The most common radiotherapy side effect is a skin reaction. This can develop during treatment and up to one month after. This generally only occurs within the boundaries of the radiotherapy treatment fields. This often resembles sunburn. The rash will depend on the dose delivered and the body area treated. This reaction is generally self-limiting and will settle in time.
Patients treated at Edinburgh Cancer Centre are provided with skincare advice and creams, with specific advice given dictated by their assessed risk level for a reaction (low, medium or high). Patients are advised to apply any creams that have been provided by the Cancer Centre throughout the entire duration of radiotherapy and for two weeks post-treatment completion.
If a patient presents to Primary Care with a likely radiotherapy-induced skin reaction, despite use of prophylactic creams, please follow the RTOG skin scoring tool and management guidelines below.
In addition, the Edinburgh Cancer Centre team also recommends treatment for any suspected secondary infection. Use of anti-fungal treatments is generally not recommended, but anti-bacterial agents should be prescribed if there is purulent discharge and suspected additional infection. This is typically flucloxacillin, provided the patient does not have a penicillin allergy, but please follow local microbial guidance for skin and soft tissue infections.
If you have any queries, please contact the Edinburgh Cancer Centre Acute Oncology Team, as per the Primary Care Management tab below.
Typical Skin Reactions Grading – RTOG Skin Score
| Grade | Features |
| RTOG 0 | No change over baseline |
| RTOG 1 | Mild erythema, dry desquamation, decreased sweating |
| RTOG 2a | Tender, bright erythema, dry desquamation, rash with itch |
| RTOG 2b | Patchy moist desquamation, moderate erythema, oedema |
| RTOG 3 | Confluent moist desquamation, pitting oedema |
NB Black/brown skin will not demonstrate typical erythema; instead, it will be shades of brown, deep black, ebony or purple hues
Management of Radiotherapy Skin Reactions
| Radiotherapy Site | RTOG Grade | |
| 1 – 2A | 2B – 3 | |
| Breast | See Breast Radiotherapy RefHelp Guidance | |
| Anorectal: Anal Cancer, Rectal Cancer | Continue Betamethasone x 1 day and Zerobase/Diprobase emollient twice daily. | Switch to Flaminal Hydro/Forte and low adherent dressings eg Kliniderm Border/Mepilex Border or non stick dressing pads may be used. |
| Gynaecological/Pelvis: Endometrial Cancer, Cervical Cancer. | Continue Betamethasone 0.1% x 1 day and Zerobase/Diprobase emollient twice daily. | Flaminal Hydro/Forte and low adherent dressings or non stick dressing pads may be used. |
| Gynaecological/Pelvis: Vulval Cancer | Flamigel RT x 3 daily | Flaminal Hydro/Forte and low adherent dressings or non stick dressing pads may be used. |
| Head and Neck Cancers, Skin Cancer | Continue Betamethasone 0.1% x 1 day and Zerobase/Diprobase emollient twice daily | Switch to Flaminal Hydro/Forte and non adherent dressings may be used |
M.A, J.W, K.E – 25-3-26
Who to refer:
Any patient with a cancer diagnosis who is on treatment, within 6 weeks of treatment, or has had immunotherapy within last 12 months.
Who not to refer:
If in doubt please do not hesitate to call the on call oncology team. You may be advised to refer via medical team if patient is no longer under oncology follow up.
How to refer:
Contact the Acute Oncology team at the Edinburgh Cancer Centre on 07798774842 or 0131 537 1000 and ask to speak to Acute Oncology team for oncology.
Primary Care Management
All patients on or within six weeks of treatment should be encouraged to monitor symptoms and call The Cancer Treatment Helpline (CTH; 08009177711) with any treatment-related concerns. Please note, the CTH is a call operator service provided by NHS 24, who then refer on to an acute care specialist. They cannot give specialist advice.
If the patient has been assessed by a healthcare practitioner in Primary Care, and Oncology advice/input is felt to be required, the Primary Care clinician should call the Acute Oncology team at the Edinburgh Cancer Centre (based in the WGH) and discuss directly. The Acute Oncology team can be contacted during working hours (Mon-Fri 9-5) on 07798774842; If out of hours, please discuss with the Oncology Registrar On-Call via NHS Lothian Switchboard (0131 537 1000).
If the primary care clinician requires any further guidance on the suitability of referral to Acute Oncology, they can consult Pg 10 of the The UKONS Oncology/Haematology 24 Hour Triage Toolkit.
Note if a patient has presented to primary care for assessment, the patient should NOT be advised to call the CTH themselves to pass on this information or seek further advice.
