Cosmetic considerations after breast cancer treatment

Treatments for breast cancer can have an array of adverse effects, including hair loss, scarring, and irritated skin. These physical outcomes can, in turn, lead to body image concerns, anxiety, and depression. Fortunately, there is growing evidence that certain cosmetic therapies can improve patient self-image. Here we review various cosmetic treatment options including hair camouflage, eyebrow and eyelash camouflage, treatments for hirsutism, nipple and areola tattooing, post-mastectomy scar tattooing, treatments for dry skin/xerosis, removal of post-radiation telangiectasias, and lightening of post-radiation hyperpigmentation. For each patient concern, we report potential procedures, clinical evidence of impact on quality of life, special considerations, and safety concerns. This article aims to equip dermatologists with resources so that they may effectively counsel breast cancer survivors who express treatment-related cosmetic concerns.

The Therapeutic Application of Stem Cells and Their Derived Exosomes in the Treatment of Radiation-Induced Skin Injury

Radiation-induced skin injury (RISI) is a serious concern for nuclear accidents and cancer radiotherapy, which seriously affects the quality of life of patients. This injury differs from traditional wounds due to impaired healing and the propensity to recurrence and is divided into acute and chronic phases on the basis of the injury time. Unfortunately, there are few effective therapies for preventing or mitigating this injury. Over the last few decades, various studies have focused on the effects of stem cell-based therapies to address the tissue repair and regeneration of irradiated skin. These stem cells modulate inflammation and instigate tissue repair by differentiating into specific kinds of cells or releasing paracrine factors. Stem cell-based therapies, including bone marrow-derived stem cells (BMSCs), adipose-derived stem cells (ADSCs) and stromal vascular fraction (SVF), have been reported to facilitate wound healing after radiation exposure. Moreover, stem cell-derived exosomes have recently been suggested as an effective and cell-free approach to support skin regeneration, circumventing the concerns respecting direct application of stem cells. Based on the literature on stem cell-based therapies for radiation-induced skin injury, we summarize the characteristics of different stem cells and describe their latest animal and clinical applications, as well as potential mechanisms. The promise of stem-cell based therapies against radiation-induced skin injury contribute to our response to nuclear events and smooth progress of cancer radiotherapy.

Laser therapy as a treatment for chronic radiation fibrosis

BACKGROUND

Chronic radiation fibrosis (CRF) is a long-term sequala of radiation therapy that has a significant impact on patient quality of life. There is no standard of care or single therapeutic modality that has been found to be consistently effective.

OBJECTIVE

To describe our experience using fractional 10,600 nm carbon dioxide (CO₂ ) laser therapy and vascular laser therapy in a series of patients with CRF.

METHODS

Patients presenting to the dermatology service for CRF were evaluated for laser therapy eligibility. Patients were eligible if they had a clinical diagnosis of CRF confirmed by physical examination.

RESULTS

We identified five patients with CRF treated with fractional ablative CO₂ laser and vascular laser. Patients were a median age of 57 years old, and the amount of time between the initiation of radiotherapy and laser treatment ranged between 3 months and 40 years. The satisfactory response was achieved in all cases.

LIMITATIONS

Lack of standardized laser protocol, small sample size, lack of a control group, different anatomical locations CONCLUSION: Fractional ablative and vascular laser therapy may serve as an additional treatment for CRF, leading to functional improvements.

Comparison of clinical practice guidelines on radiation dermatitis: a narrative review

PURPOSE

Radiation dermatitis (RD) is a common side effect of radiation therapy (RT). While many different treatment strategies are currently used to address RD, there is a lack of consensus and RD prophylaxis and management guidelines have remained largely unchanged over the last 10 years. This review aims to formulate unambiguous supportive care interventions by comparing RD clinical practice guidelines published between 2010 and 2021 by several organizations: Multinational Association for Supportive Care in Cancer (MASCC), British Columbia Cancer Agency (BCCA), Cancer Care Manitoba (CCMB), Oncology Nursing Society (ONS), Society and College of Radiographers (SCoR), and International Society of Nurses in Cancer Care (ISNCC).

METHODS

Areas of agreement and discordance were assessed among the MASCC, BCCA, CCMB, ONS, SCoR, and ISNCC guidelines.

RESULTS

Treatment recommendations across guidelines for acute RD and chronic RT-induced skin toxicities have been summarized. The strongest agreement among the guidelines exists for the use of topical corticosteroids, silver sulfadiazine, washing, and deodorant. All guidelines recommend the use of topical corticosteroids, and washing with water and soap is consistently supported. There is minimal consensus on an optimal dressing or barrier film for RD prophylaxis or management. MASCC weakly recommends prophylactic use of silver sulfadiazine to reduce RD, while BCCA, CCMB, and SCoR recommend its use upon signs of infection. MASCC and CCMB recommend the use of a long-pulsed dye laser to manage telangiectasia, a late effect of RT.

CONCLUSIONS

Given the extent of discordance among guideline recommendations, further research is recommended to establish optimal treatments for RD prophylaxis and management.

Comparison of clinical practice guidelines on radiation dermatitis: a narrative review

PURPOSE

Radiation dermatitis (RD) is a common side effect of radiation therapy (RT). While many different treatment strategies are currently used to address RD, there is a lack of consensus and RD prophylaxis and management guidelines have remained largely unchanged over the last 10 years. This review aims to formulate unambiguous supportive care interventions by comparing RD clinical practice guidelines published between 2010 and 2021 by several organizations: Multinational Association for Supportive Care in Cancer (MASCC), British Columbia Cancer Agency (BCCA), Cancer Care Manitoba (CCMB), Oncology Nursing Society (ONS), Society and College of Radiographers (SCoR), and International Society of Nurses in Cancer Care (ISNCC).

METHODS

Areas of agreement and discordance were assessed among the MASCC, BCCA, CCMB, ONS, SCoR, and ISNCC guidelines.

RESULTS

Treatment recommendations across guidelines for acute RD and chronic RT-induced skin toxicities have been summarized. The strongest agreement among the guidelines exists for the use of topical corticosteroids, silver sulfadiazine, washing, and deodorant. All guidelines recommend the use of topical corticosteroids, and washing with water and soap is consistently supported. There is minimal consensus on an optimal dressing or barrier film for RD prophylaxis or management. MASCC weakly recommends prophylactic use of silver sulfadiazine to reduce RD, while BCCA, CCMB, and SCoR recommend its use upon signs of infection. MASCC and CCMB recommend the use of a long-pulsed dye laser to manage telangiectasia, a late effect of RT.

CONCLUSIONS

Given the extent of discordance among guideline recommendations, further research is recommended to establish optimal treatments for RD prophylaxis and management.

Aesthetic Treatments in Cancer Patients

Cancer patients are experiencing an increase in overall survival as a consequence of earlier diagnosis and newer effective anticancer therapies. However, cancer survivors often face long-term consequences from their original cancer diagnosis and long-term sequelae of anticancer treatment. Maintaining patients’ quality of life is of paramount importance and this can be accomplished by a multidisciplinary treatment approach, including aesthetic treatments to improve patients’ body image and positively impact their quality of life. In this perspective, we will discuss the importance of aesthetic treatments in cancer patients. In addition, we will summarise the data available regarding the use of several aesthetic treatments such as fillers, botulinum toxin and laser use in cancer patients, their safety, their efficacy, and the specific precautions that need to be implemented in this particular subset of cancer patients.

Dermatologic toxicities associated with radiation therapy in women with breast cancer

Breast-conserving surgery with adjuvant radiation therapy has become the standard of care for women with early stage breast cancer, and as a result, a large number of patients are affected by the cutaneous sequelae of radiation therapy. These dermatologic toxicities may present during treatment or years later and can significantly impact patients’ quality of life. In this review, we discuss the clinical presentation, prevention, and management of radiation-induced cutaneous toxicities in women with breast cancer, including radiation dermatitis, radiation recall, radiation-induced morphea, radiation-induced fibrosis, and cutaneous malignancies in irradiated skin.

Restorative oncodermatology: Diagnosis and management of dermatologic sequelae from cancer therapies

The long-term survival of patients with cancer has risen dramatically during the last few decades. Despite this remarkable success, the same treatments that have enabled cure or remission often secondarily affect the skin, hair, and nails. Conditions including scarring, striae distensae, persistent alopecia, pigmentary changes, nail alterations, chronic radiation dermatitis, and radiation fibrosis have been associated with anxiety, depression, decreased quality of life, and impaired function. These dermatologic changes are cosmetically disfiguring, may limit activities, and are a visual reminder of past illness. Interventions toward improving these untoward sequelae and restoring the appearance and function of skin and appendages are critical for normalization and may contribute to improved quality of life in cancer survivors. Here, we outline dermatologic sequelae of cancer therapies with a review of medical and procedural treatment strategies to restore dermatologic health in the survivorship population.

Topical brimonidine reduces IPL-induced erythema without affecting efficacy: A randomized controlled trial in patients with facial telangiectasias

BACKGROUND

Laser and intense pulsed light (IPL) are standard symptomatic treatments for superficial telangiectasias, but postoperative erythema, oedema, and pain may prolong downtime.

OBJECTIVES

To investigate whether topical brimonidine reduces IPL-induced inflammation in patients with moderate to severe facial telangiectasias.

METHODS

A randomized, two-centre, single-blinded, split-face trial on adjuvant brimonidine and air-cooling versus air-cooling alone (control) in 19 patients treated in Denmark (n = 10 patients) and Belgium (n = 9). Brimonidine was applied to the allocated side after each of three facial IPL-treatments, given at 3-week intervals. Patients were assessed up to 1 month after the final treatment. Outcome measures included blinded clinical on-site evaluation of erythema and oedema (5-point-scales), objective erythema-scores (red-filter analysis), patient-evaluated pain (Visual Analogue Scale), IPL-efficacy (blinded photo-evaluation of telangiectasia clearance), and patient preference.

RESULTS

In total, 19 patients were enrolled and completed the study. IPL induced moderate to severe erythema after each treatment. Application of brimonidine, reduced erythema to baseline values compared to air-cooling alone and sustained efficacy 24 hours after treatment (median difference reduction: score 1 at each assessment, P ≤ 0.022). Objective erythema-scores supported clinical findings, demonstrating a median erythema reduction of 50-95% after application of brimonidine and air-cooling compared to 9-28% reduction after air-cooling alone (P ≥ 0.002). No difference in reduction of IPL-induced oedema was observed between facial sides (P ≥ 0.227). Brimonidine and air-cooling slightly and consistently reduced postoperative pain compared to air-cooling alone (VAS 1.0 after brimonidine versus VAS 1.5-2.0 after air-cooling alone at treatment 1-3, P ≤ 0.032). At 1-month follow-up, patients experienced excellent clearance of telangiectasias (75-100% clearance) on both facial sides (P = 1.000). Patient preference supported clinical data and 79% of patients preferred brimonidine to control (P = 0.019).

CONCLUSION

Compared to air-cooling alone, adjuvant brimonidine reduces IPL-induced erythema and associated pain while maintaining a high IPL-efficacy. Lasers Surg. Med. 50:1002-1009, 2018. © 2018 Wiley Periodicals, Inc.

Effect of laser therapy on quality of life in patients with radiation-induced breast telangiectasias

OBJECTIVE

To evaluate the effects of laser monotherapy on quality of life in breast cancer patients with chronic radiation dermatitis.

STUDY DESIGN

A prospective, IRB-approved study was conducted at Memorial Sloan Kettering Cancer Center. Breast cancer patients with chronic radiation dermatitis completed health-related quality of life (HR-QOL) questionnaires before and after laser monotherapy for radiation-induced breast telangiectasias (RIBT).

METHODS

After informed consent, all patients were issued the Skindex-16 and Breast-Q Adverse Effects of Radiation HR-QOL questionnaires prior to receiving laser treatment. Patients were treated with a 595 nm pulsed dye laser at 4- to 6-week intervals, with percent telangiectasia clearance and adverse events recorded at each visit. Post-treatment HR-QOL questionnaires were collected after clinician-assessed telangiectasia clearance of >50%. Median HR-QOL scores before and after therapy were reported for individual HR-QOL domains (Skindex-16) and HR-QOL totals (Skindex-16 and Breast-Q Adverse Effects of Radiation). Before- and after-differences were calculated using the Wilcoxon Signed-Rank Test.

RESULTS

Twenty-two female patients (average age 56 years) enrolled in this study. A majority (13/22, 59%) exhibited telangiectasias across the décolletage and axilla in addition to the breast. Sixteen patients reached the 50% RIBT clearance threshold during the study period, and 11 of these patients (69%) completed follow-up HR-QOL questionnaires. Patients showed statistically significant improvements in emotional and functional Skindex-16 HR-QOL domains and in overall Skindex-16 HR-QOL score. Breast-Q scores also improved significantly, illustrating a decrease in specific physical and cosmetic concerns common to radiated breast skin. Common adverse events were transient post-treatment pain and redness.

CONCLUSION

Breast cancer patients with RIBT presented with substantial deficits in several HR-QOL arenas. Laser monotherapy effectively treated the appearance of radiation dermatitis in these patients and also significantly improved HR-QOL. Lasers Surg. Med. 50:284-290, 2018. © 2017 Wiley Periodicals, Inc.

Prevention and treatment of acute and chronic radiodermatitis

More than half the number of patients with cancer, who are treated with radiotherapy, will have radiodermatitis at some point during their treatment. Radiodermatitis either occurs early on in the treatment period or appears months or up to several years later. Acute radiodermatitis is a burn injury that varies in severity according to both treatment and inherent patient factors. Most acute radiodermatitis reactions resolve after several weeks but some reactions persist and can cause complications. Late-onset radiodermatitis is characterized by telangiectasia that forms on atrophic and fragile skin. These radiodermatitis reactions can have a significant negative impact on concomitant and subsequent therapeutic protocols and most particularly on the patient’s quality of life. Today, treatment of radiodermatitis reactions is in its infancy. Although there is insufficient evidence available to form recommendations that would prevent or reduce radiodermatitis, some advances have been made using low level light therapy (LLLT) or vascular lasers to control the symptoms. Some recent preclinical and clinical research suggests that LLLT has biostimulating properties which allow the tissues to regenerate and heal faster, reduce inflammation, and prevent fibrosis. Also, in late-onset radiodermatitis pulsed dye laser treatment has been shown to be beneficial in clearing radiation-induced telangiectasia. In the absence of evidence-based recommendations, the objective of this paper is to review how to prevent or manage the symptoms of radiodermatitis reactions.

Radiodermatitis: A Review of Our Current Understanding

Radiodermatitis (radiation dermatitis, radiation-induced skin reactions, or radiation injury) is a significant side effect of ionizing radiation delivered to the skin during cancer treatment as well as a result of nuclear attacks and disasters, such as that which occurred in Fukushima in 2011. More specifically, 95 % of cancer patients receiving radiation therapy will develop some form of radiodermatitis, including erythema, dry desquamation, and moist desquamation. These radiation skin reactions result in a myriad of complications, including delays in treatment, diminished aesthetic appeal, and reduced quality of life. Recent technological advancements and novel treatment regimens have only been successful in partly ameliorating these adverse side effects. This article examines the current knowledge surrounding the pathogenesis, clinical manifestations, differential diagnoses, prevention, and management of radiodermatitis. Future research should examine therapies that incorporate the current understanding of the pathophysiology of radiodermatitis while measuring effectiveness using objective and universal outcome measures.

Comparative effectiveness of nonpurpuragenic 595-nm pulsed dye laser and microsecond 1064-nm neodymium:yttrium-aluminum-garnet laser for treatment of diffuse facial erythema: A double-blind randomized controlled trial

BACKGROUND

Facial erythema is a common symptom that responds to vascular laser treatment, but there are few comparative studies.

OBJECTIVE

We sought to compare the effectiveness of microsecond 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with nonpurpuragenic 595-nm pulsed dye laser (PDL) for diffuse facial erythema.

METHODS

This was a split-face, double-blind randomized controlled trial. Bilateral cheeks received 4 treatments each at one month intervals with PDL or Nd:YAG. Spectrophotometer measurements, digital photographs, pain scores, and patient preferences were recorded.

RESULTS

Sixteen patients enrolled and 2 dropped out. Fourteen patients, all skin types I to III, 57% women, mean age 42 years, completed the study and were analyzed. Spectrophotometer readings changed after both PDL (8.9%) and Nd:YAG (2.5%), but varied by treatment type, with PDL reducing facial redness 6.4% more from baseline than Nd:YAG (P = .0199; 95% confidence interval -11.6 to -1.2). Pain varied (P = .0028), with Nd:YAG associated with less pain, at 3.07, than PDL at 3.87. Subjects rated redness as improved by 52% as a result of PDL, and 34% as a result of Nd:YAG (P = .031; 95% confidence interval -34.6 to -1.94). No serious adverse events were observed.

LIMITATIONS

Lasers settings are not standardized across devices.

CONCLUSION

Facial erythema is safely and effectively treated with PDL and Nd:YAG. Nonpupuragenic PDL may be more effective for lighter-skinned patients, but microsecond Nd:YAG may be less painful.

Intense pulsed light (IPL): a review

BACKGROUND

Intense pulsed light (IPL) devices use flashlamps and bandpass filters to emit polychromatic incoherent high-intensity pulsed light of determined wavelength spectrum, fluence, and pulse duration. Similar to lasers, the basic principle of IPL devices is a more or less selective thermal damage of the target. The combination of prescribed wavelengths, fluences, pulse durations, and pulse intervals facilitates the treatment of a wide spectrum of skin conditions.

OBJECTIVE

To summarize the physics of IPL, to provide guidance for the practical use of IPL devices, and to discuss the current literature on IPL in the treatment of unwanted hair growth, vascular lesions, pigmented lesions, acne vulgaris, and photodamaged skin and as a light source for PDT and skin rejuvenation.

METHODS

A systematic search of several electronic databases, including Medline and PubMed and the authors experience on intense pulsed light.

RESULTS

Numerous trials show the effectiveness and compatibility of IPL devices.

CONCLUSION

Most comparative trials attest IPLs similar effectiveness to lasers (level of evidence: 2b to 4, depending on the indication). However, large controlled and blinded comparative trials with an extended follow-up period are necessary.

[Vascular lasers]

After reviewing the main technical features of the lasers and flashlamps currently available, the indications for these devices are detailed, mainly port wine stains, facial telangiectasia, hemangiomas, and lower-limb varicosities. Respecting the principles of treatment (briefly reviewed herein), contributes to preventing complications, which are consequently becoming rare.