Treatments for head and neck cancers include surgery, chemotherapy, and radiotherapy, used either alone or in combination. Used to treat inoperable tumors, radiotherapy can cause radiation-induced dermatitis, which is treated with steroidal, nonsteroidal, and metallic topical medications. Researchers have studied the use of skin care products containing aloe vera (Aloe vera, Asphodelaceae) in patients undergoing radiotherapy. Aloe vera has been shown to have anti-inflammatory properties and researched for its use in treating a variety of skin ailments including eczema, psoriasis, burns, wounds, and ultraviolet (UV)-induced skin erythema. These authors conducted a single-center, investigator-blinded, randomized, clinical study to evaluate the efficacy of a topical aloe vera-based cream (AVC) in preventing radiation-induced dermatitis in patients undergoing therapeutic radiation for head and neck cancers.
The study was conducted between July 2012 and December 2012 in the Department of Radiation Oncology at Mangalore Institute of Oncology in Pumpwell, Mangalore, India. Eligible patients were those scheduled to receive radiotherapy or chemoradiotherapy 6 weeks following surgery and who had a Karnofsky Performance Status Scale score above 70, meaning that patients could care for themselves but could not carry on normal activity or do active work.
Sixty patients were randomly assigned, with 30 in each group, to either the Johnson’s® Baby Oil (JBO) (Johnson & Johnson; Mumbai, India) control group or the AVC Elovera® (Glenmark; Mumbai, India) group. Elovera consists primarily of 10% aloe vera extract and 0.5% vitamin E. At baseline, the mean age for the JBO group was 55.2 ± 9.66 years, and for the AVC group, 55.9 ± 8.99 years. Males represented 24 patients in the JBO group and 26 in the AVC group. During the second week of treatment, 1 patient in the JBO group died of cancer.
All patients received irradiation at a maximum energy level of 6 MV at a rate of 300 MU per minute. All fields were treated 5 days a week with no more than 1 fraction of 2 Gy daily. Patients scheduled for chemoradiotherapy received carboplatin infusions weekly 3 hours before the first weekly radiation treatment. Before starting the study, the patients and their caregivers were taught how to apply the JBO (5 mL) or AVC (5 g) 5 times daily as follows: 2 hours before, immediately after, and 2, 4, and 6 hours after radiotherapy. Use of JBO or AVC was discontinued if moist desquamation occurred, and 1% gentian violet paint was applied instead.
The patients were assessed for radiation-induced dermatitis weekly according to the criteria of the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer, which ranks skin condition as follows: grade 0 (no skin rending, ulceration, inflammation, or damage); grade 1 (faint erythema or dry desquamation); grade 2 (moderate to brisk erythema, patchy moist desquamation mostly confined to skin folds and creases, moderate edema); grade 3 (moist desquamation ≤1.5 cm in diameter in areas other than skin folds or creases, and bleeding induced by minor trauma or abrasion); and grade 4 (skin necrosis or ulceration of full-thickness dermis and spontaneous bleeding from the involved site).
After weeks 1 and 2, patients in both groups had normal skin, without any signs of radiation-induced dermatitis. Following week 2, dermatitis was observed in the 2 groups as follows:
- Week 3: 41.4% in the JBO group and 16.7% in the AVC group
- Week 4: 82.8% in the JBO group and 70% in the AVC group
- Week 5: 93.1% in the JBO group and 90% in the AVC group
- Weeks 6 and 7: 96.6% in the JBO group and 90% in the AVC group
- Two weeks post-treatment: 86.2% in the JBO group and 73.3% in the AVC group
Dermatitis reported in both groups at week 3 was grade 1; the between-group difference in the incidence was significant (P=0.04). After week 4, grade 2 dermatitis was seen in both groups. The most severe dermatitis of grade 3 was reported by 34.48% in the JBO group and 40% in the AVC group at week 7 (P=0.07). No one developed grade 4 dermatitis. Two weeks post-treatment, the average grade of dermatitis was lower in the AVC group compared with the JBO group; specifically, the patients in the AVC group had a significantly lower incidence of grade 2 dermatitis compared with the JBO group (P<0.02).
Earlier studies reported that aloe vera gel, used with mild soap, relieved dermatitis in women undergoing radiation for breast cancer1; “[h]owever,” write the authors of the study reported here, “the observation that an Aloe vera-based cream delays the incidence of dermatitis (when evaluated from the initiation of the treatment) is novel and indicates the usefulness of Aloe vera in enhancing the healing of radiation dermatitis.” Other studies have shown that aloe vera enhances wound healing.2,3
The authors conclude that the prophylactic use of an AVC delays the development of radiation-induced dermatitis in patients being treated for head and neck cancers. Further studies with a larger sample size are needed to further validate the efficacy of aloe vera.
1Ryan JL. Ionizing radiation: the good, the bad, and the ugly. J Invest Dermatol. 2012;132(3 Pt 2):985-993.
2Atiba A, Nishimura M, Kakinuma S, et al. Aloe vera oral administration accelerates acute radiation-delayed wound healing by stimulating transforming growth factor-β and fibroblast growth factor production. Am J Surg. 2011;201(6):809-818.
3Visuthikosol V, Chowchuen B, Sukwanarat Y, Sriurairatana S, Boonpucknavig V. Effect of Aloe vera gel to healing of burn wound: a clinical and histologic study. J Med Assoc Thai. 1995;78(8):403-409.
Rao S, Hegde SK, Baliga-Rao MP, Palatty PL, George T, Baliga MS. An Aloe vera-based cosmeceutical cream delays and mitigates ionizing radiation-induced dermatitis in head and neck cancer patients undergoing curative radiotherapy: a clinical study. Medicines (Basel). June 2017:4(3):44. doi: 10.3390/medicines4030044.