Somnolence Syndrome Central Nervous System

typically occur several days to weeks after commencement of RT and after multifraction- ated doses totaling 20 Gy Archambeau et al. 1995 ; Chopra and Bogart 2009 ; Salvo et al. 2010 ; Feight et al. 2011 . Dose tolerance in normal skin is 45 Gy with increasing symptoms with greater cumulative RT doses and concomitant chemo- therapy Archambeau et al. 1995 . Fluorouracil and epidermal growth factor receptor inhibitors such as cetuximab have been reported to worsen radiation dermatitis in adult patients Archambeau et al. 1995 ; Budach et al. 2007 . Concurrent che- motherapy with radiosensitizers such as dactino- mycin and doxorubicin may play a role in the severity of radiation dermatitis in pediatric patients but has not been characterized in part due to the scheduling of these agents around RT Archambeau et al. 1995 ; Krasin et al. 2009 . Areas most affected are those containing skin folds such as the axillae, groin and inframam- mary folds Feight et al. 2011 . The earliest skin changes are pruritus, mild erythema, anhydrosis, and dry desquamation progressing to tender ery- thema, edema, and moist desquamation and, in severe cases, ulceration and necrosis. Data on incidence of dermatitis in children are lacking. Radiation recall, which can be precipitated by multiple agents and can occur days to years after RT, most often presents as low-grade dermatitis in a previously irradiated region although more severe reactions can also occur Burris and Hurtig 2010 . Although there are a large number of adult studies which have reported on prevention and management of acute radiation dermatitis, many have small patient numbers with confl icting results. Pediatric data are almost completely lacking with only one reported study with 45 patients Merchant et al. 2007 . Multiple system- atic reviews have been conducted though which are a useful guide from which to give direction Bolderston et al. 2006 ; Kedge 2009 ; Kumar et al. 2010 ; Salvo et al. 2010 ; Feight et al. 2011 ; McQuestion 2011 ; Chan et al. 2012 ; Wong et al. 2013 . General management recommendations include the use of loose fi tting clothing, preven- tion of scratching or other abrasive activities, protection from the sun with hats and sunscreen, avoidance of temperature extremes, avoidance of cornstarch or baby powder especially to skin folds, use of an electric razor rather than a straight blade, use of non-aluminum-based deodorant on intact skin, avoidance of cosmetic products in the treatment fi eld, avoidance of swimming in lakes or chlorinated pools, and use of gentle, non- perfumed soaps and lotions Feight et al. 2011 ; McQuestion 2011 . Although initially thought that washing of skin and hair in the radiation fi eld would lead to increased toxicity, multiple studies have shown this to be safe Bolderston et al. 2006 ; Kumar et al. 2010 ; Salvo et al. 2010 ; Feight et al. 2011 ; McQuestion 2011 ; Chan et al. 2012 ; Wong et al. 2013 . It is vital though that the irradiated areas be dry at the immediate time of treatment to prevent increasing the RT dose to the skin surface Bernier et al. 2008 . Multiple topical agents for the prevention and treatment of radiation dermatitis have been studied including aloe vera, steroid creams, trola- mine Biafi ne ® , calendula marigold extract, hyaluronic acid Xclair ® , sucralfate, silver sulfa- diazine, 3M™ Cavilon™ no-sting barrier fi lm, and petroleum-based ointment Aquaphor, among other more obscure substances Salvo et al. 2010 ; Feight et al. 2011 ; McQuestion 2011 ; Wong et al. 2013 . Certain agents such as aloe vera, sucralfate, and trolamine are clearly without benefi t, while others such as calendula, Aquaphor, hyaluronic acid, steroid creams, and silver sulfa- diazine are lacking in evidence Kumar et al. 2010 ; Salvo et al. 2010 ; Feight et al. 2011 ; Wong et al. 2013 . Benefi t of silymarin milk thistle extract has also been reported in a nonrandom- ized trial Becker-Schiebe et al. 2011 . Due to the lack of consistent and well-powered results, rec- ommendations from the systematic reviews are variable with Salvo et al. 2010 and Chan et al. 2012 favoring no topical agent, McQuestion 2011 and Feight et al. 2011 endorsing calen- dula and hyaluronic acid, Bolderston et al. 2006 supporting topical steroids, Kumar et al. 2010 favoring calendula, Cavilon™, and topical ste- roids, and Wong et al. 2013 sanctioning topical steroids and silver sulfadiazine. All agree that larger, prospective, better designed studies are required to answer the many remaining questions