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Original Investigation
December 2018

Assessing the Validity of Clinician Advice That Patients Avoid Use of Topical Agents Before Daily Radiotherapy Treatments

Author Affiliations
  • 1Department of Radiation Oncology, Washington University in St. Louis, St Louis, Missouri
  • 2Department of Radiation Oncology, University of Pennsylvania, Philadelphia
  • 3Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
  • 4Department of Dermatology, University of Pennsylvania, Philadelphia
  • 5Department of Dermatology, Johns Hopkins University, Baltimore, Maryland
  • 6Department of Radiation Oncology, University of California, San Francisco, San Francisco
JAMA Oncol. 2018;4(12):1742-1748. doi:10.1001/jamaoncol.2018.4292
Key Points

Question  Do topical agents applied just before radiotherapy alter the surface dose?

Findings  Surveys of 241 clinicians and patients found that avoiding topical agents prior to radiation treatments was widespread. In this dosimetric and preclinical study, there was no difference in the measured radiation dose at the skin surface with or without a 1- to 2-mm-thick layer of metallic or nonmetallic topical agents regardless of beam energy or beam incidence, although very thickly applied topical agents increased the surface dose; irradiated skin in mice showed no differences in phosphorylated histone H2AX–positive foci or in terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining with or without topical agents of varying thickness.

Meaning  Use of topical agents just before radiotherapy may be safely liberalized, although it appears that very thick applications of topical treatments just before radiotherapy should be avoided.


Importance  Radiation dermatitis is common and often treated with topical therapy. Patients are typically advised to avoid topical agents for several hours before daily radiotherapy (RT) out of concern that topical agents might increase the radiation dose to the skin. With modern RT’s improved skin-sparing properties, this recommendation may be irrelevant.

Objective  To assess whether applying either metallic or nonmetallic topical agents before radiation treatment alters the skin dose.

Design, Setting, and Participants  A 24-question online survey of patients and clinicians was conducted from January 15, 2015, to March 15, 2017, to determine current practices regarding topical therapy use. In preclinical studies, dosimetric effect of the topical agents was evaluated by delivering 200 monitor units and measuring the dose at the surface and at 2-cm depth in a tissue-equivalent phantom with or without 2 common topical agents: a petroleum-based ointment (Aquaphor, petrolatum 41%) and silver sulfadiazine cream, 1%. Skin doses associated with various photon and electron energies, topical agent thicknesses, and beam incidence were assessed. Whether topical agents altered the skin dose was also evaluated in 24 C57BL/6 mice by using phosphorylated histone (γ-H2AX) immunofluorescent staining and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Preclinical studies took place at the University of Pennsylvania.

Main Outcomes and Measures  Patient and clinician survey responses; surface radiation dose readings in tissue-equivalent phantom; and γ-H2AX and TUNEL intensity measured in mice.

Results  The 133 patients surveyed received RT for cancer and had a median (range) age of 60 (18-86) years; 117 (87.9%) were women. One hundred eight clinicians completed the survey with 105 reporting that they were involved in managing patient skin care during RT. One hundred eleven (83.4%) of the patients and 96 (91.4%) of the 105 clinicians received or gave the advice to avoid applying topical agents before RT treatments. Dosimetric measurements showed no difference in the delivered dose at either the surface or a 2-cm depth with or without a 1- to 2-mm application of either topical agent when using en face 6- or 15-megavoltage (MV) photons. The same application of topicals did not alter the surface dose as a function of beam incident angle from 15° to 60°, except for a 6% increase at 60° with the silver sulfadiazine cream. Surface dose for 6- and 15-MV beams were significantly increased with a thicker (≥3-mm) topical application. For 6 MV, the surface dose was 1.05 Gy with a thick layer of petroleum-based ointment and 1.02 Gy for silver sulfadiazine cream vs 0.88 Gy without topical agents. For 15 MV, the doses were 0.70 Gy for a thick layer of petroleum-based ointment and 0.60 Gy for silver sulfadiazine cream vs 0.52 Gy for the controls. With 6- and 9-MeV electrons, there was a 2% to 5% increase in surface dose with the use of the topical agents. There were no dose differences at 2-cm depth. Irradiated skin in mice showed no differences in γ-H2AX–positive foci or in TUNEL staining with or without topical agents of varying thickness.

Conclusions and Relevance  Thin or moderately applied topical agents, even if applied just before RT, may have minimal influence on skin dose regardless of beam energy or beam incidence. The findings of this study suggest that applying very thick amounts of a topical agent before RT may increase the surface dose and should be avoided.