Preventing ADRs

The nature and effects of ADRs have been described earlier. Central to prevention is familiarity with the drugs commonly causing drug eruptions and risk factors such as medication history or medical conditions such as an allergy history and renal or liver impairment that may affect elimination. Other risk factors include new drugs and first doses and contraindicated drugs, which are by definition those drugs where risk of patient harm is high. Assessment is therefore essential with a review of medical and medication history, allergy and the nature of any prior ADRs.

Managing lymphoedema
Evidence suggests that a combination of physical treatments are effective for managing lymphoedema (Ko et al., 1998), although there is limited evidence to identify which components are most important. The key elements include compression using bandaging or garments, massage, exercise and skin care. The international consensus document on lymphoedema management provides an evidence-based guideline on effective service models (Lymphoedema Framework, 2006). The skin care component highlights the importance of maintaining skin integrity and the care management of skin problems to minimise the risk of infection. Whilst the principles are summarised in Box 4.3, the guidelines specify the details.

Box 4.3 General principles of skin care for lymphoedema management. Wash daily using pH neutral soap or a soap substitute and dry thoroughly. Ensure skin folds, if present, are clean and dry. Monitor for affected and unaffected skin for cuts, abrasions or insect bites, paying specific attention to any areas affected by sensory neuropathy. Apply emollients. Avoid scented products. Source: Lymphoedema Framework (2006).

Vaqas and Ryan (2003) examined the management of lymphoedema in resource-poor settings. Those affected may include people with lymphatic filariasis, which affects up to 40 million people (Global Alliance to Eliminate Lymphatic Filariasis [GAELF]). Vaqas and Ryan highlighted the importance of ankle movement to improve lymph flow, limb elevation to reduce venous pressure in the lower limb and breathing exercises to support clearance of the central lymphatics. The role of skin care has been highlighted – especially maintaining epidermal integrity through careful washing of the skin and use of emollients to help maintain skin barrier integrity which in turn will help to prevent bacterial penetration. This is important given that recurrent inflammatory episodes are a common complication of lymphoedema and correlate with its grade of severity (Pani and Srividya, 1995).

Protecting the skin during radiotherapy
The consensus in the literature is that the severity of skin reactions can be reduced by washing the skin with mild soap or a cleansing agent and moisturising with a light moisturising cream or emollient (e.g. National Breast and Ovarian Cancer Centre, 2008). Mild soaps are typically considered those that are less irritant to the skin and have reduced levels of irritating additives such as perfumes. Furthermore, patients should also use sunscreen or wear protective clothing, avoid irritants (such as deodorant, perfume, hair dye) and keep the skin folds dry. Trial evidence in the breast cancer context suggests that washing irradiated skin during radiotherapy can be undertaken as it is not associated with increased skin toxicity (Roy et al., 2001). In a key study, Campbell and Illingworth (1992) found no statistically significant difference in the severity reaction between those washing with water alone and those using soap, although skin reactions were worse in patients who were not allowed to wash at all.

A review indicates that two preparations reduce the severity of skin reactions experienced by patients, i.e. sucralfate cream and hyaluronic acid cream (Naylor and Mallett, 2001), however, these may are not now available through the standard formulary (BNF). Furthermore, it is suggested that some cream (non-steroidal water in oil preparations) can limit the effects of radiation. A paper by Leonardi et al. (2008) evaluated a cream containing hyaluronic acid (which is a major component of the extracellular matrix of the skin) and shea butter. They found a statistically significant difference with the control vehicle on the severity of skin toxicity, burning and desquamation in favour of the cream, although the small number of patients may limit the study. Hyaluronic acid is the most powerful moisturising agent known because of its significant hygroscopic properties that enable it to attract 1,000 times its weight in water. Shea butter resembles sebum in its fatty acid composition and as such can help to restore skin barrier function, by supporting the skin elasticity and turgidity (Abramovits and Boguniewicz, 2006).

Well and MacBride (2003) gave an excellent summary of radiation skin reactions and their management. They highlight that there is limited data depicting patients’ experiences of skin reactions and much conflicting evidence on their prevention and management. The importance of patient information targeting at risk patients is also emphasised on the risks of breakdown and self-care strategies to minimise problems. Those at high risk include people with greater UV sensitivity, smokers, those with heavier breasts or larger tumours.