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Radiation Ulcers

Practice Essentials

Radiation ulcers are wounds caused by the acute or chronic effects of ionizing radiation.
The injury may involve the skin, underlying soft tissue, and even deep structures such as bone. The most common cause of radiation injury is an adverse effect of therapeutic radiation therapy. Other causes are occupational or environmental exposures.
See the image below.

Case A. Cutaneous injury caused by irradiation of

Case A. Cutaneous injury caused by irradiation of the chest wall to treat advanced lung cancer with metastases to the head and spine. This patient was transferred to a burn unit for adequate care of the burns and ulcerations caused by the radiation treatments.

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Workup of radiation ulcers

Lab studies

Routine presurgical testing should be done, as indicated by the patient’s age and comorbid conditions. Nutritional parameters, such as albumin, prealbumin, and ferritin levels, should be obtained if suboptimal nutrition is a possibility. Patients with chronic wounds are often debilitated, and they may have anemia due to chronic, minor blood loss.

Check the prealbumin and albumin levels, which indicate whether the patient’s wound healing capability is optimized.

Imaging studies

Plain radiographs may be useful to look at the condition of the underlying bone and to screen for osteoradionecrosis. Computed tomography (CT) scanning or magnetic resonance imaging (MRI) may be useful in defining the extent of large, deep wounds and the involvement of underlying muscle and bone.

Biopsy

Biopsy of suspicious wounds should be done to rule out malignancy (Marjolin ulcer)

Management of radiation ulcers

Medical therapy

As a result of vascular changes and the resultant hypoxia, irradiated fields have a decreased capacity to fight infection. Impaired delivery of antibiotics also hinders the eradication of infection. As a result, use topical antibiotics, preferably those with tissue penetrance capabilities, to decontaminate irradiated wound beds.

Regarding acute radiation injury, radiation therapy, even when properly administered, may cause adverse skin effects. Treatment is supportive and includes protection from further trauma and use of topical antimicrobials (eg, silver sulfadiazine for partial-thickness skin losses). If frank, full-thickness ulcerations develop, they are unlikely to heal with purely medical intervention.

Chronic radiation injury decreases the ability of the body to tolerate bacterial contamination. When elective surgery is undertaken through radiated tissue, meticulous technique, gentle tissue handling, and antibiotic prophylaxis are essential.

Hyperbaric oxygen treatment is of value in healing of tissues of the head and neck, anus, and rectum. It can also be useful in preventing osteoradionecrosis of the mandible when dental work is needed after radiation.

Medical therapy with amifostine reduces the incidence of xerostomia.

Surgical therapy

Immediate, tension-free reconstruction should be performed at the time of ulcer excision since granulation tissue tends not to arise in irradiated beds. Because skin grafts typically fail, arterial-based flaps (free, locoregional, musculocutaneous, or fasciocutaneous) are the preferred means of reconstruction.

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