Managing Radiotherapy Induced Skin Reactions

Transcription

1 Managing Radiotherapy Induced Skin Reactions A Toolkit for Healthcare Professionals The Princess Royal Radiotherapy Review Team Supported by:

2 Introduction This Toolkit has been developed as an educational resource supporting the assessment and management of radiotherapy induced skin reactions. The toolkit can be adapted to suit the clinical needs of your patients and the healthcare setting in which they are being treated. We hope that you will find it useful. Princess Royal Radiotherapy Review Team St James s Institute of Oncology, The Leeds Teaching Hospitals NHS Trust A Joint Working initiative NHS organisations and staff are encouraged to consider the opportunities for joint working with the pharmaceutical industry, where the benefits that this could bring to patient care and the difference it can make to their health and well-being are clearly advantageous. A philosophy of developing appropriate partnerships to help achieve high quality patient care could further enhance the objectives of a patient-centred NHS. The development of effective and clinically appropriate joint working with external stakeholders can contribute to building an NHS that is truly a beacon to the world. The learning from a number of partnership projects has confirmed that joint working can provide real benefits to patients whilst supporting the strategic objectives of the delivery partners. Accordingly, NHS organisations and staff are encouraged to consider joint working as a realistic option for the delivery of high-quality healthcare. Joint working between the pharmaceutical industry and the NHS must be for the benefit of patients or the NHS, preserve patient care and should be of mutual benefit, with the principal beneficiary being the patient. All content and clinical guidance is drawn from current clinical practice and a review of evidence by the Princess Royal Radiotherapy Review Clinic. Under a joint working initiative, Aspen Medical Europe Ltd, Molnlycke Healthcare Ltd and Smith and Nephew Ltd are supporting the production and wider awareness of this Toolkit. (Excerpts from Best Practice Guidance on joint working between the NHS and pharmaceutical industry and other commercial organistions, DoH, 2008) Contents This toolkit aims to provide Healthcare Professionals with: 1. An understanding of the mechanism of skin damage specific to radiotherapy and factors that can exacerbate the reaction. 2. A guide to care goals and objectives. 3. An assessment framework and the treatment options, with rationale for each stage, including information about the best use of suitable products.. 4. A resources section containing: Materials for use when advising patients and other health professionals involved in patients continuing care A short post-training assessment Links to information and further advice

3 Radiotherapy Induced Skin Reactions Radiotherapy is a major modality in the management of cancer treatment, along with chemotherapy and surgery. One of the most common side effects of radiation is acute skin reaction which can range from mild erythema to confluent moist desquamation and occasionally, ulceration. All patients receiving external beam radiotherapy are at potential risk of developing a reaction within the treatment field with approximately 85 87% of these patients experiencing a moderate to severe skin reaction 1,2,3 of which 10-15% will progress to moist desquamation 4. Radiation skin reactions are not burns ; they occur as a result of damage to the basal cell layer of the skin and the resultant imbalance between the normal production of cells in this layer and the destruction of cells at the skin surface. It is essential that any damage is minimised, as far as possible, by ensuring that interventions are based upon best practice and supported by evidence based guidelines 5. There is a lack of randomised controlled trials to evaluate prophylactic skin care interventions and treatment of radiotherapy skin reactions. Therefore this guidance has been drawn from available published evidence, expert opinion from specialists within the field of radiotherapy and the Leeds Teaching Hospitals Trust Radiotherapy Skin Care Guidelines.

4 1. Radiotherapy and the skin Structure of normal skin Effect of radiotherapy Epithelial cells in basal membrane damaged by radiation Damaged cells from basal membrane migrating upwards New epithelial cells generated in basal membrane Radiotherapy causes biochemical changes within cells, as the DNA molecules are susceptible to radiation damage during mitosis. Radiobiological damage affects regeneration of the skin by the process of repair, redistribution, repopulation and reoxygenation. Damaged cells are replaced by cells moving from the resting phase into the active cycle (repopulation). Skin damage occurs when the rate of repopulation of the basal cell layer (Stratum Germinativum) cannot match the rate of cell destruction by treatment 6. The inflammatory response activated is a normal physiological reaction to radiotherapy. Radiotherapy induced skin damage is seen approximately days following the first fraction of radiation, corresponding with the time it takes for the damaged basal cells to migrate to the skin surface. Initially the skin will become warm, and reddened (erythema), and in some patients the area may also feel itchy. As the skin is damaged through further exposure to radiation it tries to compensate by increasing mitotic activity in order to replace the damaged cells. However, if the new cells reproduce faster than the old cells are shed then the skin will become dry and flaky (dry desquamation). As radiotherapy continues the basal layer cannot produce enough new cells to replace the old ones and therefore the outer layer of the epidermis will become broken, oedematous with exudate (moist desquamation). The exudate is normal and rich in nutrients which helps the growth of new skin cells. Skin necrosis is rarely seen primarily due to the advanced techniques used in the delivery of radiotherapy. The severity of skin reactions may increase for 7-10 days after radiotherapy has finished. It can take this amount of time for the cells that have been affected by radiotherapy to reach the outer epidermis. This is often referred to as the peak, when the side effects can be at their worse. After this time side effects will gradually start to settle down and the condition of the skin will slowly improve. 4-6 weeks after treatment has been completed, skin should be healing well and may even be fully healed with the exception that the area may still look hyperpigmented (darker). It takes this amount of time for the basal cells of the epidermis to recover and for new skin to start to grow and heal 7,8.

5 Radiotherapy cycle Treatment completed. Takes days for basal cells to recover & new skin to grow. Radiotherapy commences. Activates inflammatory response. No new cells to replace dead cells = moist desquamation days from 1st treatment. Damaged basal cells migrate to skin surface. Erythema develops. Further skin damage New cells reproduce before old dead cells shed = dry desquamation. How are radiotherapy skin reactions different to burns? The assessment and management of burns is different to that of radiotherapy-induced skin reactions. They differ in terms of cause mechanisms, extent, duration and trajectory. Inaccurate assessment can lead to inappropriate treatment Understanding the differences is pivotal in implementing correct interventions. Radiotherapy Skin Reaction Cause Absorption of energy from ionising radiation affecting the process of regeneration Time to Delayed - days Reaction Skin Layers Epidermal layers only Affected Sequence Damaged basal cells migrate upwards to the surface of the skin of Damage Burn Injury Trauma - e.g. fire, hot liquids, hot objects, freezing objects, corrosive chemicals, electric current, UV light, etc. Immediate - minutes Potentially all layers from epidermis down to muscle / tendon / bone. (Superficial - full thickness depths) Damage occurs downwards through skin layers in relation to degree of burn

6 2. Intrinsic & Extrinsic Predisposing Factors for Radiotherapy-induced skin reactions Intrinsic Age: The natural ageing process affects the epidermal cell cycle which can result in extended healing times. Nutrition: Adequate nutritional intake is necessary for optimum repair of tissue damage. The skin of undernourished patients may be at increased risk of damage. 6,9,10,11 Smoking and Alcohol Can decrease capillary blood flow and oxygen levels thus increasing the severity of the skin reaction and impairing the body s ability to heal damaged tissues and fight infection. Co-morbidities: Other illnesses and some medications can increase the risk and intensity of skin reactions and impact upon the healing process e.g. diabetes 12,steroids. UV exposure / ethnic origin: There is a suggestion that patients with long term UV exposure will experience a more severe radiation-induced skin reaction and impaired healing. Patients from BME groups have reported more severe post-treatment skin reactions compared to white patients 13. Obesity: Extra adipose tissue can compromise healing and exacerbate skin toxicity due to the extra skin folds or areas where there is a natural skin fold e.g. natal cleft and inframammary fold. Infection: The presence of bacterial and/or fungal infection can damage the cells in the basal layer resulting in delayed healing 14. Extrinsic Radiotherapy: Energy of radiotherapy: Radiosensitisers: Higher doses; larger fields; increased volume and presence of bolus can all lead to increased skin reactions The higher the energy the lesser the skin reaction. Megavoltage beams (energies above 1MV) deliver maximum dose underneath the surface of the skin (skin sparing effect) whilst kilovoltage beams (energies below 1 MV) deliver maximum dose to the surface of the skin therefore increasing the skin reaction. Some chemotherapy agents are radiosensitisers (e.g. 5-Fluorouracil, Mitomycin C, Cisplatin) and therefore increase the severity of skin reaction. Chemical/Thermal/Mechanical: irritants can exacerbate the skin reaction and delay the healing process. Chemicals such as deodorants, perfume, talcum powder and aftershave, metal-containing dressings and creams. Extremes in temperature e.g. hot water bottles, ice packs. Friction by rubbing skin or wearing tight fitting clothing.

7 3. Goals of Care for Skin Reactions During Radiotherapy Initially, maintaining integrity and hydration of the skin Reducing potential for further exacerbation of the skin reaction Promotion of comfort and compliance Reduction of pain Protection from trauma Prevention of infection Promotion of a moist wound healing environment, in the stages where skin is broken Control of bleeding, odour and excessive exudate, where radiotherapy is being given for symptom management of a fungating lesion Post-Radiotherapy The severity of skin reactions can increase and peak around 7-10 days after treatment has finished. - Within this 7-10 day period there is a continuing lack of new cells being produced to replace the old cells. Within 4 6 weeks of completing radiotherapy treatment, skin should be improving significantly, if not fully healed. - It takes this amount of time for the basal cells of the epidermis to recover and for these new cells to reach the surface enabling new skin to grow and heal. 7,8 The rationales for interventions post radiotherapy are the same as during radiotherapy - Comfort, reduce the risk of infection and further trauma and ultimately, promotion of healing. - Interventions should be matched to the skin reaction based on continuous assessment of the skin and RTOG score. As part of the expected radiotherapy skin reaction the body produces a greenish/yellow exudate within areas of moist desquamation. - This should not be cleaned off (unless there are excessive amounts) as it assists with the healing process post treatment and provides pain relief by bathing the exposed nerve endings within the area of moist desquamation.

8 4. Assessment of Skin Reactions Skin Assessment Assessment of the skin forms an integral part of the patient s holistic care and starts with asking the right questions: WHAT - are we assessing? What do we see? What does the skin look like? What other structures are within the treatment field? What lies beneath the skin reaction? What does the patient report? What has changed? What is the cause? WHY - has it happened? Why are things changing - cause and effect? HOW - do we treat it? How do we make the right choices about appropriate actions and interventions? Predicting the severity of skin reactions can be difficult due to the varying radio-sensitivity of skin and a number of contributing factors 15. Intrinsic and extrinsic factors may significantly increase the severity of radiotherapy skin reactions which may delay the healing process 16. Individuals with darker skin may notice that the skin in the treatment field becomes darker initially before going through the other stages of the reaction. A study by Ryan et al (2007) reported that patients with dark/black skin reported more severe skin reactions at the treatment site than white skinned patients 13. A consistent approach to skin assessment is essential to ensure that the right interventions are implemented at the right time in response to ongoing assessment and evaluation. Without accurate assessment and relevant knowledge interventions may be inappropriate, dressing selection is likely to be arbitrary and ineffective, as well as wasteful both in terms of time and resources. Most importantly, inaccurate assessment and inappropriate interventions may cause harm and distress to the patient and ultimately, compromise the healing process. The use of an acute radiation scoring assessment tool is recommended to promote consistency and continuity of appropriate management and interventions during, and after, radiotherapy, until the reaction has settled. The most commonly used framework for objective evaluation of skin reactions is the Radiation Therapy Oncology Group (RTOG) grading system 17. The RTOG scoring criteria does not take account of the subjective aspects of skin damage such as pain and discomfort 18. If the skin reaction is causing pain or discomfort, our Trust guidelines recommend that the WHO analgesic ladder is used as a framework for appropriate pain management. RTOG Grading System: WHO Analgesic Ladder: Assessment / Observation RTOG 0 No visible change to skin RTOG 1 Faint or dull erythema. Mild tightness of skin and itching may occur RTOG 2 Bright erythema / dry desquamation. Sore, itchy and tight skin RTOG 2.5 Patchy moist desquamation Yellow/pale green exudate. Soreness with oedema RTOG 3 Confluent moist desquamation. Yellow/pale green exudate. Soreness with oedema RTOG 4 Ulceration, bleeding, necrosis (rarely seen) Effects of Radiotherapy on Skin Cells Step 3 Opioid for moderate to Severe pain +/- adjuvant analgesia Morphine, fentanyl etc Step 2 Opioid for mild to moderate pain Plus non opioid. +/- adjuvant analgesia Codeine, tramadol etc Step 1 Non opioid +/-adjuvant analgesia Paracetamol, aspirin or NSAID Adapted from World Health Organisation (WHO) analgesic ladder Pain persisting, move up one step Side effects reduce or signs of toxicity move down one step

9 5. Management of Radiotherapy Skin Reactions General advice given to all patients receiving radiotherapy treatment (in relation to the treatment field): - Continue washing/bathing as normal using non-perfumed soap and toiletries - Pat skin dry using a soft towel to avoid friction - Do not use perfumes, deodorants, talcum powder, creams or gels in the treatment field (other than ones recommended / prescribed by the Clinical Oncologist / Radiotherapy treatment centre) - The use of a plain, un-perfumed emollient (e.g. aqueous cream), recommended by the Radiotherapy treatment centre, to cleanse, soothe and soften the skin in the radiotherapy treatment field can help maintain skin moisture levels, skin integrity and patient comfort 19,20,21 - Advise to wear loose fitting clothing - Avoid exposure of skin to sun until healed then use a high factor suncream of SPF30 or above 23 as irradiated skin will always be more sensitive and at increased risk of sun damage. Sunscreens should be used in addition to clothing and shade to offer maximum protection - Swimming in chlorinated water can have a drying effect on the skin therefore it is advised that swimming is avoided until the skin reaction has completely settled and the skin is fully intact 21,24 - Avoid applying extremes of temperature e.g. hot water bottle/ice pack (specialist cooling dressings as recommended by the radiotherapy treatment centre can be used for symptomatic relief) - Do not wet shave or use hair removing products. Electric razors are suitable if used with care Treatment aims Assessment / Observation Effects of Radiotherapy on Skin Cells Rationale RTOG 0 To promote hydrated skin & maintain skin No visible change to skin integrity RTOG 1 Faint or dull erythema. Mild tightness of skin and itching may occur RTOG 2 Bright erythema / dry desquamation. Sore, itchy and tight skin RTOG 2.5 Patchy moist desquamation Yellow/pale green exudate. Soreness with oedema RTOG 3 Confluent moist desquamation. Yellow/pale green exudate. Soreness with oedema RTOG 4 Ulceration, bleeding, necrosis (rarely seen) To promote hydrated skin, patient comfort and maintain skin integrity. To treat itchy skin. To reduce pain, soreness and discomfort. As RTOG 1 To promote comfort. Reduce risk of complications of further trauma and infection. To reduce pain, soreness and discomfort To promote comfort Reduce risk of complications of further trauma and infection

10 Appropriate dressings* Atraumatic - to reduce pain when changed, does not adhere to the area of damaged skin Non-adhesive or silicone-based only - to avoid further damage to delicate, irradiated skin Absorbent - able to contain exudate (moist desquamation stage) Conformable for difficult to dress areas e.g. neck or pelvic area Comfortable for patient compliance and reduced pain while in situ Ease of application and removal - possible for patients to change their own dressings whilst at home Appropriate dressings - Infection Infections are rare in radiotherapy skin reactions, but are possible. Infections identified whilst the patient is in the radiotherapy treatment stage will be managed by the specialist radiotherapy staff according to local guidelines. It has been documented that the use of metallic-based topical products on the radiation field should be avoided whilst the patient is receiving radiotherapy due to the association with radiation scatter and increased surface dose. 15,21,22 Once radiotherapy is completed, if the area of skin reaction becomes infected, appropriate local wound infection management policy should be followed, and may then include the use of metallic dressings e.g. silver-containing dressings. Intervention guidelines Assessment / Observation RTOG 0 No visible change to skin Effects of Radiotherapy on Skin Cells Intervention (action) To apply aqueous cream initially twice daily Rationale To promote hydrated skin & maintain skin integrity RTOG 1 Faint or dull erythema. Mild tightness of skin and itching may occur RTOG 2 Bright erythema / dry desquamation. Sore, itchy and tight skin Increase application of aqueous cream as needed. 1% Hydrocortisone cream may also be prescribed for symptomatic relief. Commence analgesia as guided by WHO analgesic ladder Increase application of aqueous cream as needed. Continue as RTOG 1 interventions To promote hydrated skin, patient comfort and maintain skin integrity. To treat itchy skin. To reduce pain, soreness and discomfort. As RTOG 1 RTOG 2.5 Patchy moist desquamation Yellow/pale green exudate. Soreness with oedema RTOG 3 Confluent moist desquamation. Yellow/pale green exudate. Soreness with oedema RTOG 4 Ulceration, bleeding, necrosis (rarely seen) Continue aqueous cream on unbroken skin. To promote comfort. Reduce Stop hydrocortisone on broken skin. Apply an appropriate risk of complications of further dressing* to exuding areas (e.g. PolyMem, Mepilex, Allevyn trauma and infection. To N.A. / Gentle are all suitable options). Analgesia as guided by reduce pain, soreness and WHO analgesic ladder. Wear loose fitting clothing discomfort Stop using aqueous cream on moist/broken skin. Continue with RTOG 2.5 interventions Seek specialist advice (i.e. Clinical Oncologist, Radiotherapy Clinical Nurse/Radiographer Specialist in your area). To promote comfort Reduce risk of complications of further trauma and infection * Based on the Princess Royal Radiotherapy Review Team s experience to date.

11 Recommended Reading List 1. Campbell J. (2004) Skincare for patients undergoing radiotherapy. In: Feber T (ed) Head and Neck Oncology Nursing. London: Whurr 2. Faithfull S & Wells M, (eds) (2003) Supportive Care in Radiotherapy. Edinburgh: Churchill Livingstone. 3. Kedge E M. (2009) A systematic review to investigate the effectiveness and acceptability of interventions for moist desquamation in radiotherapy patients. Radiotherapy, (Aug) 15(3): Naylor W, Laverty D & Mallett J (eds) (2001) The Royal Marsden Hospital Handbook of Wound Management in Cancer Care. Oxford: Blackwell Science Further information sources: The Society of Radiographers - Ellen Trueman Ellen.Trueman@leedsth.nhs.uk Resources Contents Advice sheets A short post-training assessment Information on where to look for further information and advice Product information sheets and advice on usage

12 References DoH, Best Practice Guidance on joint working between the NHS and pharmaceutical industry and other commercial organistions. [online] Available at Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_ Olson D, Raub, W Bradley C, Johnson, M. Machias. JL, Love, V and Markoe A ( 2001). The effect of Aloe Vera gel/mild soap alone in preventing skin reactions in patients undergoing radiation. Oncology Nursing Forum. No Robson V, Cooper R. (2009) Using Leptospermum honey to manage wounds impaired by radiotherapy: a case series. Ostomy Wound Management 55, 1, Salvo N, Barnes E, van Draanen J, Stacey E, Mitera G, Breen D, Giotis A, Czarnota G, Pang J, De Angelis C (2010) Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Current Oncology. Vol 17, No Hornsby C, Fletcher J, Blyth CM. (2005) The production of a best practice statement in the skincare of patients receiving radiotherapy. Journal of Radiotherapy in Practice. 4, 2-3, Porock, D Kristjanson, L ( 1999). Skin reactions during radiotherapy for Breast Cancer: the use and impact of topical agents and dressing. European journal of Cancer. 6. Sitton E. (1992) Early and late radiation - induced skin alterations. Part 1 : Mechanisms of skin changes. Oncology Nursing Forum Vol 19, No5. 7. Rae Noble -Adams. (1999) Radiation induced Reactions. 1. An examination of the phenomenon. British Journal of Nursing. Sept 23-Oct 13: Aistars.J ( 2006). Validity of skin care protocols for external radiotherapy. Clinical Journal of Oncology Nursing. Vol 10. No Porock D (2002). Factors Influencing the Severity of Radiation Skin and Oral Mucosal Reactions: Development of a Conceptual Framework. Eur J Cancer Care (Engl) 11(1): Ginot A; Doyen J; Hannoun-Levi JM; Courdi A (2010). [Normal Tissue Tolerance to External Beam Radiation Therapy: Skin]. Cancer Radiother 14(4-5): Nayel H; el-ghoneimy E; el-haddad S (1992). Impact of Nutritional Supplementation on Treatment Delay and Morbidity in Patients with Head and Neck Tumors Treated with Irradiation. Nutrition 8(1): McNees P (2006). Skin and wound assessment and care in Oncology. Semin.Oncol.Nurs. 22 (3): Ryan JL, Bole C, Hickok JT, Figueroa-Moseley C, Colman L, Khanna RC, Pentland AP and Morrow GR. (2007) Post-treatment skin reactions reported by cancer patients differ by race, not by treatment or expectations. British Journal of Cancer. 97, Krishnasamy M (2008). Wound Management. In: Corner J, Bailey CD, editors. Cancer Nursing: care in context. 2nd ed. Oxford: Blackwell; p Wells, M and MacBride S. (2003) Radiation Skin Reactions. Chapter 8 in: Faithfull S & Wells M (Eds) Supportive Care in Radiotherapy. Elsevier Science Ltd. 16. Wells M, Macmillan M, Raab G, MacBride S, Bell N, MacKinnon K, MacDougall H, Samuel L & Munro A. (2004) Does aqueous cream or sucralfate cream affect the severity of erythematous radiation skin reactions? A randomised controlled trial. Radiotherapy and Oncology 73, Cox, J. Stetz, J and Pajak, T. ( 1995). Toxicity criteria of the radiation therapy oncology group ( RTOG) and the European Organisation for Research and Treatment of Cancer ( EORTC), International Journal of Oncology, Biology and Physicis. 31, 5, College of Radiographers, (2000). Treatment of Radiotherapy induced Acute Skin Reactions: A Clinical Guidelines for Use by the College of Radiographers. 19. Bolderston A., Lloyd N.S., Holden L., Robb-Blenderman L., The prevention and management of acute skin reactions related to radiation therapy: a systematic review and practice guideline. (2006) Support Care Cancer. 14: Kumar S, Juresic E, Barton M & Shafiq J (2001) Management of skin toxicity during radiation therapy: A review of the evidence. Journal of Medical Imaging and Radiation Oncology, 54, NHS QIS (2010) Best Practice Statement - Skincare of Patients Receiving Radiotherapy. Edinburgh: NHS Quality Improvement Scotland. 22. Harper J L, Franklin L E, Jenrette J M, Aguero E G. (2004) Skin toxicity during breast irradiation: pathophysiology and management. South Med J. 7: British Association of Dermatologists (2009) Sunscreen factsheet. Sun Awareness. 24. Byrne P, Copeland L, Mansell J, Trueman E & Wem L. (2003, re-validated 2010) Radiotherapy Skin Care Guidelines. St James s Institute of Oncology. Leeds Teaching Hospitals Trust. First Published September PolyMem - Bode C, Woodman H. Two Novel Treatments for the Prevention and Treatment of Radiation Induced Moist Desquamation. Poster Presented at CoR Conference January 2010, UK. Munro DC, McLinton A. Challenges of Gynaecological Radiotherapy Skin Reactions. Poster Presented at Wounds UK November 2010, UK. Trueman E. Understanding and Managing Radiotherapy Induced Skin Reactions. Poster presented at EWMA Conference May 2011, Brussels. Mepilex/SafeTac Range - Diggelmann KV et al. Mepilex Lite dressings for the management of radiation-induced erythema: a systematic in-patient controlled clinical trial. The British Journal of Radiology, MacBride et al. A Case Study to Evaluate a New Soft Silicone Dressing, Mepilex Lite, for Patients With Radiation Skin Reactions. Cancer Nursing, Vol. 31, No. 1, 2008 Adamietz IA, Mose S, Haberl A, Saran FH, Thilmann C, Bottcher HD (1995) Effect of self-adhesive, silicone-coated polyamide net dressing on irradiated human skin. Radiation Oncology Investigations 2: Haas, M.l., Coletti,J. Managing skin reaction from radiation or combined chemoradiation therapy. Poster presented at the American Society for Therapeutic Radiology and Oncology (ASTRO) 49th Annual Meeting, Los Angeles, Ca. USA, Hatcher, A., Main, N. The bottom line radiation therapy: creative solutions to complex perineal and perianal wounds. Poster presented at 20th Annual Symposium on Advanced Wound Care and the Wound Healing Society Meeting, Tampa, Fl. USA, Disclaimer - The information and recommendations in this publication are provided by the healthcare professionals of the Radiotherapy review clinic at St James Institute of Oncology, Leeds Teaching Hospitals NHS Trust and have not been verified by Aspen Medical, Molnlycke Healthcare and Smith& Nephew. The companies accept no responsibility for the content of this publication and shall not be responsible for any reliance placed on the content. Professional medical advice should be sought for the use of any product named in this publication. It may harm a patient s health or cause you injury to use the products listed in this publication otherwise than in accordance with the uses for which they are licensed. The companies do not recommend or promote unlicensed use of any of their products. Aspen Medical Europe Ltd. Thornhill Road, North Moons Moat, Redditch, Worcestershire B98 9NL, UK. Freephone: (UK) Facsimile: +44 (0) Mölnlycke Health Care Ltd. The Arenson Centre, Arenson Way, Dunstable, Bedfordshire, LU5 5UL, UK. Telephone: Facsimile: Smith & Nephew UK Ltd. Registered Number: Registered Office: 15 Adam Street, London, WC2N 6LA Aspen 159(L) XS295