Abstract: Radiation-induced skin injury is the most common side effect of radiotherapy (RT), affecting up to 95% of patients. Severe skin reactions may restrict radiation delivery or limit further treatment. Acute radiation dermatitis (ARD) arises within three months of the initiation of RT and is characterized by erythema, desquamation, ulceration, and even necrosis. To prevent or manage ARD, multiple systemic and topical medications have been employed, including topical vitamins, metallic ointments, and dressings. Among them, dressings are widely used and competitive, as they provide an intact, moist environment to facilitate the re-epithelialization of impaired skin. Polyurethane film dressings (such as Mepitel film and Hydrofilm dressings) are guaranteed in preventing ARD, whereas foam dressings (such as Mepilex® Lite dressings) can effectively manage ARD. Hydrogels are the most promising material for radiation-induced wound dressings due to their biodegradability, porous structure, and delivery features. However, due to the complexity of the skin repair process and the uncertainty surrounding its underlying mechanisms, the wide clinical application of hydrogels in ARD still requires further investigation. This review discusses the classification and pathological processes of ARD, the types of dressings available for clinical use, and modern dressings used to prevent and treat ARD. The aim is to provide valuable insights for optimizing ARD prevention and management.
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References
1.
FangKC, LeeCH, ChuangHC, et al.Acute radiation dermatitis among patients with nasopharyngeal carcinoma treated with proton beam therapy: Prognostic factors and treatment outcomes. Int Wound J. 2023; 20(2):499–507.
2.
BrayFN, SimmonsBJ, WolfsonAH, et al.Acute and chronic cutaneous reactions to ionizing radiation therapy. Dermatol Ther (Heidelb). 2016; 6(2):185–206.
3.
SalvoN, BarnesE, van DraanenJ, et al.Prophylaxis and management of acute radiation-induced skin reactions: A systematic review of the literature. Curr Oncol. 2010; 17(4):94–112.
4.
FisherJ, ScottC, StevensR, et al.Randomized phase III study comparing best supportive care to biafine as a prophylactic agent for radiation-induced skin toxicity for women undergoing breast irradiation: Radiation therapy oncology group (RTOG) 97-13. Int J Radiat Oncol Biol Phys. 2000; 48(5):1307–1310.
5.
RosenthalA, IsrailevichR, MoyR. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm. J Am Acad Dermatol. 2019; 81(2):558–567.
6.
LillaC, AmbrosoneCB, KroppS, et al.Predictive factors for late normal tissue complications following radiotherapy for breast cancer. Breast Cancer Res Treat. 2007; 106(1):143–150.
7.
SharpL, JohanssonH, HatschekT, et al.Smoking as an independent risk factor for severe skin reactions due to adjuvant radiotherapy for breast cancer. Breast. 2013; 22(5):634–638.
8.
VespriniD, DavidsonM, BosnicS, et al.Effect of supine vs prone breast radiotherapy on acute toxic effects of the skin among women with large breast size: A randomized clinical trial. JAMA Oncol. 2022; 8(7):994–1000.
9.
SutherlandAE, BennettNC, HerstPM. Psychological stress affects the severity of radiation-induced acute skin reactions in breast cancer patients. Eur J Cancer Care (Engl). 2017; 26(6).
10.
KozakKR, SmithBL, AdamsJ, et al.Accelerated partial-breast irradiation using proton beams: Initial clinical experience. Int J Radiat Oncol Biol Phys. 2006; 66(3):691–698.
11.
ArimuraT, OginoT, YoshiuraT, et al.Effect of film dressing on acute radiation dermatitis secondary to proton beam therapy. Int J Radiat Oncol Biol Phys. 2016; 95(1):472–476.
12.
SinghM, AlaviA, WongR, et al.Radiodermatitis: A review of our current understanding. Am J Clin Dermatol. 2016; 17(3):277–292.
13.
RzepeckiA, BirnbaumM, OhriN, et al.Characterizing the effects of radiation dermatitis on quality of life: A prospective survey-based study. J Am Acad Dermatol. 2022; 86(1):161–163.
14.
BeanesSR, DangC, SooC, et al.Skin repair and scar formation: The central role of TGF-beta. Expert Rev Mol Med. 2003; 5(8):1–22.
15.
FinkelsteinS, KaneeL, BehroozianT, et al.Comparison of clinical practice guidelines on radiation dermatitis: A narrative review. Support Care Cancer. 2022; 30(6):4663–4674.
16.
JP. Evidence based recommendations for the assessment and management of radiation-induced skin toxicities in breast cancer. In: Part 4. Management of acute radiation-induced skin toxicities. CancerCare Manitoba; 2018.
17.
BarnesL, KayaG, RollasonV. Topical corticosteroid-induced skin atrophy: A comprehensive review. Drug Saf. 2015; 38(5):493–509.
18.
ChanRJ, WebsterJ, ChungB, et al.Prevention and treatment of acute radiation-induced skin reactions: A systematic review and meta-analysis of randomized controlled trials. BMC Cancer. 2014; 14:53.
19.
DejonckheereCS, DejonckheereE, LayerJP, et al.Barrier films for the prevention of acute radiation dermatitis in breast cancer: A systematic review and meta-analysis of randomised controlled trials. Breast. 2023; 71:31–41.
20.
BehroozianT, BonomoP, PatelP, et al.; Multinational Association of Supportive Care in Cancer (MASCC) Oncodermatology Study Group Radiation Dermatitis Guidelines Working Group. Multinational association of supportive care in cancer (MASCC) clinical practice guidelines for the prevention and management of acute radiation dermatitis: International Delphi consensus-based recommendations. Lancet Oncol. 2023; 24(4):e172–e185.
21.
GosselinT, GinexPK, BacklerC, et al.ONS guidelines™ for cancer treatment-related radiodermatitis. Oncol Nurs Forum. 2020; 47(6):654–670.
22.
McQuestionM. Evidence-based skin care management in radiation therapy: Clinical update. Semin Oncol Nurs. 2011; 27(2):e1–e17.
23.
LeeYC, TsengHC, YangHF, et al.CSMed(®) wound dressing for prophylaxis and management of radiation dermatitis in breast and head-neck cancer patients: A single hospital prospective clinical trial. J Cancer Res Clin Oncol. 2024; 150(2):101.
24.
GarbuioDC, RibeiroVDS, HamamuraAC, et al.A chitosan-coated chamomile microparticles formulation to prevent radiodermatitis in breast: A double-blinded, controlled, randomized, phase II clinical trial. Am J Clin Oncol. 2022; 45(5):183–189.
25.
BehroozianT, MiltonL, KaramI, et al.Mepitel film for the prevention of acute radiation dermatitis in breast cancer: A randomized multicenter open-label phase III trial. J Clin Oncol. 2023; 41(6):1250–1264.
26.
HerstPM, BennettNC, SutherlandAE, et al.Prophylactic use of mepitel film prevents radiation-induced moist desquamation in an intra-patient randomised controlled clinical trial of 78 breast cancer patients. Radiother Oncol. 2014; 110(1):137–143.
27.
MøllerPK, OllingK, BergM, et al.Breast cancer patients report reduced sensitivity and pain using a barrier film during radiotherapy - A Danish intra-patient randomized multicentre study. Tech Innov Patient Support Radiat Oncol. 2018; 7:20–25.
28.
WoodingH, YanJ, YuanL, et al.The effect of mepitel film on acute radiation-induced skin reactions in head and neck cancer patients: A feasibility study. Br J Radiol. 2018; 91(1081):20170298.
29.
SchmeelLC, KochD, SchmeelFC, et al.Hydrofilm polyurethane films reduce radiation dermatitis severity in hypofractionated whole-breast irradiation: An objective, intra-patient randomized dual-center assessment. Polymers (Basel). 2019; 11(12):2112.
30.
SchmeelLC, KochD, StumpfS, et al.Prophylactically applied hydrofilm polyurethane film dressings reduce radiation dermatitis in adjuvant radiation therapy of breast cancer patients. Acta Oncol. 2018; 57(7):908–915.
31.
ChanRJ, BladesR, JonesL, et al.A single-blind, randomised controlled trial of StrataXRT® - A silicone-based film-forming gel dressing for prophylaxis and management of radiation dermatitis in patients with head and neck cancer. Radiother Oncol. 2019; 139:72–78.
32.
PerréardM, HeutteN, ClarisseB, et al.Head and neck cancer patients under radiotherapy undergoing skin application of hydrogel dressing or hyaluronic acid: Results from a prospective, randomized study. Support Care Cancer. 2023; 32(1):7.
33.
MacmillanMS, WellsM, MacBrideS, et al.Randomized comparison of dry dressings versus hydrogel in management of radiation-induced moist desquamation. Int J Radiat Oncol Biol Phys. 2007; 68(3):864–872.
34.
BazireL, FromantinI, DialloA, et al.Hydrosorb® versus control (water based spray) in the management of radio-induced skin toxicity: Results of multicentre controlled randomized trial. Radiother Oncol. 2015; 117(2):229–233.
35.
GrahamP, BrowneL, CappA, et al.Randomized, paired comparison of no-sting barrier film versus sorbolene cream (10% glycerine) skin care during postmastectomy irradiation. Int J Radiat Oncol Biol Phys. 2004; 58(1):241–246.
36.
LamAC, YuE, VanwynsbergheD, et al.Phase III randomized pair comparison of a barrier film vs. standard skin care in preventing radiation dermatitis in post-lumpectomy patients with breast cancer receiving adjuvant radiation therapy. Cureus. 2019; 11(6):e4807.
37.
ShawSZ, NienHH, WuCJ, et al.3M cavilon no-sting barrier film or topical corticosteroid (mometasone furoate) for protection against radiation dermatitis: A clinical trial. J Formos Med Assoc. 2015; 114(5):407–414.
38.
DiggelmannKV, ZytkoviczAE, TuaineJM, et al.Mepilex Lite dressings for the management of radiation-induced erythema: A systematic inpatient controlled clinical trial. Br J Radiol. 2010; 83(995):971–978.
39.
NiaziTM, VuongT, AzoulayL, et al.Silver clear nylon dressing is effective in preventing radiation-induced dermatitis in patients with lower gastrointestinal cancer: Results from a phase III study. Int J Radiat Oncol Biol Phys. 2012; 84(3):e305–e310.
40.
Aquino-ParsonsC, LomasS, SmithK, et al.Phase III study of silver leaf nylon dressing vs standard care for reduction of inframammary moist desquamation in patients undergoing adjuvant whole breast radiation therapy. J Med Imaging Radiat Sci. 2010; 41(4):215–221.
41.
VavassisP, GelinasM, Chabot TrJ, et al.Phase 2 study of silver leaf dressing for treatment of radiation-induced dermatitis in patients receiving radiotherapy to the head and neck. J Otolaryngol Head Neck Surg. 2008; 37(1):124–129.
42.
WinkfieldKM, HughesRT, BrownDR, et al.Randomized pilot study of a keratin-based topical cream for radiation dermatitis in breast cancer patients. Technol Cancer Res Treat. 2024; 23:15330338231222137.
43.
HughesRT, LevineBJ, FrizzellBA, et al.Keratin-based topical cream for radiation dermatitis during head and neck radiotherapy: A randomised, open-label pilot study. J Radiother Pract. 2024; 23:e11.
44.
PrestaG, PuliattiA, BonettiL, et al.Effectiveness of hyaluronic acid gel (Jalosome soothing gel) for the treatment of radiodermatitis in a patient receiving head and neck radiotherapy associated with cetuximab: A case report and review. Int Wound J. 2019; 16(6):1433–1439.
45.
CoxJD, StetzJ, PajakTF. Toxicity criteria of the radiation therapy oncology group (RTOG) and the European organization for research and treatment of cancer (EORTC). Int J Radiat Oncol Biol Phys. 1995; 31(5):1341–1346.
46.
DiCarloAL, BandremerAC, HollingsworthBA, et al.Cutaneous radiation injuries: Models, assessment and treatments. Radiat Res. 2020; 194(3):315–344.
47.
MüllerA, HennigA, LorscheidS, et al.IκBζ is a key transcriptional regulator of IL-36-driven psoriasis-related gene expression in keratinocytes. Proc Natl Acad Sci U S A. 2018; 115(40):10088–10093.
48.
TewaryG, FreyterB, Al-RazaqMA, et al.Immunomodulatory effects of histone variant H2A.J in ionizing radiation dermatitis. Int J Radiat Oncol Biol Phys. 2024; 118(3):801–816.
49.
HuangWY, LaiSF, ChiuHY, et al.Mobilizing transit-amplifying cell-derived ectopic progenitors prevents hair loss from chemotherapy or radiation therapy. Cancer Res. 2017; 77(22):6083–6096.
50.
PazdrowskiJ, Gornowicz-PorowskaJ, KaźmierskaJ, et al.Radiation-induced skin injury in the head and neck region: Pathogenesis, clinics, prevention, treatment considerations and proposal for management algorithm. Rep Pract Oncol Radiother. 2024; 29(3):373–390.
ZhongWH, TangQF, HuLY, et al.Mepilex lite dressings for managing acute radiation dermatitis in nasopharyngeal carcinoma patients: A systematic controlled clinical trial. Med Oncol. 2013; 30(4):761.
53.
WongHCY, LeeSF, CainiS, et al.Barrier films or dressings for the prevention of acute radiation dermatitis in breast cancer: A systematic review and network meta-analysis. Breast Cancer Res Treat. 2024; 207(3):477–496.
54.
AhnS, SungK, KimHJ, et al.Reducing radiation dermatitis using a film-forming silicone gel during breast radiotherapy: A pilot randomized-controlled trial. In Vivo. 2020; 34(1):413–422.
55.
ChaoMWT, SpencerS, KaiC, et al.StrataXRT is non inferior to mepitel Film in preventing radiation induced moist desquamation. Radiotherapy and Oncology. 2019; 133:S704–S705.
56.
Kennedy-EvansKL. An innovative solution for skin tears: A case study. Ostomy Wound Manage. 2004; 50(2):9–10.
57.
YinHQ, LangfordR, BurrellRE. Comparative evaluation of the antimicrobial activity of ACTICOAT antimicrobial barrier dressing. J Burn Care Rehabil. 1999; 20(3):195–200.
58.
HolderIA, DurkeeP, SuppAP, et al.Assessment of a silver-coated barrier dressing for potential use with skin grafts on excised burns. Burns. 2003; 29(5):445–448.
59.
WrightJB, LamK, BuretAG, et al.Early healing events in a porcine model of contaminated wounds: Effects of nanocrystalline silver on matrix metalloproteinases, cell apoptosis, and healing. Wound Repair Regen. 2002; 10(3):141–151.
60.
AggagME, YousefRT. Study of antimicrobial activity of chamomile oil. Planta Med. 1972; 22(2):140–144.
61.
ZhangM, ZhaoX. Alginate hydrogel dressings for advanced wound management. Int J Biol Macromol. 2020; 162:1414–1428.
62.
AhmedA, BoatengJ. Calcium alginate-based antimicrobial film dressings for potential healing of infected foot ulcers. Ther Deliv. 2018; 9(3):185–204.
63.
BonomoP, DesideriI, LoiM, et al.Management of severe bio-radiation dermatitis induced by radiotherapy and cetuximab in patients with head and neck cancer: Emphasizing the role of calcium alginate dressings. Support Care Cancer. 2019; 27(8):2957–2967.
64.
GaoF, LiW, KanJ, et al.Insight into the regulatory function of human hair keratins in wound healing using proteomics. Adv Biosyst. 2020; 4(6):e1900235.
65.
PorankiD, WhitenerW, HowseS, et al.Evaluation of skin regeneration after burns in vivo and rescue of cells after thermal stress in vitro following treatment with a keratin biomaterial. J Biomater Appl. 2014; 29(1):26–35.
66.
LiS, ChenL, YangZ, et al.The effect of sanyrene liquid dressing in preventing radiation dermatitis: A systematic review and meta-analysis. Adv Skin Wound Care. 2022; 35(11):1–8.
67.
KamounEA, KenawyES, ChenX. A review on polymeric hydrogel membranes for wound dressing applications: PVA-based hydrogel dressings. J Adv Res. 2017; 8(3):217–233.
68.
GutierrezAM, FrazarEM, X KlausMV, et al.Hydrogels and hydrogel nanocomposites: Enhancing healthcare through human and environmental treatment. Adv Healthc Mater. 2022; 11(7):e2101820.
69.
ZhaoH, HuangJ, LiY, et al.ROS-scavenging hydrogel to promote healing of bacteria infected diabetic wounds. Biomaterials. 2020; 258:120286.
70.
XieJ, WangC, WangN, et al.Graphdiyne nanoradioprotector with efficient free radical scavenging ability for mitigating radiation-induced gastrointestinal tract damage. Biomaterials. 2020; 244:119940.
71.
GuoJ, SunW, KimJP, et al.Development of tannin-inspired antimicrobial bioadhesives. Acta Biomater. 2018; 72:35–44.
72.
GriceEA, SnitkinES, YockeyLJ, et al.; NISC Comparative Sequencing Program. Longitudinal shift in diabetic wound microbiota correlates with prolonged skin defense response. Proc Natl Acad Sci U S A. 2010; 107(33):14799–14804.
73.
ZhangJ, ZhuY, ZhangY, et al.A balanced charged hydrogel with anti-biofouling and antioxidant properties for treatment of irradiation-induced skin injury. Mater Sci Eng C Mater Biol Appl. 2021; 131:112538.
74.
HaoJ, SunM, LiD, et al.An IFI6-based hydrogel promotes the healing of radiation-induced skin injury through regulation of the HSF1 activity. J Nanobiotechnology. 2022; 20(1):288.
75.
FengZ, ZhangY, YangC, et al.Bioinspired and inflammation-modulatory glycopeptide hydrogels for radiation-induced chronic skin injury repair. Adv Healthc Mater. 2023; 12(1):e2201671.
76.
ShenJ, JiaoW, YangJ, et al.In situ photocrosslinkable hydrogel treats radiation-induced skin injury by ROS elimination and inflammation regulation. Biomaterials. 2025; 314:122891.
77.
ZhangZ, XiaY, LiX, et al.Arginine-solubilized lipoic acid-induced β-sheets of silk fibroin-strengthened hydrogel for postoperative rehabilitation of breast cancer. Bioact Mater. 2024; 40:667–682.
78.
ChitaleS, RichlyH. DICER and ZRF1 contribute to chromatin decondensation during nucleotide excision repair. Nucleic Acids Res. 2017; 45(10):5901–5912.
79.
GuoJ, ZhangX, MaoR, et al.Multifunctional glycopeptide-based hydrogel via dual-modulation for the prevention and repair of radiation-induced skin injury. ACS Biomater Sci Eng. 2024; 10(8):5168–5180.
80.
HuangC, HuangfuC, BaiZ, et al.Multifunctional carbomer based ferulic acid hydrogel promotes wound healing in radiation-induced skin injury by inactivating NLRP3 inflammasome. J Nanobiotechnology. 2024; 22(1):576.
81.
FahimiradS, AbtahiH, SateiP, et al.Wound healing performance of PCL/chitosan based electrospun nanofiber electrosprayed with curcumin loaded chitosan nanoparticles. Carbohydr Polym. 2021; 259:117640.
82.
PapadimitriouA, KetikidisI, StathopoulouMK, et al.Innovative material containing the natural product curcumin, with enhanced antimicrobial properties for active packaging. Mater Sci Eng C Mater Biol Appl. 2018; 84:118–122.
83.
LiuX, GuoT, HuangZ, et al.Acellular dermal matrix hydrogels promote healing of radiation-induced skin injury in a rat model. J Mater Chem B. 2024; 12(43):11218–11229.
84.
HaoY, LiH, GuoJ, et al.Bio-inspired antioxidant heparin-mimetic peptide hydrogel for radiation-induced skin injury repair. Adv Healthc Mater. 2023; 12(20):e2203387.
85.
LuoX, LiuH, WenJ, et al.Composite hydrogels with antioxidant and robust adhesive properties for the prevention of radiation-induced dermatitis. J Mater Chem B. 2024; 12(28):6927–6939.
86.
FrankS, KämpferH, WetzlerC, et al.Nitric oxide drives skin repair: Novel functions of an established mediator. Kidney Int. 2002; 61(3):882–888.
87.
StallmeyerB, KämpferH, KolbN, et al.The function of nitric oxide in wound repair: Inhibition of inducible nitric oxide-synthase severely impairs wound reepithelialization. J Invest Dermatol. 1999; 113(6):1090–1098.
88.
LeeHR, LeeHY, HeoJ, et al.Liquid-type nonthermal atmospheric plasma enhanced regenerative potential of silk-fibrin composite gel in radiation-induced wound failure. Mater Sci Eng C Mater Biol Appl. 2021; 128:112304.
89.
GürsoyK, OruçM, KankayaY, et al.Effect of topically applied sildenafil citrate on wound healing: Experimental study. Bosn J Basic Med Sci. 2014; 14(3):125–131.
90.
KulshresthaS, ChawlaR, SinghS, et al.Protection of sildenafil citrate hydrogel against radiation-induced skin wounds. Burns. 2020; 46(5):1157–1169.
91.
XuG, ZhangL, RenG, et al.Immunosuppressive properties of cloned bone marrow mesenchymal stem cells. Cell Res. 2007; 17(3):240–248.
92.
RustadKC, WongVW, SorkinM, et al.Enhancement of mesenchymal stem cell angiogenic capacity and stemness by a biomimetic hydrogel scaffold. Biomaterials. 2012; 33(1):80–90.
93.
MaziniL, RochetteL, AdmouB, et al.Hopes and limits of adipose-derived stem cells (ADSCs) and mesenchymal stem cells (MSCs) in wound healing. Int J Mol Sci. 2020; 21(4):1306.
94.
NieS, RenC, LiangX, et al.Supramolecular hydrogel-wrapped gingival mesenchymal stem cells in cutaneous radiation injury. Cells. 2022; 11(19):3089.
95.
YaoWD, ZhouJN, TangC, et al.Hydrogel microneedle patches loaded with stem cell mitochondria-enriched microvesicles boost the chronic wound healing. ACS Nano. 2024; 18(39):26733–26750.
96.
WangH, MuG, CaiX, et al.Glucopeptide superstructure hydrogel promotes surgical wound healing following neoadjuvant radiotherapy by producing NO and anticellular senescence. Adv Healthc Mater. 2024; 13(20):e2400406.
97.
KahkeshaniN, FarzaeiF, FotouhiM, et al.Pharmacological effects of gallic acid in health and diseases: A mechanistic review. Iran J Basic Med Sci. Mar., 2019; 22(3):225–237.
98.
KumarKJ, VaniMG, WangSY, et al.In vitro and in vivo studies disclosed the depigmenting effects of gallic acid: A novel skin lightening agent for hyperpigmentary skin diseases. Biofactors. 2013; 39(3):259–270.
99.
ZhangZ, CaoQ, XiaY, et al.Combination of biodegradable hydrogel and antioxidant bioadhesive for treatment of breast cancer recurrence and radiation skin injury. Bioact Mater. 2024; 31:408–421.
100.
YuD, LiS, WangS, et al.Development and characterization of VEGF165-chitosan nanoparticles for the treatment of radiation-induced skin injury in rats. Mar Drugs. 2016; 14(10):182.
101.
KakabadzeZ, ChakhunashviliD, GogilashviliK, et al.Bone marrow stem cell and decellularized human amniotic membrane for the treatment of nonhealing wound after radiation therapy. Exp Clin Transplant. 2019; 17(Suppl 1):92–98.
102.
LiangY, HeJ, GuoB. Functional hydrogels as wound dressing to enhance wound healing. ACS Nano. 2021; 15(8):12687–12722.
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