Popromienny zespół skórny rozwija się na skutek ekspozycji na promieniowanie jonizujące powstałe w wyniku wybuchu nuklearnego. Uraz ten nieco różni się od odczynu skóry będącego skutkiem ubocznym radioterapii. Zmiany przybierają różne postacie w zależności od pochłoniętej dawki promieniowania i mogą rozwinąć się do przewlekłego stadium lub nowotworu.
W historii zarejestrowano tylko dwa przypadki użycia broni atomowej do działań zbrojnych – w Hiroszimie i Nagasaki w 1945 r. Popromienny zespół skórny obserwowano i zbadano jedynie u ofiar tych wybuchów.
Radioterapia a broń nuklearna – czym różnią się zmiany skórne?
Zespół popromienny skóry powstały w wyniku ekspozycji na promieniowanie jonizujące po wybuchu nuklearnym, w odróżnieniu od zmian skórnych wywołanych radioterapią lub powstałych w wyniku wypadków radiacyjnych (obserwowanych po katastrofie w Czarnobylu), dodatkowo powikłany jest oparzeniem termicznym, w którym nośnikiem energii jest promieniowanie świetlne, podczerwone i nadfioletowe emitowane w czasie wybuchu. Oparzenia termiczne lokalizują się na odkrytych częściach ciała, chociaż ciemna odzież może pochłaniać promieniowanie. Ponadto u ofiar wybuchów obserwowano również tzw. oparzenia typu beta, podobne do oparzeń słonecznych.
W przypadku uszkodzeń popromiennych, w porównaniu do zmian skórnych wywołanych radioterapią, wczesne rumienie są bezbolesne, a zmiany skórne rozwijają się później i dłużej. W przypadku napromienienia całego ciała epilacje i pęcherze naskórkowe pojawiają się na całej powierzchni skóry, natomiast w przypadku radioterapii ma to miejsce tylko na ograniczonym obszarze. Pochłonięcie tak dużej dawki promieniowania kończy się zgonem po kilku dniach.
Objawy popromiennego zespołu skórnego
Zmiany skórne mogą mieć różny charakter w zależności od pochłoniętej dawki promieniowania. Pierwszym objawem jest pojawienie się przejściowego rumienia wczesnego, któremu towarzyszy niewielki obrzęk i uczucie pieczenia.
Rumień wtórny pojawia się po pochłonięciu dawki promieniowania rzędu 3-7 Grejów (Gy) i jest wstępem do dalszych zmian w skórze i naskórku. Po około 2-3 tygodniach od napromieniowania pojawia się tzw. późny (właściwy) rumień oraz epilacja. Dochodzi wówczas do obrzęku i mikrowylewów, które objawiają się jako plamica. W otoczeniu naczyń rozwijają się nieliczne granulocyty, a śródbłonki ulegają złuszczeniu, natomiast w świetle naczyń mogą się pojawiać zakrzepy. Przy dawkach rzędu 3-10 Gy zmiany są ograniczone do warstwy brodawkowatej skóry właściwej, a przy większych – sięgają do tkanki podskórnej, a nawet mięśni szkieletowych. Zwykle dochodzi wtedy do martwicy komórek przydatków skóry, co prowadzi do epilacji i wysychania skóry.
Pochłonięcie dawki rzędu 10-25 Gy po 3 tygodniach od napromieniowania prowadzi do oddzielania się wierzchniej warstwy naskórka od jego warstwy podstawnej, co określane jest jako złuszczanie suche, złuszczanie wilgotne, tworzenie się pęcherzy.
Wyższe dawki napromieniowania 20-25 Gy po 2-3 tygodniach skutkują pojawianiem się głębokich owrzodzeń, czyli ubytków naskórka i skóry właściwej. Może również dojść do głębokiej martwicy skóry, w której ubytki sięgają tkanki podskórnej i mięśniowej. Przy pochłonięciu tak wysokiej dawki stwierdza się również martwicę włóknikowatą naczyń oraz zakrzepy. Zmiany prowadzą do niedotlenienia i niedożywienia skóry, utraty reakcji termoregulacyjnych, a także upośledzonej penetracji leków.
Stadium przewlekłe popromiennego zespołu skórnego i ryzyko rozwoju nowotworu
Po około 3-4 miesiącach do 2 lat od napromieniowania, jeżeli nie ma powikłań bakteryjnych, zmiany przechodzą w stadium przewlekłe. Dochodzi do włóknienia i zaburzeń naczyniowych w skórze. Zmiany są postępujące i prowadzą do zaniku tkanki podskórnej.
W dalszym okresie, który może trwać nawet latami, zanikają przydatki skórne, a skóra i naskórek stają się cienkie, podatne na zranienia. Pigmentacja skóry jest zaburzona, unaczynienie jest nieprawidłowe z ogniskami teleangiektazji. Inne naczynia skórne mają natomiast pogrubiałe ściany, a w ich świetle występują zwłókniałe i rekanalizowane zakrzepy.
Uszkodzenie popromienne skóry może prowadzić do rozwoju nowotworów podstawno- i kolczystokomórkowych. Zmiany powstałe w uszkodzonej skórze mają charakter zbliżony do łagodnych nowotworów lub malformacji naczyniowych, ale obserwowano również zmiany złośliwe, o obrazie zbliżonym do mięsaka Kaposiego lub naczyniakomięsaka.
Źródło: K. W. Zieliński i wsp., „Patologia obrażeń i schorzeń wywołanych współczesną bronią w działaniach wojennych i terrorystycznych, Ministerstwo Obrony Narodowej, Warszawa, 2010
Przeczytaj także: Skale nasilenia popromiennego odczynu skóry
Przeczytaj bezpłatnie pokrewny artykuł w czasopiśmie „Forum Zakażeń”:
Zapobieganie i pielęgnacja wczesnych skórnych odczynów popromiennych podczas radioterapii
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