**7. Managements of radiation-induced ulcers**

#### **7.1 Non-surgical managements**

Biafine cream, hydrogel or hydrocolloid dressings, human bone marrow mesenchymal stem cells, hyperbaric oxygen, and laser therapy were reported to benefit wound healing [49–53].

Biafine promoted wound healing via the attraction of macrophase, an increase in the ratio of IL-1 to IL-6. IL-1 plays an important role in collagen synthesis and collagenase activation and IL-6 stimulates epidermal growth, thus, enhancing skin healing [54]. Human bone marrow mesenchymal stem cells also inhibit the inflammatory process via downregulation of IL-1β levels, activation of CD80+ macrophages, and upregulation of IL-10. Immunoregulation was considered a mechanism for the healing property of human bone marrow mesenchymal stem cells [55].

Hydrocolloid dressings could form a soft gel when they contact with the wound, therefore, the wound surface could keep its moisture, assisting in the liquefaction and separation of debris [56, 57].

#### **7.2 Surgical management**

#### *7.2.1 Management of RT-induced ulcers*

Complete excision of lesion both in width and depth is important in treating radiation-induced skin lesions. Many authors agreed to thoroughly treat the lesion before performing covering measures. This helps to eliminate damaged tissue, promote wound healing and reduce the risk of recurrence ulcer as well as the abnormal growth of tissue damaged by radiation. According to research by Wei et al. [58], dividing the cut-off depth is a challenge. Theoretically, the most seriously affected area is within 2 cm below the skin surface. Therefore, the depth of the cut-off is at least 2 cm, but it depends on the anatomical region. Above all, the deep removal into healthy tissues is very important. However, according to the author's experience, no cut-off depth must exceed the muscular layer [58]. In Fujioka's 2012 research and review [59], it is necessary to remove all infiltrated skin area, damaged bones and cartilage to ensure the cleanest wounds before covering. Removing the chest ulcerative lesion in the absence of recurrent cancer, it requires remove the entire non-important structure such as the large skin area, the bone and the cartilage until covering all lesion areas, then performing the defect covering [60].

However, the removal of all lesion is extremely difficult, because the post-radiotherapy lesion usually progresses lately for months and years, not only in width but depth into the structure under the irradiated area, which makes management more complex and difficult.

#### *7.2.2 Plasty techniques of covering post-resection defects*

#### *7.2.2.1 Skin grafting*

Most authors in the world said that skin grafting was not effective in covering defects for treating radiation-induced ulcers, because radiation damage is an area of atrophied dry tissue with sclerosis and prolonged anemia, inability to form complete granular tissue. According to the research conducted by Strawberry et al. [61], the rate of skin graft failure in his study was nearly 100%. Vu Quang Vinh in his report 2010, also reached the same conclusion, by reporting one case of radiation-induced ulcer, treated with surgical excision and skin graft on average 9 times, grafted skin still was not alive [62].

Some authors used skin grafting method for lesions of radiation with low dose, or after removing thoroughly the lesion, the lesion base/background was well supplied, or used great omentum flap and fascial flap to cover first, then performed the skin grafts [63].
