Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Radiation dermatitis

Julie L Ryan Wolf, PhD, MPH
Marilyn Ling, MD
Section Editor
Joseph Fowler, MD
Deputy Editor
Rosamaria Corona, MD, DSc


Radiation dermatitis is one of the most common side effects of radiotherapy for cancer, affecting approximately 95 percent of patients receiving radiotherapy [1-5]. Cutaneous adverse effects of radiation therapy can be divided into early/acute reactions, occurring within 90 days of initiating treatment, and late effects, which often become apparent months to years after radiation treatment has been completed (table 1).

Acute injury, which occurs within hours to weeks after radiation exposure, results from immediate structural tissue damage, generation of short-lived free radicals, irreversible double-stranded breaks in nuclear and mitochondrial DNA, and initiation of an inflammatory response in the epidermis and dermis [6-8]. Repeated exposure to low-dose ionizing radiation does not allow time for cells to repair DNA or tissue damage. The accumulation of radiation-induced changes to dermal vasculature, appendageal structures, and epidermal stem cells results in the progression of radiation dermatitis through characteristic stages of severity (picture 1).

Radiation dermatitis has a profound impact on the quality of a patient's life, due to pain and discomfort. In addition, it may be the cause of premature interruption of radiation therapy, resulting in inadequate disease treatment [9-11].

This topic will discuss the pathogenesis, clinical manifestations, and treatment of radiation dermatitis. The complications of breast and chest wall irradiation and radiation-induced fibrosis are discussed separately. (See "Clinical manifestations, prevention, and treatment of radiation-induced fibrosis" and "Patterns of relapse and long-term complications of therapy in breast cancer survivors", section on 'Chest wall and breast complications'.)


Incidence — Radiation dermatitis occurs in approximately 95 percent of patients receiving radiotherapy, especially patients with breast cancer, head and neck cancer, lung cancer, or sarcoma [1,6,7,12]. The reason for the higher incidence in these cancer patient populations is due to a higher radiation dose to the skin. In most cases, the skin reaction is mild or moderate (table 2). Approximately 20 to 25 percent of patients experience moist desquamation and ulceration [13].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: May 09, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Hickok JT, Morrow GR, Roscoe JA, et al. Occurrence, severity, and longitudinal course of twelve common symptoms in 1129 consecutive patients during radiotherapy for cancer. J Pain Symptom Manage 2005; 30:433.
  2. Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol 2006; 54:28.
  3. Brown KR, Rzucidlo E. Acute and chronic radiation injury. J Vasc Surg 2011; 53:15S.
  4. Bray FN, Simmons BJ, Wolfson AH, Nouri K. Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy. Dermatol Ther (Heidelb) 2016; 6:185.
  5. Singh M, Alavi A, Wong R, Akita S. Radiodermatitis: A Review of Our Current Understanding. Am J Clin Dermatol 2016; 17:277.
  6. McQuestion M. Evidence-based skin care management in radiation therapy: clinical update. Semin Oncol Nurs 2011; 27:e1.
  7. Salvo N, Barnes E, van Draanen J, et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Curr Oncol 2010; 17:94.
  8. Ryan JL. Ionizing radiation: the good, the bad, and the ugly. J Invest Dermatol 2012; 132:985.
  9. Duncan W, MacDougall RH, Kerr GR, Downing D. Adverse effect of treatment gaps in the outcome of radiotherapy for laryngeal cancer. Radiother Oncol 1996; 41:203.
  10. Robertson C, Robertson AG, Hendry JH, et al. Similar decreases in local tumor control are calculated for treatment protraction and for interruptions in the radiotherapy of carcinoma of the larynx in four centers. Int J Radiat Oncol Biol Phys 1998; 40:319.
  11. Isomura M, Oya N, Tachiiri S, et al. IL12RB2 and ABCA1 genes are associated with susceptibility to radiation dermatitis. Clin Cancer Res 2008; 14:6683.
  12. Archambeau JO, Pezner R, Wasserman T. Pathophysiology of irradiated skin and breast. Int J Radiat Oncol Biol Phys 1995; 31:1171.
  13. Bernier J, Bonner J, Vermorken JB, et al. Consensus guidelines for the management of radiation dermatitis and coexisting acne-like rash in patients receiving radiotherapy plus EGFR inhibitors for the treatment of squamous cell carcinoma of the head and neck. Ann Oncol 2008; 19:142.
  14. Delfino S, Brunetti B, Toto V, Persichetti P. Burn after breast reconstruction. Burns 2008; 34:873.
  15. Vandeweyer E, Deraemaecker R. Radiation therapy after immediate breast reconstruction with implants. Plast Reconstr Surg 2000; 106:56.
  16. Meyer F, Fortin A, Wang CS, et al. Predictors of severe acute and late toxicities in patients with localized head-and-neck cancer treated with radiation therapy. Int J Radiat Oncol Biol Phys 2012; 82:1454.
  17. Lin A, Abu-Isa E, Griffith KA, Ben-Josef E. Toxicity of radiotherapy in patients with collagen vascular disease. Cancer 2008; 113:648.
  18. Giaj-Levra N, Sciascia S, Fiorentino A, et al. Radiotherapy in patients with connective tissue diseases. Lancet Oncol 2016; 17:e109.
  19. Gold DG, Miller RC, Pinn ME, et al. Chronic toxicity risk after radiotherapy for patients with systemic sclerosis (systemic scleroderma) or systemic lupus erythematosus: association with connective tissue disorder severity. Radiother Oncol 2008; 87:127.
  20. Gold DG, Miller RC, Petersen IA, Osborn TG. Radiotherapy for malignancy in patients with scleroderma: The Mayo Clinic experience. Int J Radiat Oncol Biol Phys 2007; 67:559.
  21. Tejwani A, Wu S, Jia Y, et al. Increased risk of high-grade dermatologic toxicities with radiation plus epidermal growth factor receptor inhibitor therapy. Cancer 2009; 115:1286.
  22. Shaitelman SF, Schlembach PJ, Arzu I, et al. Acute and Short-term Toxic Effects of Conventionally Fractionated vs Hypofractionated Whole-Breast Irradiation: A Randomized Clinical Trial. JAMA Oncol 2015; 1:931.
  23. Jagsi R, Griffith KA, Boike TP, et al. Differences in the Acute Toxic Effects of Breast Radiotherapy by Fractionation Schedule: Comparative Analysis of Physician-Assessed and Patient-Reported Outcomes in a Large Multicenter Cohort. JAMA Oncol 2015; 1:918.
  24. Mendelsohn FA, Divino CM, Reis ED, Kerstein MD. Wound care after radiation therapy. Adv Skin Wound Care 2002; 15:216.
  25. Shakhov AN, Singh VK, Bone F, et al. Prevention and mitigation of acute radiation syndrome in mice by synthetic lipopeptide agonists of Toll-like receptor 2 (TLR2). PLoS One 2012; 7:e33044.
  26. López E, Guerrero R, Núñez MI, et al. Early and late skin reactions to radiotherapy for breast cancer and their correlation with radiation-induced DNA damage in lymphocytes. Breast Cancer Res 2005; 7:R690.
  27. McBride WH, Chiang CS, Olson JL, et al. A sense of danger from radiation. Radiat Res 2004; 162:1.
  28. Williams JP, McBride WH. After the bomb drops: a new look at radiation-induced multiple organ dysfunction syndrome (MODS). Int J Radiat Biol 2011; 87:851.
  29. Holler V, Buard V, Gaugler MH, et al. Pravastatin limits radiation-induced vascular dysfunction in the skin. J Invest Dermatol 2009; 129:1280.
  30. Müller K, Meineke V. Radiation-induced alterations in cytokine production by skin cells. Exp Hematol 2007; 35:96.
  31. Müller K, Meineke V. Radiation-induced mast cell mediators differentially modulate chemokine release from dermal fibroblasts. J Dermatol Sci 2011; 61:199.
  32. Yuan H, Goetz DJ, Gaber MW, et al. Radiation-induced up-regulation of adhesion molecules in brain microvasculature and their modulation by dexamethasone. Radiat Res 2005; 163:544.
  33. Okunieff P, Xu J, Hu D, et al. Curcumin protects against radiation-induced acute and chronic cutaneous toxicity in mice and decreases mRNA expression of inflammatory and fibrogenic cytokines. Int J Radiat Oncol Biol Phys 2006; 65:890.
  34. Xiao Z, Su Y, Yang S, et al. Protective effect of esculentoside A on radiation-induced dermatitis and fibrosis. Int J Radiat Oncol Biol Phys 2006; 65:882.
  35. Benderitter M, Isoir M, Buard V, et al. Collapse of skin antioxidant status during the subacute period of cutaneous radiation syndrome: a case report. Radiat Res 2007; 167:43.
  36. Martin M, Lefaix J, Delanian S. TGF-beta1 and radiation fibrosis: a master switch and a specific therapeutic target? Int J Radiat Oncol Biol Phys 2000; 47:277.
  37. Pohlers D, Brenmoehl J, Löffler I, et al. TGF-beta and fibrosis in different organs - molecular pathway imprints. Biochim Biophys Acta 2009; 1792:746.
  38. Jensen JM, Gau T, Schultze J, et al. Treatment of acute radiodermatitis with an oil-in-water emulsion following radiation therapy for breast cancer: a controlled, randomized trial. Strahlenther Onkol 2011; 187:378.
  39. Schmuth M, Sztankay A, Weinlich G, et al. Permeability barrier function of skin exposed to ionizing radiation. Arch Dermatol 2001; 137:1019.
  40. Cox JD, Stetz J, Pajak TF. 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; 31:1341.
  41. Benderitter M, Gourmelon P, Bey E, et al. New emerging concepts in the medical management of local radiation injury. Health Phys 2010; 98:851.
  42. González Sanchis A, Brualla González L, Sánchez Carazo JL, et al. Evaluation of acute skin toxicity in breast radiotherapy with a new quantitative approach. Radiother Oncol 2017; 122:54.
  43. Zenda S, Ota Y, Tachibana H, et al. A prospective picture collection study for a grading atlas of radiation dermatitis for clinical trials in head-and-neck cancer patients. J Radiat Res 2016; 57:301.
  44. Hill A, Hanson M, Bogle MA, Duvic M. Severe radiation dermatitis is related to Staphylococcus aureus. Am J Clin Oncol 2004; 27:361.
  45. Junkins-Hopkin JM. Disorders associated with physical agents: heath, cold, radiation, and trauma. In: Lever's Histopathology of the Skin, 10th Edition, Elder DE, Elenitsas R, Johnson B, Murphy G, Xu G (Eds), Wolters Kluwer-Lippincott Williams & Wilkins, 2009.
  46. Casamiquela KM, Cohen PR. Radiation port dermatophytosis: tinea corporis occurring at the site of irradiated skin. Dermatol Online J 2012; 18:5.
  47. Rosen T, Dupuy J, Maor M, Altman A. Radiation port dermatophytosis. J Am Acad Dermatol 1988; 19:1053.
  48. Wong RK, Bensadoun RJ, Boers-Doets CB, et al. Clinical practice guidelines for the prevention and treatment of acute and late radiation reactions from the MASCC Skin Toxicity Study Group. Support Care Cancer 2013; 21:2933.
  49. Chan RJ, Webster J, Chung B, 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.
  50. Campbell IR, Illingworth MH. Can patients wash during radiotherapy to the breast or chest wall? A randomized controlled trial. Clin Oncol (R Coll Radiol) 1992; 4:78.
  51. Roy I, Fortin A, Larochelle M. The impact of skin washing with water and soap during breast irradiation: a randomized study. Radiother Oncol 2001; 58:333.
  52. Lewis L, Carson S, Bydder S, et al. Evaluating the effects of aluminum-containing and non-aluminum containing deodorants on axillary skin toxicity during radiation therapy for breast cancer: a 3-armed randomized controlled trial. Int J Radiat Oncol Biol Phys 2014; 90:765.
  53. Ulff E, Maroti M, Serup J, et al. Prophylactic treatment with a potent corticosteroid cream ameliorates radiodermatitis, independent of radiation schedule: A randomized double blinded study. Radiother Oncol 2017; 122:50.
  54. Miller RC, Schwartz DJ, Sloan JA, et al. Mometasone furoate effect on acute skin toxicity in breast cancer patients receiving radiotherapy: a phase III double-blind, randomized trial from the North Central Cancer Treatment Group N06C4. Int J Radiat Oncol Biol Phys 2011; 79:1460.
  55. Hindley A, Zain Z, Wood L, et al. Mometasone furoate cream reduces acute radiation dermatitis in patients receiving breast radiation therapy: results of a randomized trial. Int J Radiat Oncol Biol Phys 2014; 90:748.
  56. Elliott EA, Wright JR, Swann RS, et al. Phase III Trial of an emulsion containing trolamine for the prevention of radiation dermatitis in patients with advanced squamous cell carcinoma of the head and neck: results of Radiation Therapy Oncology Group Trial 99-13. J Clin Oncol 2006; 24:2092.
  57. Pommier P, Gomez F, Sunyach MP, et al. Phase III randomized trial of Calendula officinalis compared with trolamine for the prevention of acute dermatitis during irradiation for breast cancer. J Clin Oncol 2004; 22:1447.
  58. Heggie S, Bryant GP, Tripcony L, et al. A Phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nurs 2002; 25:442.
  59. Sharp L, Finnilä K, Johansson H, et al. No differences between Calendula cream and aqueous cream in the prevention of acute radiation skin reactions--results from a randomised blinded trial. Eur J Oncol Nurs 2013; 17:429.
  60. Richardson J, Smith JE, McIntyre M, et al. Aloe vera for preventing radiation-induced skin reactions: a systematic literature review. Clin Oncol (R Coll Radiol) 2005; 17:478.
  61. Wells M, Macmillan M, Raab G, et al. Does aqueous or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomised controlled trial. Radiother Oncol 2004; 73:153.
  62. Hoopfer D, Holloway C, Gabos Z, et al. Three-Arm Randomized Phase III Trial: Quality Aloe and Placebo Cream Versus Powder as Skin Treatment During Breast Cancer Radiation Therapy. Clin Breast Cancer 2015; 15:181.
  63. Pinnix C, Perkins GH, Strom EA, et al. Topical hyaluronic acid vs. standard of care for the prevention of radiation dermatitis after adjuvant radiotherapy for breast cancer: single-blind randomized phase III clinical trial. Int J Radiat Oncol Biol Phys 2012; 83:1089.
  64. Hemati S, Asnaashari O, Sarvizadeh M, et al. Topical silver sulfadiazine for the prevention of acute dermatitis during irradiation for breast cancer. Support Care Cancer 2012; 20:1613.
  65. Chan RJ, Mann J, Tripcony L, et al. Natural oil-based emulsion containing allantoin versus aqueous cream for managing radiation-induced skin reactions in patients with cancer: a phase 3, double-blind, randomized, controlled trial. Int J Radiat Oncol Biol Phys 2014; 90:756.
  66. Kaul R, Mishra BK, Sutradar P, et al. The role of Wobe-Mugos in reducing acute sequele of radiation in head and neck cancers--a clinical phase-III randomized trial. Indian J Cancer 1999; 36:141.
  67. Aygenc E, Celikkanat S, Kaymakci M, et al. Prophylactic effect of pentoxifylline on radiotherapy complications: a clinical study. Otolaryngol Head Neck Surg 2004; 130:351.
  68. Lin LC, Que J, Lin LK, Lin FC. Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: a double-blind, randomized study. Int J Radiat Oncol Biol Phys 2006; 65:745.
  69. Lievens Y, Haustermans K, Van den Weyngaert D, et al. Does sucralfate reduce the acute side-effects in head and neck cancer treated with radiotherapy? A double-blind randomized trial. Radiother Oncol 1998; 47:149.
  70. Ryan JL, Heckler CE, Ling M, et al. Curcumin for radiation dermatitis: a randomized, double-blind, placebo-controlled clinical trial of thirty breast cancer patients. Radiat Res 2013; 180:34.
  71. Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol 2008; 26:2085.
  72. Bazire L, Fromantin I, Diallo A, 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; 117:229.
  73. WINTER GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature 1962; 193:293.
  74. Macmillan MS, Wells M, MacBride S, et al. Randomized comparison of dry dressings versus hydrogel in management of radiation-induced moist desquamation. Int J Radiat Oncol Biol Phys 2007; 68:864.
  75. Gollins S, Gaffney C, Slade S, Swindell R. RCT on gentian violet versus a hydrogel dressing for radiotherapy-induced moist skin desquamation. J Wound Care 2008; 17:268.
  76. Mak SS, Molassiotis A, Wan WM, et al. The effects of hydrocolloid dressing and gentian violet on radiation-induced moist desquamation wound healing. Cancer Nurs 2000; 23:220.
  77. Anscher MS. Targeting the TGF-beta1 pathway to prevent normal tissue injury after cancer therapy. Oncologist 2010; 15:350.
  78. Lee JW, Tutela JP, Zoumalan RA, et al. Inhibition of Smad3 expression in radiation-induced fibrosis using a novel method for topical transcutaneous gene therapy. Arch Otolaryngol Head Neck Surg 2010; 136:714.
  79. Rosenthal RA, Fish B, Hill RP, et al. Salen Mn complexes mitigate radiation injury in normal tissues. Anticancer Agents Med Chem 2011; 11:359.
  80. Cummings RJ, Mitra S, Foster TH, Lord EM. Migration of skin dendritic cells in response to ionizing radiation exposure. Radiat Res 2009; 171:687.
  81. Gudkov AV, Komarova EA. Radioprotection: smart games with death. J Clin Invest 2010; 120:2270.
  82. Bey E, Prat M, Duhamel P, et al. Emerging therapy for improving wound repair of severe radiation burns using local bone marrow-derived stem cell administrations. Wound Repair Regen 2010; 18:50.
  83. Lataillade JJ, Doucet C, Bey E, et al. New approach to radiation burn treatment by dosimetry-guided surgery combined with autologous mesenchymal stem cell therapy. Regen Med 2007; 2:785.
  84. Waghmare CM. Radiation burn--from mechanism to management. Burns 2013; 39:212.
  85. Wolbarst AB, Wiley AL Jr, Nemhauser JB, et al. Medical response to a major radiologic emergency: a primer for medical and public health practitioners. Radiology 2010; 254:660.
  86. Burris HA 3rd, Hurtig J. Radiation recall with anticancer agents. Oncologist 2010; 15:1227.
  87. Kodym E, Kalinska R, Ehringfeld C, et al. Frequency of radiation recall dermatitis in adult cancer patients. Onkologie 2005; 28:18.
  88. Boussemart L, Boivin C, Claveau J, et al. Vemurafenib and radiosensitization. JAMA Dermatol 2013; 149:855.
  89. Levy A, Hollebecque A, Bourgier C, et al. Targeted therapy-induced radiation recall. Eur J Cancer 2013; 49:1662.
  90. Forschner A, Zips D, Schraml C, et al. Radiation recall dermatitis and radiation pneumonitis during treatment with vemurafenib. Melanoma Res 2014; 24:512.
  91. Anker CJ, Grossmann KF, Atkins MB, et al. Avoiding Severe Toxicity From Combined BRAF Inhibitor and Radiation Treatment: Consensus Guidelines from the Eastern Cooperative Oncology Group (ECOG). Int J Radiat Oncol Biol Phys 2016; 95:632.
  92. Korman AM, Tyler KH, Kaffenberger BH. Radiation recall dermatitis associated with nivolumab for metastatic malignant melanoma. Int J Dermatol 2017; 56:e75.
  93. Wei KC, Yang KC, Mar GY, et al. STROBE--Radiation Ulcer: An Overlooked Complication of Fluoroscopic Intervention: A Cross-Sectional Study. Medicine (Baltimore) 2015; 94:e2178.
  94. Hivnor CM, Seykora JT, Junkins-Hopkins J, et al. Subacute radiation dermatitis. Am J Dermatopathol 2004; 26:210.
  95. LeBoit PE. Subacute radiation dermatitis: a histologic imitator of acute cutaneous graft-versus-host disease. J Am Acad Dermatol 1989; 20:236.
  96. Stone MS, Robson KJ, LeBoit PE. Subacute radiation dermatitis from fluoroscopy during coronary artery stenting: evidence for cytotoxic lymphocyte mediated apoptosis. J Am Acad Dermatol 1998; 38:333.
  97. Bridges BA, Adam A, Holt D, et al. High dose radiation effects and tissue injury: Report of the independent advisory group on ionizing radiation. In: Radiation, Chemical, and Environmental Hazards, Elsevier, Chilton 2009. Vol RCE-10, p.1.
  98. Magnusson M, Höglund P, Johansson K, et al. Pentoxifylline and vitamin E treatment for prevention of radiation-induced side-effects in women with breast cancer: a phase two, double-blind, placebo-controlled randomised clinical trial (Ptx-5). Eur J Cancer 2009; 45:2488.
  99. Jacobson G, Bhatia S, Smith BJ, et al. Randomized trial of pentoxifylline and vitamin E vs standard follow-up after breast irradiation to prevent breast fibrosis, evaluated by tissue compliance meter. Int J Radiat Oncol Biol Phys 2013; 85:604.
  100. Delanian S, Porcher R, Rudant J, Lefaix JL. Kinetics of response to long-term treatment combining pentoxifylline and tocopherol in patients with superficial radiation-induced fibrosis. J Clin Oncol 2005; 23:8570.
  101. Fruchter R, Kurtzman DJ, Mazori DR, et al. Characteristics and treatment of postirradiation morphea: A retrospective multicenter analysis. J Am Acad Dermatol 2017; 76:19.
  102. Walsh N, Rheaume D, Barnes P, et al. Postirradiation morphea: an underrecognized complication of treatment for breast cancer. Hum Pathol 2008; 39:1680.