What type of burn may not develop findings shown until days to weeks after the exposure?

  1. Chemical
  2. Electrical
  3. Radiation
  4. Thermal

[Image generated via Google Gemini]

3. Radiation

Background

Radiation burns are caused by exposure to high-level ionizing radiation in the form of gamma rays, X-rays, or highly energetic beta particles [1]. Exposures can occur inadvertently when a person handles or is near an unshielded radiation source that emits penetrating ionizing radiation in the form of gamma or X-rays. External skin contamination with radioactive material that emits gamma rays or highly energetic beta particles can also lead to cutaneous radiation injury. This can happen with medical or industrial exposure, or in the aftermath of a nuclear detonation, a nuclear power plant emergency, or a radiological dispersal device (e.g., dirty bomb) [2].

In the medical setting, skin injury due to radiation is the most common side effect of radiotherapy and is reported in nearly 85-95% of patients during or after radiotherapy treatment [3,4].  Initial erythema may be followed by a latent phase where intense erythema and blistering may occur several days to weeks after exposure at the irradiated site [5].

How does radiation affect the skin? [3,6,7]

  • Radiation causes initial damage to the structural elements of the skin
  • Germinal epidermal and hair matrix cells are damaged, affecting skin cell repair/replacement
  • An inflammatory response inhibits cellular proliferation due to the release of proinflammatory cytokines and growth factors
  • Fibrosis, apoptosis, and changes in neovascularization also may occur, worsening the damage.
  • Injury is worsened with repetitive exposure, such as in radiotherapy treatment
  • Radiation dermatitis can be classified as:
    • Grade 1 – Faint erythema
    • Grade 2 – Moderate erythema, patchy moist desquamation
    • Grade 3 – Confluent moist desquamation, pitting edema
    • Grade 4 – Skin necrosis or full-thickness ulceration

What is the clinical presentation of radiation skin injury? [4,5,8]

  • Early signs and symptoms include itching, tingling, and transient erythema or edema.
  • A latent phase of days to weeks can occur after exposure.
  • Following the latent phase, patients may develop intense erythema, blistering, desquamation (both dry and moist), and ulceration, leading to necrosis.
  • Improvement and then worsening may occur in several waves depending on the extent of exposure: dosage, frequency, amount of irradiated tissue, and depth of tissue penetration.
  • Affected skin carries an increased risk of infection.
  • Comorbid conditions and concomitant chemotherapy increase the risk for severe skin manifestations.
  • Severe symptoms early post exposure indicates poorer prognosis.

 What is the management of radiation skin injury? [1,3,4]

  • Decontamination if indicated
  • Maintain good hygiene and moisture
  • Burn wound dressings
  • Pain management
  • Management of skin infections
  • Topical corticosteroids can be considered for intact skin
  • Surgical debridement if indicated
  • Consider the possibility of deeper injury

Bedside Pearls

  • Radiation skin injury can occur in patients undergoing radiotherapy.
  • Radiation injury may cause delayed skin symptoms after a latent phase.
  • The mainstay of treatment is skin hygiene, topical corticosteroids if intact skin, and management of infections and pain.

The American College of Medical Toxicology hosts this Toxicology Visual Pearls series. The post was peer reviewed on behalf of ACMT by Drs. Howard A Greller, Louise Kao, and Ziad Kazzi.

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References

  1. Ullah S, Mansoor S, Ayub A, et al. An update on stem cells applications in burn wound healing. Tissue Cell. 2021;72:101527. PMID: 33756272.
  2. “Ionizing Radiation and Health Effects.” World Health Organization, World Health Organization, 27 July 2023, www.who.int/news-room/fact-sheets/detail/ionizing-radiation-and-health-effects.
  3. Yang X, Ren H, Guo X, Hu C, Fu J. Radiation-induced skin injury: pathogenesis, treatment, and management. Aging (Albany NY). 2020;12(22):23379-23393. PMCID: PMC7746368.
  4. Rosenthal A, Israilevich R, Moy R. Management of acute radiation dermatitis: A review of the literature and proposal for treatment algorithm. J Am Acad Dermatol. 2019;81(2):558-567. PMID: 30802561.
  5. Cutaneous Radiation Injury (CRI): Information for Clinicians | Radiation Emergencies | CDC. April 17, 2024.  Accessed April 3, 2026
  6. Alexopoulou E, Katsila T, Tolia M, et al. An Exploratory Study of Radiation Dermatitis in Breast Cancer Patients. Anticancer Res. 2018;38(3):1615-1622. PMID: 29491093.
  7. Hymes SR, Strom EA, Fife C. Radiation dermatitis: clinical presentation, pathophysiology, and treatment 2006. J Am Acad Dermatol. 2006;54(1):28-46. PMID: 16384753.
  8. Iddins CJ, DiCarlo AL, Ervin MD, Herrera-Reyes E, Goans RE. Cutaneous and local radiation injuries. J Radiol Prot. 2022;42(1):10.1088/1361-6498/ac241a. Published 2022 Jan 12. PMID: 34488201.
Kevin Black, DDS, MD

Kevin Black, DDS, MD

Emergency Medicine Ultrasound Fellow
Carolinas Medical Center
Kevin Black, DDS, MD

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Erik Fisher, MD

Erik Fisher, MD

Associate Program Director, Medical Toxicology Fellowship
Atrium Health Carolinas Medical Center and Levine Children's Hospital
Clinical Assistant Professor of Emergency Medicine
Wake Forest School of Medicine