# Radiation-induced skin injury: a review of pathophysiology, assessment, management, and re-irradiation protocols

## TL;DR

This review discusses the causes, assessment, and treatment of skin injuries caused by radiation therapy, with a focus on new therapies and re-irradiation challenges.

## Contribution

The paper provides an updated synthesis of RISI mechanisms, assessment tools, and emerging therapies, particularly for re-irradiation scenarios.

## Key findings

- Mesenchymal stem cells and mitochondrial-targeted antioxidants show promise in reducing radiation-induced skin injury.
- Re-irradiation increases the risk of severe dermatitis, emphasizing the need for improved dose constraints.
- The RTOG scale is the gold standard for grading skin toxicity, alongside CTCAE and RISRAS.

## Abstract

Radiation-induced skin injury (RISI) is a common dose-limiting toxicity of radiotherapy, characterized by erythema, desquamation, fibrosis, atrophy, and ulceration. It results from DNA damage, reactive oxygen species, and dysregulated inflammation.

This review synthesizes current knowledge on the mechanisms, assessment tools, and management strategies of RISI, with a focus on emerging therapeutic approaches, particularly in patients requiring re-irradiation.

A search of PubMed, Embase, and Web of Science for English-language studies from 2020 to 2025 using terms like “radiation dermatitis,” “skin toxicity,” and “stem cell therapy” identified 122 pre-clinical and clinical studies.

Key grading tools for RISI include the Radiation Therapy Oncology Group (RTOG), Common Terminology Criteria for Adverse Events (CTCAE), and Radiation-Induced Skin Reaction Assessment Scale (RISRAS). Conventional treatments like corticosteroids and emollients alleviate symptoms but do not prevent chronic damage. Novel therapies, including mesenchymal stem cells and mitochondrial-targeted antioxidants, show promise in reducing dermal injury and enhancing repair. Re-irradiated patients experience increased severe dermatitis, highlighting the need for better dose-to-skin constraints.

While current management remains mostly palliative, emerging therapies when guided by standardized assessment tools (including the widely used RTOG scale, which remains the clinical gold standard for skin toxicity grading), alongside CTCAE and RISRAS and individualized treatment planning offer hope for reducing acute and long-term skin damage, especially in re-irradiation cases.