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Table 4 Proposal of a new grading system for bio-radiation dermatitisa

From: Asian expert recommendation on management of skin and mucosal effects of radiation, with or without the addition of cetuximab or chemotherapy, in treatment of head and neck squamous cell carcinoma

TERM G1 G2 G3 G4
Dermatitis Bio-radiation Faint erythema or dry desquamation; and lesions due to bio-treatment (e.g. xerosis, papules, pustules, and other clinical signs) which may or may not be associated with symptoms of pruritus or tenderness. Moderate to brisk erythema; patchy moist desquamation in folds and creases; lesions due to bio-treatment (e.g. crusts, papules, pustules, and other clinical signs) mostly confined to less than 50 % of radiated area; bleeding lesions with friction or trauma. Moist desquamation in areas other than skin folds and creases; extensive (>50 % of involved field) confluent lesions due to bio-treatment (e.g. crusts, papules, pustules, and other clinical signs) associated to bleeding by minor trauma or abrasion. Life-threatening consequences; skin necrosis or ulceration of full thickness dermis; extensive (>50 % of involved field) confluent lesions due to bio-treatment (e.g. crusts, papules, pustules, and other clinical signs) associated to signs of spontaneous bleeding. Systemic inflammation response syndrome (SIRS)
Activity of Daily living (ADL) No limiting age-appropriate ADL Limiting age-appropriate instrumental ADL Limiting self-care ADL  
Action Topical therapy indicated (moisturizers, corticosteroids, antibiotics) Topical and oral therapy indicated Topical and oral therapy indicated; dressing and wound indicated; inpatient therapy may be necessary Hospitalize the patient
Grade-specific management approaches Weekly follow-up is adequate, unless rapid progression is noted Consider twice-weekly assessments to monitor rapid change Evaluate the need for daily assessment Closely monitor signs of local or systemic infection For grade 3 reactions occurring at <50 Gy, consider brief interruption in treatment Consider interrupting treatment with both radiotherapy and cetuximab. Cetuximab should be interrupted until the skin reaction has resolved to at least grade 2 In the case of severe superinfection, consider the use of i.v. antibiotics if unresponsive to oral antibiotics
  1. aAdapted from references 18 and 19