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Challenging cases of transplantation dermatology

Johnson, R.A.

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doi: 10.1097/01.cmr.0000382791.74676.c1
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Systemic immunosuppression in solid organ transplant recipients (SOTR) is associated with increased risk of skin cancer in individuals with significant prior photoaging (dermatoheliosis). Risk factors for UVR-associated skin cancer in solid organ transplant recipients (SOTR) include Fitzpatrick skin phototype (SPT) 1 to III, age at time of transplanation, immunosuppression (duration, intensity, type), prior UVR exposure, history of skin cancer prior to transplantation, CD4 lymphopenia. Squamous cell carcinoma (SCC) in SOTR accounts for 90% of skin cancers in this population, is often more aggressive than in the general population, has a higher risk of metastasis, occurs at a younger age, and occurs at multiple primary sites. Risk of SCC is associated with blue/hazel iris color, time-resident in a hot climate, and post-transplantation SCC. The number of SCCs is associated with birth in a hot climate, childhood sunburn, pretransplantation actinic keratoses (AK), and cigarette smoking. Topical management of multiple precancerous lesions (AK, SCC in situ) includes patient-applied preparatons (imiquimod 5% creams, retinoids, 5-fluorouracil), ALA blue light photodynamic therapy (PDT), methyl-ALA red light PDT, Jessner 35% TCA peels as well as cyro- and electrosurgery. Systemic acetretin is effective in reducing the number of precancerous lesions while the drug is being administered. Immunosuppression with sirolimus rather than cyclosporine is associated with fewer SCCs. Patients at high risk for new and aggressive invasive SCC may require monthly follow-up; new lesions suspicious for SCC are treated surgically. Discontinuation of systemic immunosuppression in some renal transplant recipients (RTR) with high-risk carcinogenesis may be required. Local recurrence and satellite, in transit, and lymph node metastatic of SCC may be treated with surgical excision and radiotherapy.

Infection with oncogenic human papillomavirus (HPV) types increases risk of in situ and invasive squamous cell carcinoma (SCC) at anogenital and cutaneous sites. Infection with human herpesvirus-8 (Kaposi-sarcoma associated herpesvirus) prior to transplantation increases risk of Kaposi sarcoma with immunosuppression. Epstein-Barr virus infection is associated with posttransplantation lymphoproiferative disease which rarely involves the skin.

© 2010 Lippincott Williams & Wilkins, Inc.