Cutaneous Radiation Syndrome



Definitions


  • Cutaneous Radiation Syndrome (CRS)
    • One of the four subsyndromes of Acute Radiation Syndrome (ARS)
    • Clinical continuum of pathophysiological reactions of the skin and skin appendages to significant levels of ionizing radiation after:
      • Exposure of the skin from whole or partial body radiation which penetrates deeply into tissues (e.g., gamma, neutron)
      • Exposure of very large areas of skin from high energy beta radiation, which usually does not penetrate deeply enough in tissue to cause the 3 other subsyndromes of ARS (hematopoietic, gastrointestinal, neurovascular) but can cause major skin effects
    • Phases of CRS are the same as for the other 3 ARS subsyndromes
      • Prodromal
      • Latent
      • Manifest Illness
      • Recovery (± with chronic or late effects)
    • CRS in this context represents Cutaneous Radiation Syndrome, not Chronic Radiation Syndrome, which has also been called CRS.
  • Cutaneous Radiation Injury (CRI)
    • Clinical continuum of pathophysiological reactions of the skin and skin appendages to significant levels of ionizing radiation
    • Differences between CRS and CRI
      • CRI need not occur in the context of ARS.
      • CRI may occur when radiation injury (from therapeutic or unintentional exposure) is more localized or if radiation dose is insufficient to penetrate to deeper organs and cause ARS.
      • CRS and CRI may be confused or used interchangeably (though incorrectly) in the medical literature
    • Synonyms of CRI
      • Radiodermatitis
      • Radiation dermatitis
      • Cutaneous radiation effects
    • Phases of CRI
      • Acute
      • Subacute
      • Chronic
      • Late
  • Threshold dose
    • Medical literature provides wide range of minimal threshold radiation doses necessary to produce ionizing radiation-induced skin injury (e.g., 350 - 500 cGy).
    • Intrinsic biological (i.e., host) and inherent physical (i.e., radiation) factors may raise or lower dose required to cause skin injury, therefore no value or value range is provided by REMM.
    • Consult Bibliography for references.

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Clinical information


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Management of cutaneous radiation syndrome


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Radiation physics and skin effects


  • With some exceptions, radiation dose decreases (attenuates) as it passes through skin and deeper tissues.
  • Beta burns
    • Represent the effects of beta radiation on the skin.
    • Radiation effects on skin may be significant, but effects rarely go deeper, due to the physical properties of the beta radiation.
    • Nevertheless, widespread beta burns can increase morbidity and mortality of ARS when ARS develops after significant whole body gamma or neutron radiation in addition to the beta burns.E-3
  • Physical properties of radiation associated with increasing injury severity
    • Total dose: higher dose → more severe damage
    • Dose rate: faster dose delivery rate → more severe damage
    • Extent of area affected: larger/wider area → worse effects
    • Dose depth: deeper dose → more severe damage
    • Radiation with higher RBE → more severe damage

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Manifestations of Acute Skin Injury


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Manifestations of Late/Chronic Skin Injury


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Evaluation of Cutaneous Radiation Syndrome


  • Specialized tests may be helpful in managing selected cases with poorly characterized or severe skin injury.A-16, C-2, H-3
    • Sequential color photography: to document skin changes over time
    • Ultrasonography and/or MRI: to evaluate injury depth
    • Thermography: tissue necrosis lowers skin temperature while inflammation raises skin temperature
    • Capillary microscopy: to assess severity of injury by viewing vessels in dermal stratum papillae
    • Profilometry: to evaluate changes to skin surface
    • Histology/biopsy

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Phases of Cutaneous Radiation Syndrome


Phases of Cutaneous Radiation Syndrome (CRS)*

ProdromalLatentManifest IllnessPossible Chronic/Late Effects
  • Erythema
  • Edema
  • Pruritis, increased skin temperature, dysesthesias
  • Variable time, longer duration with lower dose
  • Prodromal symptoms may stabilize or slightly improve
Early:
  • Second wave of erythema, swelling and edema of skin and subcutaneous tissues, corresponding to the renewal of epidermal cells
Later:

Note: Many of these late/chronic effects can appear years to decades later.
*Adapted from references A-16, E-4, H-3, H-4

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Prognosis of Cutaneous Radiation Syndrome


Prognosis of Cutaneous Radiation Syndrome (CRS)*

Syndrome GradeSeverityPrognosis
1MildRecovery likely
2ModerateRecovery likely without significant deficit
3SevereRecovery likely with deficit
4CriticalSerious deficit, with reconstruction probably needed in appropriate setting
*Adapted from references E-4, H-4

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Gallery of Clinical Photographs

Normal skin
  1. Normal skin architecture
  2. Skin anatomy and levels of burn injury
Acute effects:
  1. Erythema and skin edema
  2. Epilation
  3. Blister
  4. Dry desquamation
  5. Moist desquamation
Evolution of skin effects:
  1. Patient OAF in Goiania incident, 1987 -
    blister, evolution to moist desquamation
  2. Peruvian patient exposed to Iridium-192 -
    blister, moist desquamation, ulcer progressing to tissue necrosis
  3. Wife of the Peruvian patient exposed to Iridium-192 -
    Dry desquamation, necrosis, fibrosis, and telangiectasia
  4. Patient involved in a x-ray diffraction accident, 9-96 days postexposure -
    erythema, telangiectasias, blisters, desquamation, cellulitis
Chronic effects:
  1. Skin atrophy
  2. Chronic radiation dermatitis
  3. Fibrosis, contractures, and keratoses
  4. Keratosis and fibrosis
  5. Telangiectases and epidermal atrophy
  6. Telangiectases and xerosis
  7. Telangiectases
  8. Telangiectases and muscle contractures/fibrosis
  9. Lentiginous changes in skin
  10. Hyperpigmentation, keratoses, and telangiectases
  11. Hyperpigmentation and onychodystrophy
  12. Onycholysis (Onychodystrophy)
  13. Ulcer
  14. Chronic radiation ulcer
  15. Tissue necrosis
  16. Skin cancer

Submit pictures for use in the gallery

Cutaneous Radiation Injury - Introduction (YouTube - 2:43 minutes) (HHS/CDC) Watch video

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Bibliography


A. Overview and clinical articles

  1. Medical Management of Radiation Injuries See page 14 for section on cutaneous injury. (IAEA, PAHO, IFRC, 2020)
  2. DiCarlo AL, Bandremer AC, Hollingsworth BA, Kasim S, Laniyonu A, Todd NF, Wang SJ, Wertheimer ER, Rios CI. Cutaneous Radiation Injuries: Models, Assessment and Treatments. Radiat Res. 2020 Sep 16;194(3):315-344. [PubMed Citation]
  3. Rios CI, DiCarlo AL, Marzella L. Cutaneous Radiation Injuries: Models, Assessment and Treatments. Radiat Res. 2020 Sep 16;194(3):310-313. [PubMed Citation]
  4. Soriano JL, Calpena AC, Souto EB, Clares B. Therapy for prevention and treatment of skin ionizing radiation damage: a review. Int J Radiat Biol. 2019 May;95(5):537-553. [PubMed Citation]
  5. Huang A, Glick SA. Genetic susceptibility to cutaneous radiation injury. Arch Dermatol Res. 2017 Jan;309(1):1-10.  [PubMed Citation]
  6. Dainiak N, Gent RN, et al. Literature Review and Global Consensus on Management of Acute Radiation Syndrome Affecting Nonhematopoietic Organ Systems. Disaster Med Public Health Prep. 2011 Oct;5(3):183-201. [PubMed Citation]
  7. Kagan RJ, Peck MD, Ahrenholz DH et al. Surgical management of the burn wound and use of skin substitutes: an expert panel white paper. J Burn Care Res 2013;34(2):60-79.
  8. Muller K, Meineke V. Advances in the management of localized radiation injuries. Health Phys. 2010 Jun;98(6):843-50. [PubMed Citation]
  9. Benderitter M, Gourmelon P, Bey E, Chapel A, Clairand I, Prat M, Lataillade JJ. New emerging concepts in the medical management of local radiation injury. Health Phys. 2010 Jun;98(6):851-7. [PubMed Citation]
  10. Muller K, Meineke V. Advances in the management of localized radiation injuries. Health Phys. 2010 Jun;98(6):843-50. [PubMed Citation]
  11. Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Radiology. 2010 Feb;254(2):326-41. [PubMed Citation]
  12. Mettler FA Jr, Guskova AK, Gusev I. Health effects in those with acute radiation sickness from the Chernobyl accident. Health Phys. 2007 Nov;93(5):462-9. [PubMed Citation]
  13. Berger ME, Christensen DM, Lowry PC, Jones OW, Wiley AL. Medical management of radiation injuries: current approaches. Occup Med (Lond). 2006 May;56(3):162-72. [PubMed Citation]
  14. Peter RU, Gottlöber P, Heckmann M, et al. Treatment and Follow-up of Patients Suffering from the Cutaneous Radiation Syndrome, from Proceedings of the First International Conference on 'The radiological consequences of the Chernobyl Accident', European Commission and the Belarus, Russian and Ukrainian Ministries on Chernobyl Affairs, Emergency Situations and Health, March 1996, pp 601-605.
  15. Hopewell JW. The skin: its structure and response to ionizing radiation. Int J Radiat Biol. 1990 Apr;57(4):751-73. [PubMed Citation]
  16. Meineke V. The role of damage to the cutaneous system in radiation-induced multi-organ failure. BJR Suppl. 2005;27:85-99.
  17. Peter RU. Cutaneous radiation syndrome in multi-organ failure. BJR Suppl. 2005;27:180-4
  18. Peter RU, Gottlöber P. Management of cutaneous radiation injuries: diagnostic and therapeutic principles of the cutaneous radiation syndrome. Mil Med. 2002 Feb;167(2 Suppl):110-2. [PubMed Citation]
  19. Peter RU, Cutaneous radiation syndrome: clinical and therapeutic aspects, Radiological Protection Bulletin, 183: 19-25, 1996  

 

B. HHS information

  1. Cutaneous Radiation Injury (HHS/CDC, April 4, 2018)
  2. Cutaneous Radiation Injury: Fact Sheet for Physicians (HHS/CDC, 5/10/2006)

 

C. Information from international agencies

  1. How to recognize and initially respond to an accidental radiation injury - images of radiation skin effects and injury (poster, PDF - 436 KB) (pamphlet, PDF - 322 KB) (Radiation dermatological injuries, IAEA, WHO)
  2. Diagnosis and Treatment of Radiation Injuries (PDF - 202 KB) (IAEA Safety Reports Series No. 2, Vienna 1998)
  3. The biological basis for dose limitation in the skin (International Commission on Radiological Protection, ICRP Publication 59, 1992)
  4. Erythema and skin injuries (IAEA)

 

D. Basic research

  1. DiCarlo AL, Bandremer AC, Hollingsworth BA, et al. Cutaneous Radiation Injuries: Models, Assessment and Treatments [published online ahead of print, 2020 Aug 28]. Radiat Res. 2020;10.1667/RADE-20-00120.1. [PubMed Citation]
  2. Rios CI, DiCarlo AL, Marzella L. Cutaneous Radiation Injuries: Models, Assessment and Treatments [published online ahead of print, 2020 Aug 28]. Radiat Res. 2020;10.1667/RADE-20-00132.1. [PubMed Citation]
  3. Müller K, Meineke V. Radiation-induced alterations in cytokine production by skin cells. Exp Hematol. 2007 Apr;35(4 Suppl 1):96-104. [PubMed Citation]

 

E. Incidents and incident modeling

  1. Wang YY, Yu DJ, Zhao TL, et al. Successful Rescue of the Victim Exposed to a Super High Dose of Iridium-192 during the Nanjing Radiological Accident in Nanjing Radiological Accident in 2014, 2014. Radiat Res. 2019;191(6):527-531. [PubMed Citation]
  2. Adams TG, Yeddanapudi N, Clay M, Asher J, Appler J, Casagrande R. Modeling Cutaneous Radiation Injury from Fallout. Disaster Med Public Health Prep. 2019;13(3):463-469.  [PubMed Citation]
  3. Mettler FA Jr, Guskova AK, Gusev I. Health effects in those with acute radiation sickness from the Chernobyl accident. Health Phys. 2007 Nov;93(5):462-9. [PubMed Citation]
  4. Steinert M, Weiss M, Gottlöber P, Belyi D, Gergel O, Bebeshko V, Nadejina N, Galstian I, Wagemaker G, Fliedner TM, Peter RU. Delayed effects of accidental cutaneous radiation exposure: fifteen years of follow-up after the Chernobyl accident. J Am Acad Dermatol. 2003 Sep;49(3):417-23. [PubMed Citation]
  5. Gottlöber P, Bezold G, Weber L, Gourmelon P, Cosset JM, Bahren W, Hald HJ, Fliedner TM, Peter RU. The radiation accident in Georgia: clinical appearance and diagnosis of cutaneous radiation syndrome. J Am Acad Dermatol. 2000 Mar;42(3):453-8. [PubMed Citation]
  6. The radiological accident in Yanango (PDF - 3.30 MB) (IAEA, 2000), See pages 30, 31, 35 for excellent clinical photographs of skin effects, as well as other pages with text descriptions of clinical effects.
  7. Peter RU, Braun-Falco O, Birioukov A, Hacker N, Kerscher M, Peterseim U, Ruzicka T, Konz B, Plewig G. Chronic cutaneous damage after accidental exposure to ionizing radiation: The Chernobyl experience. J Am Acad Dermatol. 1994 May;30(5 Pt 1):719-23. [PubMed Citation]
  8. Oliveira AR, et al., Skin lesions associated with the Goiania accident, in The Medical Basis for Radiation Accident Preparedness II, 173-181, Ricks RC, Fry SA (eds.),1990.

 

F. Assessing skin dose from radiation contamination and skin decontamination

  1. Dubeau J, Heinmiller BE, Corrigan M. Multiple Methods for Assessing the Dose to Skin Exposed to Radioactive Contamination. Radiat Prot Dosimetry. 2017 Apr 28;174(3):371-376. [PubMed Citation]
  2. Tazrart A, Bérard P, Leiterer A, Ménétrier F. Decontamination of radionuclides from skin: an overview. Health Phys. 2013;105(2):201-207. [PubMed Citation]

 

G. Skin and radiological protection

  1. PAG Manual: Protective Action Guides and Planning Guidance for Radiological Incidents, EPA-400/R-17/001 (PDF - 1.48 MB) (EPA, January 2017)
  2. Charles MW. The skin in radiological protection--recent advances and residual unresolved issues. Radiat Prot Dosimetry. 2004;109(4):323-30. [PubMed Citation]
  3. The biological basis for dose limitation in the skin (International Commission on Radiological Protection, ICRP Publication 59, 1992)

 

H. Books and monographs

  1. Hall EJ, Giaccia AJ, Radiobiology for the Radiologist, 8th Edition, Wolters Kluwer, Philadelphia, PA, 2018.
  2. Peter RU, Management of skin injuries in radiation accidents: The cutaneous radiation syndrome, in The Medical Basis for Radiation-accident Preparedness, the Clinical Care of Victims, Proceedings of the Fourth International Radiation Emergency Assistance Center/Training Site (REAC/TS) Conference, March 2001, Parthenon Publishing Group, New York, NY, 2002.
  3. Fliedner TM, Friesecke I, Beyrer K. Medical Management of Radiation Accidents: Manual on the Acute Radiation Syndrome, pp.27-32. (METREPOL) (PDF - 970 KB) (originally published by Oxford: British Institute of Radiology; 2001) Compendium to the main METREPOL document (PDF - 580 KB)
  4. Barabanova AJ: Local Radiation Injury. In: Gusev IA, Guskova AK, Mettler FA Jr, eds.: Medical Management of Radiation Accidents, 2nd ed. Boca Raton, Fl: CRC Press, 2001, pp. 223-240.
  5. Proceedings of the First International Conference on 'The radiological consequences of the Chernobyl Accident', European Commission and the Belarus, Russian and Ukrainian Ministries on Chernobyl Affairs, Emergency Situations and Health, March 1996.
  6. Oliveira AR, et al., Skin lesions associated with the Goiania accident, in The Medical Basis for Radiation Accident Preparedness II, 173-181, Ricks RC, Fry SA (eds.), 1990.
  7. Rubin P, Casarett GH, Clinical Radiation Pathology. Saunders, Philadelphia, PA, 1968.