used for symptomatic relief)
-Do not ‘wet shave’ or use hair removing products. Electric razors are suitable if used with care
Treatment aims
Assessment / Observation
No visible change to skin
Effects of Radiotherapy on Skin Cells
To promote hydrated skin & maintain skin
Faint or dull erythema. Mild tightness of
skin and itching may occur
To promote hydrated skin, patient comfort and
maintain skin integrity. To treat itchy skin. To
reduce pain, soreness and discomfort.
Bright erythema / dry desquamation. Sore,
itchy and tight skin
RTOG 2.5
Patchy moist desquamation
Yellow/pale green exudate. Soreness with
Confluent moist desquamation.
Yellow/pale green exudate.
Soreness with oedema
Ulceration, bleeding, necrosis
(rarely seen)
To promote comfort. Reduce risk of complications
of further trauma and infection. To reduce pain,
soreness and discomfort
To promote comfort
Reduce risk of complications of further trauma
and infection
Appropriate dressings*
• Atraumatic - to reduce pain when changed, does not adhere to the area of damaged skin
• Non-adhesive or silicone-based only - to avoid further damage to delicate, irradiated skin
•Absorbent - able to contain exudate (moist desquamation stage)
•Conformable – for difficult to dress areas e.g. neck or pelvic area
•Comfortable – for patient compliance and reduced pain while in situ
• Ease of application and removal - possible for patients to change their own dressings whilst at home
Appropriate dressings - Infection
• Infections are rare in radiotherapy skin reactions, but are possible.
• Infections identified whilst the patient is in the radiotherapy treatment stage will be managed by the specialist radiotherapy staff according to local guidelines.
• It has been documented that the use of metallic-based topical products on the radiation field should be
avoided whilst the patient is receiving radiotherapy due to the association with radiation scatter and increased
surface dose.15,21,22
• Once radiotherapy is completed, if the area of skin reaction becomes infected, appropriate local wound infection management policy should be followed, and may then include the use of metallic dressings e.g. silver-containing dressings.
Intervention guidelines†
Assessment / Observation
No visible change to skin
Effects of Radiotherapy
Intervention (action)
on Skin Cells
To apply aqueous cream initially twice daily
Faint or dull erythema.
Mild tightness of skin and
itching may occur
Increase application of aqueous cream as needed.
1% Hydrocortisone cream may also be prescribed for
symptomatic relief. Commence analgesia as guided by WHO
analgesic ladder
Bright erythema / dry
desquamation. Sore, itchy
and tight skin
Increase application of aqueous cream as needed.
Continue as RTOG 1 interventions
RTOG 2.5
Patchy moist desquamation
Yellow/pale green exudate.
Soreness with oedema
Continue aqueous cream on unbroken skin.
Stop hydrocortisone on broken skin. Apply an appropriate
dressing*† to exuding areas (e.g. PolyMem, Mepilex, Allevyn
N.A. / Gentle are all suitable options). Analgesia as guided by
WHO analgesic ladder. Wear loose fitting clothing
Stop using aqueous cream on moist/broken skin.
Continue with RTOG 2.5 interventions
Confluent moist
Yellow/pale green exudate.
Soreness with oedema
Ulceration, bleeding,
necrosis (rarely seen)
* Based on the Princess Royal Radiotherapy Review Team’s experience to date.
Seek specialist advice (i.e. Clinical Oncologist, Radiotherapy
Clinical Nurse/Radiographer Specialist in your area).
To promote hydrated skin &
maintain skin integrity
To promote hydrated skin,
patient comfort and maintain
skin integrity. To treat itchy
skin. To reduce pain, soreness
and discomfort.
To promote comfort. Reduce
risk of complications of further
trauma and infection. To
reduce pain, soreness and
To promote comfort
Reduce risk of complications
of further trauma and
Recommended Reading List
1.Campbell J. (2004) Skincare for patients undergoing radiotherapy. In: Feber T (ed) Head and Neck Oncology
Nursing. London: Whurr
2. Faithfull S & Wells M, (eds) (2003) Supportive Care in Radiotherapy. Edinburgh: Churchill Livingstone.
3.Kedge E M. (2009) A systematic review to investigate the effectiveness and acceptability of interventions for
moist desquamation in radiotherapy patients. Radiotherapy, (Aug) 15(3): 247-257
4.Naylor W, Laverty D & Mallett J (eds) (2001) The Royal Marsden Hospital Handbook of Wound Management in
Cancer Care. Oxford: Blackwell Science
Further information sources:
The Society of Radiographers -
Ellen Trueman
[email protected]
•Advice sheets
• A short post-training assessment
•Information on where to look for
further information and advice
•Product information sheets and
advice on usage
DoH, 2008. Best Practice Guidance on joint working between the NHS and pharmaceutical industry and other commercial organistions. [online] Available at
1.Olson D, Raub, W Bradley C, Johnson, M. Machias. JL, Love, V and Markoe A ( 2001). The effect of Aloe Vera gel/mild soap alone in preventing skin reactions in patients undergoing radiation. Oncology
Nursing Forum. No 3.
2. Robson V, Cooper R. (2009) Using Leptospermum honey to manage wounds impaired by radiotherapy: a case series. Ostomy Wound Management 55, 1, 38-47.
3.Salvo N, Barnes E, van Draanen J, Stacey E, Mitera G, Breen D, Giotis A, Czarnota G, Pang J, De Angelis C (2010) Prophylaxis and management of acute radiation-induced skin reactions: a systematic review
of the literature. Current Oncology. Vol 17, No 4.
4. Hornsby C, Fletcher J, Blyth CM. (2005) The production of a best practice statement in the skincare of patients receiving radiotherapy. Journal of Radiotherapy in Practice. 4, 2-3, 126-130.
5. Porock, D Kristjanson, L ( 1999). Skin reactions during radiotherapy for Breast Cancer: the use and impact of topical agents and dressing. European journal of Cancer.
6. Sitton E . (1992) Early and late radiation - induced skin alterations. Part 1 : Mechanisms of skin changes. Oncology Nursing Forum Vol 19, No5.
7. Rae Noble -Adams. (1999) Radiation induced Reactions. 1. An examination of the phenomenon. British Journal of Nursing. Sept 23-Oct 13: 8-17.
8. Aistars.J ( 2006). Validity of skin care protocols for external radiotherapy. Clinical Journal of Oncology Nursing. Vol 10. No 4.
9. Porock D (2002). “Factors Influencing the Severity of Radiation Skin and Oral Mucosal Reactions: Development of a Conceptual Framework.” Eur J Cancer Care (Engl) 11(1): 33-43.
10.Ginot A; Doyen J; Hannoun-Levi JM; Courdi A (2010). “[Normal Tissue Tolerance to External Beam Radiation Therapy: Skin].” Cancer Radiother 14(4-5): 379-85.
11.Nayel H; el-Ghoneimy E; el-Haddad S (1992). “Impact of Nutritional Supplementation on Treatment Delay and Morbidity in Patients with Head and Neck Tumors Treated with Irradiation.”
Nutrition 8(1): 13-8.
12. McNees P (2006). Skin and wound assessment and care in Oncology. Semin.Oncol.Nurs. 22 (3): 130-4.
13.Ryan JL, Bole C, Hickok JT, Figueroa-Moseley C, Colman L, Khanna RC, Pentland AP and Morrow GR. (2007) Post-treatment skin reactions reported by cancer patients differ by race, not by treatment or
expectations. British Journal of Cancer. 97, 14-21.
14. Krishnasamy M (2008). Wound Management. In: Corner J, Bailey CD, editors. Cancer Nursing: care in context. 2nd ed. Oxford: Blackwell; p.488-9.
15. Wells, M and MacBride S. (2003) Radiation Skin Reactions. Chapter 8 in: Faithfull S & Wells M (Eds) Supportive Care in Radiotherapy. Elsevier Science Ltd.
16.Wells M, Macmillan M, Raab G, MacBride S, Bell N, MacKinnon K, MacDougall H, Samuel L & Munro A. (2004) Does aqueous cream or sucralfate cream affect the severity of erythematous radiation skin
reactions? A randomised controlled trial. Radiotherapy and Oncology 73, 153-162.
17.Cox, J. Stetz, J and Pajak, T. ( 1995). Toxicity criteria of the radiation therapy oncology group ( RTOG) and the European Organisation for Research and Treatment of Cancer ( EORTC), International Journal of
Oncology, Biology and Physicis. 31, 5, 1341 - 1346.
18.College of Radiographers, (2000). Treatment of Radiotherapy induced Acute Skin Reactions: A Clinical Guidelines for Use by the College of Radiographers.
19.Bolderston A., Lloyd N.S., Holden L., Robb-Blenderman L., The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline. (2006) Support
Care Cancer. 14:802-817.
20.Kumar S, Juresic E, Barton M & Shafiq J (2001) Management of skin toxicity during radiation therapy: A review of the evidence. Journal of Medical Imaging and Radiation Oncology, 54, 264-279.
21. NHS QIS (2010) Best Practice Statement - Skincare of Patients Receiving Radiotherapy. Edinburgh: NHS Quality Improvement Scotland.
22.Harper J L, Franklin L E, Jenrette J M, Aguero E G. (2004) Skin toxicity during breast irradiation: pathophysiology and management. South Med J. 7: 989-93.
23.British Association of Dermatologists (2009) Sunscreen factsheet. Sun Awareness.
24.Byrne P, Copeland L, Mansell J, Trueman E & Wem L. (2003, re-validated 2010) Radiotherapy Skin Care Guidelines. St James’s Institute of Oncology. Leeds Teaching Hospitals Trust.
First Published September 2011.
olyMem - Bode C, Woodman H. Two Novel Treatments for the Prevention and Treatment of Radiation Induced Moist Desquamation. Poster Presented at CoR Conference January 2010, UK.
Munro DC, McLinton A. Challenges of Gynaecological Radiotherapy Skin Reactions. Poster Presented at Wounds UK November 2010, UK.
Trueman E. Understanding and Managing Radiotherapy Induced Skin Reactions. Poster presented at EWMA Conference May 2011, Brussels.
† Mepilex/SafeTac Range - Diggelmann KV et al. Mepilex Lite dressings for the management of radiation-induced erythema: a systematic in-patient controlled clinical trial. The British Journal of Radiology, 2010.
MacBride et al. A Case Study to Evaluate a New Soft Silicone Dressing, Mepilex Lite, for Patients With Radiation Skin Reactions. Cancer Nursing, Vol. 31, No. 1, 2008
Adamietz IA, Mose S, Haberl A, Saran FH, Thilmann C, Bottcher HD (1995) Effect of self-adhesive, silicone-coated polyamide net dressing on irradiated human skin. Radiation Oncology Investigations 2: 277–82
Haas, M.l., Coletti,J. Managing skin reaction from radiation or combined chemoradiation therapy. Poster presented at the American Society for Therapeutic Radiology and Oncology (ASTRO) 49th Annual Meeting, Los Angeles, Ca. USA, 2007.
Hatcher, A., Main, N. The bottom line radiation therapy: creative solutions to complex perineal and perianal wounds. Poster presented at 20th Annual Symposium on Advanced Wound Care and the Wound Healing Society Meeting, Tampa, Fl. USA, 2007.
Disclaimer - The information and recommendations in this publication are provided by the healthcare professionals of the Radiotherapy review clinic at St James’ Institute of Oncology, Leeds Teaching Hospitals NHS Trust and have not been verified by
Aspen Medical, Molnlycke Healthcare and Smith& Nephew. The companies accept no responsibility for the content of this publication and shall not be responsible for any reliance placed on the content. Professional medical advice should be sought for
the use of any product named in this publication. It may harm a patient’s health or cause you injury to use the products listed in this publication otherwise than in accordance with the uses for which they are licensed. The companies do not recommend or
promote unlicensed use of any of their products.
Aspen Medical Europe Ltd.
Thornhill Road, North Moons Moat, Redditch, Worcestershire B98 9NL, UK. Freephone: (UK) 0800 032 3399. Facsimile: +44 (0)1527 65100
Smith & Nephew UK Ltd.
Registered Number: 04421171. Registered Office: 15 Adam Street, London, WC2N 6LA
Aspen 159(L) 09.11 XS295
Mölnlycke Health Care Ltd.
The Arenson Centre, Arenson Way, Dunstable, Bedfordshire, LU5 5UL, UK. Telephone: +44 870 60 60 766 Facsimile: +44 870 60 81 888