# Radiation Oncology/Toxicity/Skin

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Skin Toxicity
Please see the skin care chapter for management
RTOG Scale
| Grade | Description |
| 0 | None or no change |
| I | Scattered macular or papular eruption or erythema that is asymptomatic |
| II | Scattered macular or papular eruption or erythema with pruritis or other associated symptoms |
| III | Generalized symptomatic macular, papular, or vesicular eruption |
| IV | Exfoliative dermatitis or ulcerating dermatitis |
| Grade | Description |
| 0 | None or no change |
| I | Faint erythema or dry desquamation |
| II | Moderate to brisk erythema; patchy moist desquamation, mostly confined to skin folds and creases; moderate edema |
| III | Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion |
| IV | Skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site |

### 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