Series No 46 - Superficial radiotherapy treatment to the skin

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law, we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to having the procedure and understand what it involves.  

Staff will explain all the risks, benefits, and possible alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do not hesitate to speak to the team looking after you.

During your time with us we aim to provide the highest standards of care and support you in your decisions regarding your treatment. We will respect your dignity, individuality, and personal preferences. 

Your care will be managed and given by therapeutic radiographers, doctors, and nurses. You will meet both male and female healthcare professionals. If you have any concerns about this, please talk to the radiographers about it. We try to be sensitive to your needs, so please do not hesitate to discuss things with the team caring for you.

Radiotherapy appointments 

All take place in the Radiotherapy Department, basement floor, main UCH hospital building. 

Superficial radiotherapy treatment is treatment using either X-rays (photons) or electrons, which are both types of ionising radiation. The treatment only penetrates into the skin and does not reach the underlying organs or tissues. This means there are fewer side effects associated with superficial radiotherapy. 

Treatment is given externally (from outside the body) with the patient lying on a treatment couch. Superficial treatment can be given using a machine called an XStrahl machine, or a machine called a linear accelerator.  

Each patient’s individual case will have been discussed by a specialist group of professionals within a multi-disciplinary team. A consensus recommendation for your treatment is reached based on your symptoms, biopsy results, scans (if applicable) and the location of your skin cancer. This provides the basis for your treatment discussion with your radiotherapy doctor, also called a clinical oncologist, or the consultant skin radiographer. Your treatment will be tailor-made for your specific needs. It may differ slightly from the description in this leaflet.  

Radiotherapy works by damaging cancer or tumour cells in the part of the body being treated. The radiation stops the cells from dividing and growing. Radiotherapy can also damage nearby normal cells. The normal cells are more likely to recover from the effects of the radiation than the cancer or tumour cells. The clinical team take great care to reduce the radiation dose to a person’s healthy cells. 

Radiotherapy does not hurt, and it will not make you radioactive. You will be completely safe to be around family, friends, and pregnant people. You will feel nothing from the treatment and the machine will not touch you. The most important thing is for you to lie very still for treatment.  

Treatment is given daily Monday to Friday. A course of treatment can vary from one to 33 treatments and can be given in several different timeframes, with the most common being every day or alternate days. Your treatment schedule will be decided by your clinical oncologist or consultant skin radiographer and confirmed on your first treatment visit to the radiotherapy department.

For patients having treatment on the XStrahl machine, your first appointment will be for radiotherapy planning. A consultant skin radiographer, who is highly skilled in planning and treating skin cancers, and your doctor, will examine the area to be treated. Using a bright light and a magnifying glass the team will define the area to be treated. This may involve using a felt pen to draw around the area.  

The radiographers will take precise measurements of the area to be treated and they will make a template of the treatment area using a sheet of clear acetate. This will ensure the radiographers have a record of the exact area to be treated to ensure accuracy for each treatment. They will also, with your permission, take a digital photograph of the treatment area. This will be accessible only to the radiographers treating you. Before you leave the department, any felt pen marks will be removed, and you will be given an appointment card with the date and time for your first radiotherapy treatment.   

When you come for your treatment, the radiographers will begin by getting you in the correct treatment position. You will be lying on a soft treatment couch in the treatment room. The radiographers will then check the area to be treated using the measurements, template and digital photograph taken at planning. They will use felt pens to draw around the area to be treated.  

For some patients, an appropriately sized and shaped lead cut-out will be selected to allow the treatment of the marked area whilst protecting the surrounding healthy skin. This cut-out will be taped to your skin. Once you are in the correct position, the treatment machine will be brought into position and will either come to rest on the lead cut-out or press gently on your skin. All that we ask is that you keep still during the setting up process and treatment. 

Once final checks have been made, the radiographers will leave the room and close the treatment room door. The radiographers will be watching you the entire time on a closed-circuit television. If you need them at any time during your treatment, please raise your arm.  

Treatment times vary, depending on the dose prescribed by the doctor, but on average are about 5-10 minutes long. You will feel nothing whilst the treatment is being delivered. The treatment machine will make a beeping noise, but you will not feel anything. It is important that you breathe normally and remain relaxed.  

Once the treatment is over the radiographers will come back into the room, move the treatment unit, remove the lead cut-out, if used, and you will be free to go home. Before you go you will be given a list of all your appointment times for your remaining treatments.  

If the area to be treated is near to a sensitive organ such as the eye, a small lens shield will be placed over the eye to protect it from the radiation. Very occasionally, if the treatment is very close to the lens of the eye, a patient may have to wear a lead contact lens, also called an internal eye shield. If this is a possibility for you, your doctor or radiographer will explain this to you. Anaesthetic eye drops are used to numb the eye before inserting the contact lens. Patients who have an internal eye shield are unable to drive for an hour or so after treatment has been given to allow the effects of the anaesthetic to wear off.  

Patients sometimes need to have a special shield (called a lead mask) made if the area to be treated is an irregular shape. This protects areas that do not need to be treated and is made by taking an impression of the area to be treated. Making the impression involves some Plaster of Paris bandages and an impression material called Alginate being placed over the treatment area and moulded to your shape. The procedure is not painful but can be a little messy. This impression is then used to produce a mask ready for your treatment.

There will be some side effects which will gradually appear during your course of treatment. These effects will vary from patient to patient. There are side effects occurring during treatment, some happening soon after treatment, and some appearing months or years after radiotherapy. 

The risk and severity of side effects occurring will depend on the dose of radiotherapy given and the exact area which receives treatment. Your doctor, or consultant skin radiographer, will discuss the risks of treatment with you before you sign a consent form. However, there will still be plenty of opportunity to talk about anything that you feel needs further discussion. 

Skin changes

The skin in the area being treated will gradually change colour. Your skin will gradually become pink /red or darker, depending on your skin colour. You may get some dry peeling of the skin in the treatment area, which may become itchy. Some patients may experience peeling of the skin which can be very sore 

Normally the side effects take about two weeks to appear. The reaction is usually at its peak by about one week after treatment has finished. This will subside after four to six weeks. It is common for the treatment area to form a ‘scab’ of dead skin. Do not be tempted to remove this. It is best to allow the skin to ‘look after itself’ and maintain its own healing process. Often several scabs will form before healing is complete. Sometimes when the scab falls off, the area may bleed a little. This is quite normal and is part of the healing process. 

If the treatment area is close to the eye, you may experience soreness and a watery eye.   

If the treatment area is on the nose, you may experience soreness inside the nose and occasional bleeding.  

All these side effects are temporary and will get better several weeks after you have finished your radiotherapy treatment.

• Wash the treatment area with warm water and the soap products you would normally use.  
• Pat the skin dry in the treatment area with a soft towel.  
• Radiotherapy skin reactions cannot be prevented, but to minimise any skin irritation we recommend using a moisturiser of your choice. Use the moisturiser frequently and gently smooth it on to your  skin until it is absorbed. You do not need to wipe the moisturiser off before treatment, but please do not apply moisturiser immediately before treatment. 
• Should you not use a regular moisturiser speak to the radiographers and they will be able to suggest a few options.  
• If your skin becomes irritated and sore, stop using the moisturiser. You will be referred to the radiotherapy review team for appropriate skin care. 
• Do not use make-up or concealers during treatment on the treated area. This will help minimise any side effects you may experience from the radiotherapy. 
• If the area being treated is on the scalp, please do not use a hair dryer, hair dye or perming lotion in the area. When washing hair be very gentle and preferably use a non-perfumed shampoo. 
• If the area being treated is on the face, please do not wet shave in that area or use hair removal creams.  
• The skin in the treatment area will be particularly sensitive to the sun during radiotherapy. It is important to remember that the skin in this area will always be more sensitive to the sun. It is advisable to use a high factor (50+ SPF) cream over the area after you have finished the treatment, whenever you go out in the sun. It is recommended that you avoid direct exposure of the area to the sun and wind during treatment.

Hair loss

Towards the end of your treatment, or once it is finished, you will begin to lose any hair that was included in the treatment area. This may start to re-grow about three months after the end of treatment. In some circumstances, hair loss may be permanent. Your doctor will discuss this if it is relevant to you.  

Tiredness

Tiredness is a very common side effect of radiotherapy. You may feel more tired than usual and have less energy, both during and after treatment. Do not worry, this is normal. It is usually a combination of travelling to hospital every day, the side effects of treatment, coping with a diagnosis of a tumour and continuing with normal life. Fatigue usually improves between six months to a year after treatment. 

We recommend that you listen to your body. Do as much as you feel you can and rest when you need to. Pick out the things that you enjoy and try to ask others for help with other tasks. Try to get a good night’s sleep where possible. Have enough water to drink to prevent tiredness from dehydration. Gentle exercise has been found to improve fatigue levels in patients and we would recommend walking as a good form of exercise.  

Please tell us if you are finding things difficult, as we will be able to offer practical advice and information.

At your first treatment appointment the radiographers will discuss the treatment with you and explain any possible side effects you may experience. They will see you every day and ask how you are and how you are feeling. They will be able to offer help and support and refer you to relevant support services if you experience any problems. Please feel free to talk about any issues that may be worrying you. 

Late side effects can occur months or years after radiotherapy has finished. The degree and frequency of late effects depends on the dose of radiotherapy given, the amount of skin treated and the site that has been treated. These late effects are the hardest to predict and, unfortunately, when they do occur, they are permanent. Your radiotherapy doctor will have explained the potential late side effects of radiotherapy to you as part of the consent process. The effects may include:  

Skin

Your skin in the treatment area may continue to be slightly more fragile than before and we suggest that you use a high factor sun cream on the treatment area if you are going to be outside. You may also wish to protect the area from severe cold, wind and abrasion. Once the initial redness has faded away, you may notice that the treated area becomes paler.  

Some patients notice that small veins appear visible just under the skin surface. This condition is known as telangiectasia. Although telangiectasia is not painful, it can cause red or purple areas on the treated skin, which look like spidery marks.  Dilation occurs because the capillaries are compensating for the destruction or narrowing of other blood vessels, due to the radiotherapy. 

Cataracts 

The lens of the eye is extremely sensitive to radiotherapy and whilst every effort is made to ensure that your eyes do not receive any radiation during your treatment, it is sometimes unavoidable. A very low dose of radiation can cause the lens to become crystalline, and this process will lead to a cataract forming in the eye. If this situation is likely to arise, your consultant will discuss it with you carefully before you start radiotherapy. It takes about two years for a cataract to form, but it can be removed in the normal way that is used to treat any patient with a cataract.

Second malignancy

Less than 1% of people who have received treatment for one tumour may develop another type of tumour in the treated area some years later. The radiotherapy doctors or consultant breast radiographer will discuss this risk if it is relevant to you.

This page deals with the physical aspects of your treatment, but your emotional wellbeing and that of your family is just as important. Having treatment can be deeply distressing for some patients. Within the radiotherapy department there will be access and support from the consultant skin radiographer, the treatment radiographers, the radiotherapy review team and the Macmillan information and support team. However, if you feel you require further medical or emotional support you can be referred to a variety of health professionals who can help with any worries or difficulties you may be having. 

The side effects you are experiencing will continue after treatment has finished. It is common to experience a worsening of the skin reactions for about ten to fourteen days after radiotherapy. You will be reviewed by your clinical oncologist or consultant skin radiographer four to six weeks after completing your radiotherapy or proton beam therapy. This may be a telephone or face-to-face appointment. Face-to-face appointments will be held in the UCLH Macmillan cancer Centre.  

Some patients will be discharged back to their local referring centres for symptom care and follow-up. Please feel free to contact the radiotherapy department if you are worried about your treatment side effects.

If you have been provided with a paper copy of this page, please fill in the deatils below.

My skin cancer Clinical Nurse Specialist

They can be contacted on:

My skin Radiographer is:

They can be contacted on:

Radiotherapy reception 

t: 020 3447 3700 / 3701 

Radiotherapy Review Team (via Radiotherapy Reception) 

t: 020 3447 3700 / 3701 

Macmillan Radiotherapy Support Worker 

t: 020 3447 3780 

If you have any concerns that you would like to discuss in confidence, please contact our PALS (Patient Advice and Liaison Service) for information and advice.

t: 020 3447 3042  

e: PALS@uclh.nhs.uk  

w: www.uclh.nhs.uk

British Association of Dermatologists (BAD)

Macmillan Cancer Support  

t: 0808 808 0000  

e: cancerline@macmillan.org.uk   

Cancer Research UK

t: 0808 800 4040   

Maggie’s (Providing cancer information and support in centres across the UK and online) 

OUTpatients (cancer support for LGBTIQ+ community)  

Carers UK  

t: 0808 808 7777  

e: adviceline@carersuk.org   

NHS Choices   

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