It's been long recognized that the immunosuppressant drugs patients are prescribed after an organ transplant come with a fair share of dangerous side effects—including squamous cell carcinoma and other types of skin disease. But despite advances to improve skin cancer prevention for these patients, little is known about how skin conditions affect African-American, Asian and Hispanic transplant recipients.
That's a problem, considering that more than half of the , Americans on the waiting list for organs are nonwhite, according to the U.
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Department of Health and Human Services. Now, new research from Drexel University College of Medicine shows that nonwhite organ transplant recipients require unique, specialized dermatological care following their procedure. It is one of the first studies to analyze the risk factors, incidence, locations and types of skin disease in this population. The researchers found that the majority of skin cancers in black transplant patients occurred in sun-protected areas, like the groin-genital area, and most of those lesions tested positive for high-risk human papillomavirus HPV.
Further, nonwhite organ transplant recipients were less likely than their white counterparts to have regular skin evaluations by a dermatologist and to know the signs of skin cancer. These findings suggest that dermatologists need to evaluate, counsel and treat organ transplant recipients differently based on their race, according to principal investigator Christina Lee Chung, MD, associate professor of dermatology in the College of Medicine. The study builds on a previous report from Drexel Dermatology, which identified 19 skin cancer lesions in 6 percent of nonwhite patients.
The authors concluded that all organ transplant recipients, regardless of race, should receive routine, total-body screenings for skin cancer. In their most recent study, the researchers compared medical records of organ transplant recipients—including white patients and nonwhite black, Asian or Hispanic —who were referred to the Drexel Dermatology Center for Transplant Patients between and That means that every patient, regardless of race is screened annually for skin cancer. This provided a rich dataset for the research team to analyze. Two hundred eighty-nine transplant recipients exhibited malignant, infectious or inflammatory conditions during their evaluation.
However, their primary acute diagnoses differed greatly by race. In 82 white patients, skin cancer was the most common acute problem requiring attention at first visit. Black and Hispanic patients, by contrast, were most often diagnosed with inflammatory or infectious processes, such as fungal infections, warts, eczema, psoriasis and rashes. Overall, squamous cell carcinoma in situ was the most common type of skin cancer diagnosed in each racial or ethnic group. But the location of the cancerous lesions again depended on the race of the patient. Most lesions in white and Asian patients occurred in sun-exposed areas of the body, like the scalp, neck, chest and back.
For black patients, the lesions were primarily found in the groin.
Moreover, six of the nine lesions found on black patients tested positive for high-risk HPV strains, suggesting a strong association between the virus and skin cancer for African-Americans. Chung says it is still unclear why African-American transplant patients would have higher rates of HPV-related skin cancer. But the findings from this study show that dermatologists need to closely examine the groin, genital and perianal areas in this population.
Additionally, although early detection of cancer is vital, nonwhite transplant recipients would also benefit from addressing fungal and HPV infections, which can be persistent and magnify over time, she said. The researchers also provided questionnaires to 66 organ transplant recipients to find out more about the patients' awareness of skin cancer prevention. Seventy-seven percent of white patients were aware their skin cancer risk was increased, compared to 68 percent of nonwhites. Only 11 percent of nonwhite patients reported having regular dermatologic examinations, compared to 36 percent of whites.
Our study aimed to determine the epidemiology of skin conditions among renal transplant recipients in the largest tertiary hospital in Singapore. We reviewed the medical records of kidney transplant recipients at Singapore General Hospital, Singapore, between 1 January and 31 December Among these patients, the clinical data of patients who sought skin consultations with either dermatologists or plastic surgeons within the hospital was captured.
A total of patients were included in our study. There were 88 Drug-induced skin conditions, mainly attributable to long-term steroids and cyclosporin use, were represented by acne 9. Our study demonstrated the spectrum of skin conditions that can be expected after renal transplantation.
We wish to highlight the importance of careful dermatological screening and long-term follow-up for these patients, in order to reduce post-transplant skin complications. In Singapore, the number of kidney transplant recipients is on the rise every year as a result of rapid surgical and medical advancements. Renal transplantation provides a better standard of care for the increasing number of patients with end-stage renal disease, reducing long-term morbidity and mortality. Skin conditions range widely from skin cancers and skin infections to drug-induced skin disorders such as acne and sebaceous gland hyperplasia.
In solid-organ transplant centres across Europe and America, skin cancer is the most common skin condition to arise after organ transplantation, and the rates of squamous cell carcinoma SCC , basal cell carcinoma BCC and Kaposi sarcoma are known to be greatly increased in organ transplant recipients. Earlier publications reported that skin cancers arise at a much lower frequency in organ transplant recipients. The age, gender, ethnicity, type of donor organ transplant, time after transplantation and regimen of immunosuppressive therapy used were recorded.
History of skin lesions and examination findings were obtained. Specific tests were performed for appropriate cases, including skin and nail scraping for microscopy and culture for suspected superficial fungal infections.
Skin Disease in Organ Transplantation by Clark C. Otley | | Booktopia
Gram staining for suspected pyogenic infections and skin biopsies were performed for appropriate cases e. Immunosuppression protocol during the study period was risk-stratified according to immunological risks and patient-related comorbidities. Antibody induction therapies were used for the majority of patients, and these were usually interleukin-2 receptor antagonists e.
Thymoglobulin and rituximab were reserved for patients at high immunological risk of rejection, such as in cases of positive crossmatch or ABO-incompatible kidney transplantation.
Antibody-mediated rejection was treated with rituximab, plasma exchange and intravenous immunoglobulin. All frequency data was presented as numbers and percentages. A total of patients were included in our study cohort. The general characteristics of these patients are summarised in Table I.
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Among these patients, were male and 70 were female. Their age range was 20—80 years with a mean age of The majority of the participants were Chinese These patients had received kidneys from either living or deceased donors, with available data indicating 44 The mean time interval from transplantation to their first skin consultation was 4.
Skin Disease in Organ Transplantation
Table II shows the various skin conditions that were diagnosed. There were 88 cases Viral warts have a predilection for sun-exposed skin, including the head and neck region, and the upper trunk. They can be generalised, covering almost the entire body. In our study, most of the warts developed within the first five years after the renal transplant. As shown in Table II, out of skin conditions, other commonly encountered skin infections included fungal infections of the skin 9.
Similar to viral warts, the majority of these infections developed within the first five years after the renal transplant Table IV. Other types of common skin infections and their duration from post renal transplant to diagnosis. There were 2 1. All these patients underwent surgical excision. In contrast to skin infections, half of these cases of skin cancers developed after the first five years following the transplant.
The drug-induced skin conditions in our study consisted of acne 9. Among the skin conditions classified as others, eczema was reported in 24 Other less commonly reported cases were epidermal cysts 2. In our study, skin infections were the most commonly encountered skin condition, with human papillomavirus HPV infection having the highest incidence, as represented by viral warts cases. HPV infection is one of the most frequent infections in transplant recipients. In practice, multiple types of treatment are used in combination.
Cutaneous warts in immunosuppressed patients are difficult to treat and were reported to have a significant impact on their quality of life, resulting in a form of physical stigma for the patients. A study by Zachariae et al reported that transplant patients with viral warts had an increased Dermatology Life Quality Index score i.
It is important to note that ultraviolet radiation from the sun is immunosuppressive, which explains the predilection of viral warts for sun-exposed sites in the transplant recipients. Ultraviolet radiation from the sun is the most important cause of skin cancers, exerting a direct mutagenic effect on the DNA of keratinocyte stem cells and an indirect tumour-promoting effect.
Skin Disease in Solid Organ Transplant Patients
Hence, sun protection as well as daily application of sunscreen must be a standard recommendation for immunosuppressed persons, to prevent viral warts and subsequently reduce the risk of skin cancers. Previous studies in Asia, especially those in Korea, Japan, India and Taiwan, reported that the proportion of transplant recipients with skin cancer was less than 2.
These incidence rates are much lower than those of Western countries. However, compared to the baseline incidence of skin cancers in Singapore, this represents a significantly increased risk. Should be included in the library of all practicing dermatologists as well as transplant physicians. Help Centre. My Wishlist Sign In Join.
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