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

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