Radiation Oncology/Toxicity/Skin

Skin Toxicity

''Please see the skin care chapter for management

RTOG Scale


 * '''NCI Common Toxicity Criteria (CTC), version 3


 * CDC Radiation Injury Sheet

Dose Tolerances

 * Temporary erythema - 2 Gy - 1 day
 * Dry desquamation - 14 Gy - 4 weeks
 * Moist desquamation - 18 Gy - 4 weeks
 * Temporary epilation - 3 Gy - 3 weeks
 * Permanent epilation - 7 Gy - 3 weeks
 * Permanent alopecia- 43 Gy (PMID 15465206)

Phenytoin-Induced Syndromes

 * Can be seen after whole-brain radiation concurrent with phenytoin
 * Erythema Multiforme minor and Erythema Multiforme major
 * Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
 * Tentatively proposed to be classified under acronym EMPACT (Erythema Multiforme associated with Phenytoin And Cranial radiation Therapy)
 * A case report also describes similar interaction between carbamazepine and cranial irradiation


 * Madrid; 2007 (Spain) PMID 17669303 -- "[Toxic epidermal necrolysis induced by phenytoin and whole brain radiotherapy] [Article in Spanish]" (Fernandez FA, Actas Dermosifiliogr. 2007 Sep;98(7):483-5.)
 * Case report. 1 patient treated with phenytoin and whole brain RT developed TEN


 * Samsun; 2006 (Turkey) PMID 16684289 -- "Stevens-Johnson syndrome in two patients treated with cranial irradiation and phenytoin." (Aydin F, J Eur Acad Dermatol Venereol. 2006 May;20(5):588-90.)
 * Case report. 2 patients. Treated with cranial RT and phenytoin developed SJS


 * Vienna; 2005 (Austria) PMID 16353748 -- "EMPACT syndrome." (Wohrl S, J Dtsch Dermatol Ges. 2005 Jan;3(1):39-43.)
 * Case report. 1 patient treated with phenytoin and cranial RT. Treated with corticosteroids and immunoglobulins
 * Conclusion: Propose definition of EMPACT


 * Istanbul; 2004 PMID 15347896 -- "Toxic epidermal necrolysis after cranial radiotherapy and phenytoin treatment." (Oner Dincbas F, Onkologie. 2004 Aug;27(4):389-92.)
 * Case reports. 1 patient treated with phenytoin and cranial irradiation, progressed to 70% of whole body, leading to death
 * Conclusion: TEN should be considered during cranial irradiation and antiepileptic prophylaxis


 * Mayo Clinic; 2004 PMID 14693027 -- "Erythema multiforme associated with phenytoin and cranial radiation therapy: a report of three patients and review of the literature." (Ahmed I, Int J Dermatol. 2004 Jan;43(1):67-73.)
 * Review. 24 cases identified in literature. Mean age 44 (23-67). Phenytoin variable duration (mean 40 days, 16-80 days). Lesions during RT or soon thereafter. No relationship between extent and severity of skin lesions and phenytoin or RT dose. Complete recovery within 1-8 weeks of discontinuing RT
 * Propose acronym EMPACT (Erythema Multiforme associated with Phenytoin and Cranial radiation Therapy)


 * Riyadh; 1999 (Saudi Arabia) PMID 10090698 -- "Stevens-Johnson syndrome in patients on phenytoin and cranial radiotherapy." (Khafaga YM, Acta Oncol. 1999;38(1):111-6.)
 * Case report. 4 patients within 24 month period. Adverse reactions to phenytoin during cranial RT
 * Conclusion: In absence of seizure history, prophylactic phenytoin use may not be warranted


 * Catania; 1999 (Italy) PMID 10030773 -- "Increased risk of erythema multiforme major with combination anticonvulsant and radiation therapies." (Micali G, Pharmacotherapy. 1999 Feb;19(2):223-7.)
 * Case report and literature review. 1 patient. Identified 20 cases in literature of phenytoin + cranial irradiation. No relationship between phenytoin dose, RT dose, histology of brain tumor, age, or gender
 * Also identified a report describing carbamazepine. Gabapentin should be considered