The Use of an Innovative Film-Forming Wound Dressing in the Treatment of Radiation Dermatitis during Concomitant Chemotherapy

There is currently no consensus regarding the management of acute cutaneous reactions emerging from a concurrent treatment of radio-and chemotherapy, the goal of this case study series is to provide scientific evidence based on clinical practice regarding the efficacy of a film-forming wound dressing for patients receiving combined cancer therapy, in particular examples where the reactions are expected to be intense. In all the described cases, management of acute skin reactions allowed the cancer therapy to be finalized, instead of being interrupted due to an increase in the severity of the reactions. It has been shown in the current literature that the lack of compliance with treatment plans correlates with poorer clinical outcome. Evidence from the cases presented suggest that the studied dressing is safe and efficacious in the treatment and the prevention of acute cutaneous reactions arising from combined cancer therapy.


Introduction
Radiation dermatitis is one of the most common side effects of radiotherapy (RT) that affects up to 95% patients receiving treatment.Generally, radiation acute skin reaction scan arise shortly after the start of radiation therapy (from 2 to 4 weeks); this can vary depending on the magnitude of the administered radiation and its severity intensifies over time, directly associated to the accruing radiation on the tissues [1] [2].
There are several described risk factors that contribute to the exacerbation of skin reactions.Among these, concomitant treatment with chemotherapeutic agents is known to deteriorate skin conditions.Some medications have been well described to sensitize patients to radiation.Adjuvant chemotherapy is therefore accepted to substantially increase the risk to develop severe skin inju- As there is currently no consensus regarding the management of acute cutaneous reactions emerging from a concurrent treatment of radio-and chemotherapy, the goal of this case study series is to provide scientific evidence based on clinical practice regarding the efficacy of an innovative film-forming wound dressing for patients receiving combined cancer therapy, in particular examples where the reactions are expected to be intense.

Methods
This study was designed as a case study series to explore the use of an innovative film-forming wound dressing (StrataXRT®-Stratpharma AG, Switzerland) in an experimental setting using a variety of methods to obtain more in-depth knowledge about the use of this technology in the treatment of radiation dermatitis during concomitant chemotherapy.This medical device is already being used in the clinic (IMQ Zorrotzaurre in Bilbao, Spain) for treating patients that develop a significant erythema (degree II+), pruritos and/or desquamation and usually if they still had 20% -50% of the RT plan to be completed, but there is a lack of knowledge in its efficacy for patients receiving concomitant chemotherapy.
As the boundaries between the evolution of radiation dermatitis and context of RT and chemotherapy are not clearly evident and it was presumed that there would be more variables of interest than data points, this study was designed to reflect a qualitative investigation of different types of cancer locations.The data was captured using interviews, questionnaires and observations by the experienced oncology nursing team.All patients were enrolled and consented in the RT nursery consultation that is performed on a weekly basis to all patients receiving RT.
All participating patients were assessed on a weekly basis and up to 2 weeks after RT finalization by the same investigator to monitor improvement or record any adverse event.

Results
5 patients were prospectively recruited for this case study.No adverse events related to the studied product was noted throughout the investigation.Clinical and demographical features are summarized in Table 1.
Case 1: An innovative wound dressing for acutecutaneous reactions to concomitant radio-and chemotherapy for tongue base cancer A 50-year old man diagnosed with epidermoid tongue base cancer with an extension to the tonsillar pillar was treated with a first line of adjuvant chemotherapy (3 cycles of Taxol-Cisplatin-5FU) followed by a second line of  Antibiotic treatment was therefore added.
21 days after wound dressing treatment start (31 RT sessions) a decreased erythema was present, with dry desquamation and signs of epidermal regeneration (Figure 1(c)).The patient also reported an improvement with regards to pruritus.It is critical to mention how overall cutaneous symptoms improved at this stage of radiotherapy, as we expect from our clinical experience that the signs of RD worsen with incremental doses.The film-forming wound dressing had been used in monotherapy and we consider it the reason for improvement.
The patient was then assessed 5 days after the end of RT (28 days from the start of topical treatment with the wound dressing).Dry desquamation in the neck area was considerably improved, although a section of the treated area presented a minor oozing.After 21 days from the start of topical treatment (corresponding to RT session 30) the patient was presenting a mild erythema with a minor dry desquamation in the irradiated area (Figure 3(d)).Treatment with the film-forming wound dressing was continued for 2 more days, after which the patient was followed up in an outpatient (dermatology) setting.
How to cite this paper: Villandiego, I.A. and Aramberri, S.G. (2018) The Use of an Innovative Film-Forming Wound Dressing in the Treatment of Radiation Dermatitis during Concomitant Chemotherapy.Journal of Cancer Therapy, 9, 1048-1056.https://doi.org/10.4236/jct.2018.912086I. A. Villandiego, S. G. Aramberri DOI: 10.4236/jct.2018.9120861049 Journal of Cancer Therapy chemotherapy (weekly Taxol-Carboplatin) and RT, consisting of VMAT radiation in the tongue base with a total dose of 70 Gy in 33 fractions, corresponding to 2.1 Gy/fraction.After 18 sessions of RT the patient started showing signs of dry desquamation and an intense erythema in the neck area coupled with intense itching.Twicedaily treatment with the innovative film-forming wound dressing was started at this time point.After 7 days from topical treatment start (23 RT sessions), nursing consultation was carried out to confirm a persistent erythema and a lower degree of pruritus (Figure1(a)).No progression to more severe cutaneous toxicity was assessed.14days after treatment start with the wound dressing (27 RT sessions) erythema in the neck area did not worsen from the previous assessment, however suppuration areas on the left side of the neck and chin emerged (Figure1(b)).

Figure 1 .Case 2 :Case 3 :
Figure 1.Radiation dermatitis evolution 7 days after wound dressing application and 23 RT sessions (a); 14 days after product application and 27 RT sessions (b); 21 days after product application and 31 RT sessions (c); and 35 days after wound dressing application and 12 days after RT finalization (d).

Figure 2 .
Figure 2. Radiation dermatitis at start with wound dressing application and end of RT (a); wound evolution at 8 days of product application (b) and 15 days of product application (c).

Case 4 :
Treatment of radiation dermatitis in patient undergoing concomitant radio-and chemotherapy for tongue base cancer A 58-year old patient diagnosed with tongue base carcinoma, was treated with surgery and chemotherapy (7 cycles of weekly Carboplatin) and concomitant VMAT RT in the tongue base with a total dose of 70 Gy divided in 35 fractions.After 21 RT sessions the patient underwent nurse consultation with an intense erythema and patchy moist desquamation on the right side of the neck (Figure 4(a)).Twice daily treatment with the innovative wound dressing was therefore initiated.10 days later (RT session 31) the overall cutaneous conditions were substantially improved, presenting a minor erythema coupled to an extended desquamation (Figure 4(b)).The same topical treatment regimen was continued.

Figure 3 .
Figure 3. Radiation dermatitis at start with wound dressing application and after 17 RT sessions (a); wound evolution 7 days after product application and 22 RT sessions (b); 14 days after product application and 26 RT sessions (c) and 21 days after product application and 30 RT sessions (d).

Figure 4 .Case 5 :
Figure 4. Radiation dermatitis at start with wound dressing application and after 21 RT sessions (a); wound evolution 10 days after product application and 31 RT sessions (b); and 18 days after product application and 4 days after RT finalization (c).

Figure 5 .
Figure 5. Evolution of cutaneous reactions in the pubic area at treatment start with the wound dressing and after 23 RT sessions (a); 18 days after product application and 2 days from RT finalization (b) and 24 days after product application and 9 days from RT finalization (c).

Figure 6 .
Figure 6.Evolution of cutaneous reactions in the perianal area after 3 days applying the wound dressing and after 24 RT sessions (a), 10 days after product application and 26 RT sessions (b) and 24 days of topical treatment and 9 days from RT finalization (c).

Table 1 .
Clinical and demographic characteristics of the study participants.