Moist Desquamation in the Inframammary Fold During Breast Radiotherapy

Reasoning

The presence of moist desquamation in the inframammary fold is consistent with CTCAE grade 2 radiation dermatitis (moist desquamation confined to skin folds). The offensive odour, surrounding erythema, pain of 7/10, and low-grade temperature raise concern for secondary bacterial infection or beginning cellulitis. Diabetes with poor glycaemic control impairs healing and increases infection risk.

Assessment should include:

• Size, depth, exudate, odour, and whether the moist area extends outside the fold.
• Surrounding skin: spreading erythema, induration, tenderness, lymphangitis, or pustules.
• Pain score and analgesic needs.
• Vital signs and blood glucose; a temperature of 37.9°C is not necessarily febrile but is a warning sign in a person with diabetes and broken skin.
• Nutritional status, hydration, and ability to self-care at home.
• Whether bolus is still being used over the affected area.

Red flags for urgent medical review include spreading cellulitis, fever, systemic symptoms, extensive moist desquamation outside the fold, or inability to manage the wound at home. This patient needs same-day oncologist and possibly diabetes team review; a wound swab should be taken before antibiotics if infection is suspected.

Reasoning

The decision must balance tumour control against acute toxicity and infection risk. The reaction is at fraction 12 of 15, so most of the whole-breast dose has been delivered. Continuing without modification risks worsening infection and poor healing; stopping unnecessarily risks underdosing.

Immediate actions:

• Notify the oncologist before treatment and ask them to review the skin.
• Remove bolus over the affected area; bolus increases surface dose and is likely contributing.
• Clean gently with warm water or saline, pat dry, and apply a non-adherent dressing; if infection is suspected, use an antimicrobial dressing and consider oral antibiotics after swab.
• Give regular analgesia and review diabetes control.
• Mark the affected area and document size and appearance.

Treatment decision: do not simply treat through an infected, painful moist desquamation without medical review. If the oncologist excludes cellulitis, treatment can often continue with bolus omitted and a plan for skin care. If cellulitis is present or the patient is systemically unwell, a short treatment break of 2–3 days may be appropriate, with documentation and a plan to complete the prescribed dose, for example by adding a fraction or treating over the weekend. The boost may need to be adjusted if the reaction remains severe. Any break must be justified and the patient told why.

Reasoning

Mrs A needs practical, written information and a safety net because she lives alone and may not recognize deterioration.

• Skin care: wash gently with lukewarm water, avoid perfumed products, avoid scrubbing or shaving the area, wear loose cotton clothing, and keep the fold dry. Do not apply creams unless prescribed.
• Dressing: show her or a district nurse how to apply and remove the dressing, and arrange community nursing support if she cannot manage.
• Pain: provide a written analgesia plan and explain when to take it. Uncontrolled pain should prompt a call.
• Diabetes: involve the diabetes team; poor glycaemic control slows healing. Encourage hydration and regular meals.
• When to call urgently: fever, spreading redness, worsening pain, offensive discharge, or feeling generally unwell. Give a direct contact number for the radiotherapy department and out-of-hours advice.
• Follow-up: review the skin in 48–72 hours, and sooner if symptoms worsen. Document the wound assessment and photographs according to local policy.
• Emotional support: acknowledge that the reaction is distressing and that living alone may increase anxiety. Offer a welfare check and transport support if needed.

The radiographer's role is to escalate, educate, and coordinate, not to manage infection independently.