Skin diseases in Turkish renal transplant recipients

BACKGROUND: Organ transplant recipients are predisposed to a variety of cutaneous complications due to immunosuppressive therapy. We aimed to determine the prevalence and the clinical spectrum of skin diseases in renal transplant recipients (RTRs). METHODS: One hundred and eleven RTRs were examined at the Renal Transplantation Center in Ege University Hospital between October 1999 and October 2001. The effects of age, gender and duration time after transplantation on cutaneous manifestations were evaluated and the dermatologic manifestations in RTRs were compared with findings in a control group consisting of 100 patients. The t-test, chi2 test and Fisher's exact test were used for statistical analysis. RESULTS: Seventy-five patients (66.4%) had an infection of the skin, 66 patients (58.4%) had drug-related manifestations, and 11 patients (9.7%) had premalignant or malignant skin lesions. Human papilloma virus (HPV) infections were the most common skin lesions. There was no significant relation between age and gender and the incidence of skin diseases in RTRs. The incidence of HPV infections, tinea versicolor and premalignant and malignant lesions increased with the duration of immunosuppression. The incidence of infectious skin diseases, especially HPV infections and tinea versicolor, was higher in the study group than in the control group. CONCLUSIONS: In this study, we observed that cutaneous lesions, especially those caused by infectious diseases, had a higher frequency in RTRs. The findings emphasize the importance of regular dermatological screening in these patients, which can provide early diagnosis and a better quality of life for RTRs.     

Skin cancers and HLA frequencies in renal transplant recipients.

An association between HLA DR7 and the development of multiple non-melanoma skin cancer was detected in immunosuppressed patients in southern Australia. The relative risk was 2.6 which was lower than for immunocompetent patients with the same skin cancers. HLA frequencies of renal transplant recipients with multiple skin cancers were determined. The types HLA B27 and HLA Dr7 were found in significantly higher frequency, and there was no absence of HLA A11.     

Non-melanoma skin cancer risk in the Queensland renal transplant population

BACKGROUND: Non-melanoma skin cancer (NMSC) is an important complication of solid organ transplantation, especially in areas of high ultraviolet light exposure. Registry data may underestimate the scale of the problem. OBJECTIVES: A single-observer study of a Queensland renal transplant population was conducted between July 1999 and April 2000 utilizing both cross-sectional and retrospective data. The aims were to determine accurately the risk of NMSC following renal transplantation and compare this with currently available registry data. PATIENTS AND METHODS: A structured interview and full skin examination was completed by 398 renal transplant recipients. Case notes and histology reports were examined for details of previous skin tumours. Independently collected data on 341 subjects from the Australia and New Zealand Dialysis and Transplantation Registry (ANZDATA) were also examined. RESULTS: One hundred and eighty-seven of 361 (51.8%) transplant recipients of Fitzpatrick skin types I-IV had developed 3979 histologically diagnosed NMSCs since first transplantation. The ratio of SCC/BCC was reversed from 1 : 3.7 before transplantation to 2 : 1 after transplantation. NMSC increased with duration of immunosuppression; 29.1%, 52.2%, 72.4% and 82.1% of those immunosuppressed for < 5, 5-10, 10-20 and > 20 years, respectively, had developed at least one tumour. The ANZDATA registry under-recorded the numbers of patients with NMSC by 28.4% and gave no indication of tumour numbers. CONCLUSIONS: NMSC is a greater clinical problem in renal transplant recipients living in subtropical Queensland, Australia, than is shown by currently available registry data. This has implications for the development of prevention and surveillance strategies.     

Contact dermatitis in the West of Scotland

Since 1970, more than 4,500 patients have been patch tested at the Contact Dermatitis Investigation Unit in Glasgow. The results of 1,312 patients patch tested to the 20 test substances as described by the ICDRG (Fregert et al. 1969) are presented. The data on frequency of the most common allergens observed are presented. The most common allergens observed are nickel, chromium, cobalt, neomycin, colophony, wool alcohols, balsam of Peru and rubber. The less common allergens are benzocaine, parabens, formaldehyde and turpentine.     

Skin surveillance of a U.K. paediatric transplant population

BACKGROUND: Solid organ transplant recipients are at increased risk of skin cancer. Melanoma is less common than nonmelanoma skin cancer (NMSC) although the relative proportion of melanoma among skin cancers has been shown to be higher in paediatric than adult recipients. Multiple melanocytic naevi and/or atypical naevi may be a risk factor for the development of melanoma. The relationship between naevus counts and phenotypic characteristics, disease-related variables and sun exposure has not been explored in paediatric transplant patients. OBJECTIVES: To determine the prevalence of premalignant and malignant skin lesions and to identify known risk factors associated with benign and atypical melanocytic naevi in a U.K. paediatric transplant population. METHODS: Paediatric (< or = 19 years) renal and liver transplant patients, who were 5 or more years post-transplantation, were reviewed over 12 months. Lifetime history of sun exposure, episodes of sunburn, sunny holidays, sunscreen use, sun bed use, demographic and transplantation details were collected using interview, questionnaire and case note review. A skin examination was performed for regional counts of malignant lesions, benign and atypical naevi. RESULTS: Ninety-eight patients (82 liver, 13 renal, three multiorgan) with a median follow up of 9 years (range 5-16) were reviewed. Neither skin cancer nor premalignant lesions for NMSC were detected in this group. Eighty-five patients had benign naevi (median 6, range 1-57). Clinical risk factors for increased counts of benign naevi included increasing age (P = 0.03), more episodes of sunburn (P = 0.003) and prolonged treatment with cyclosporin (P = 0.009). The presence of atypical naevi in six patients was significantly associated with more episodes of sunburn (P = 0.006) and more transplants (P = 0.04). Other variables including phenotype, skin type, sun exposure, holidays abroad, residence abroad and total duration of immunosuppression did not correlate with benign or atypical naevus counts. CONCLUSIONS: Skin cancer was not observed in paediatric solid organ transplant recipients who were 5-16 years post-transplantation. Both benign and atypical naevus counts were higher in children with frequent episodes of sunburn. As both naevi and sunburn are risk factors for melanoma, we should target fair-skinned transplant recipients with naevi for intensive sun avoidance education. A prospective, longitudinal follow-up study should determine the onset of skin cancer post-transplantation and the significance of benign and atypical naevus counts in this cohort.     

An unusual cause of skin "tumours" in a renal transplant recipient

Renal transplant recipients on immunosuppression are at increased risk of developing skin cancers as well as opportunistic infections though it is usually not difficult to clinically differentiate cutaneous fungal infections from skin tumours. We describe a case of tinea capitis in a renal transplant recipient presenting with such an exuberant inflammatory reaction and nodule formation that it was clinically mistaken to be an appendigeal tumor.     

Skin lesions in renal transplant patients after 10-23 years of immunosuppressive therapy

Ninety-eight patients with 10-23 years of uninterrupted immunosuppressive therapy due to renal transplants were investigated for signs of skin disease. Thirty-seven per cent had or had had premalignant or malignant skin lesions. This is significantly different from a control population (p less than 0.0001). There was also a correlation between the length of the immunosuppressive therapy and the risk of acquiring squamous cell skin cancers (p less than 0.05). Fifty-five per cent had common viral warts at the time of the present examination. The duration of immunosuppressive therapy also correlated with the presence of warts (p less than 0.01). Seven patients had mycosis and four patients had seborrheic eczema. In one-third of the patients the skin appeared normal.     

Skin lesions in transplant patients

A multitude of skin lesions that are seen following organ transplantation have been presented. Many of them, such as opportunistic infections, are related to the immunosuppressive agents used to prevent graft rejection and graft-versus-host disease. Corticosteroids and cyclosporine commonly produce other skin changes as well. A high index of suspicion for unusual infections and skin cancer should lead the dermatologist to initiate the proper diagnostic procedures in these patients.     

Presence of beta human papillomaviruses in nonmelanoma skin cancer from organ transplant recipients and immunocompetent patients in the West of Scotland

Background  Nonmelanoma skin cancer (NMSC) has been linked to cutaneous human papillomaviruses of the genus beta (betaPV).
Objectives  We sought to assess the presence of betaPV in NMSC biopsies from a group of Scottish skin cancer patients, both immunocompetent (IC) patients and immunosuppressed (IS) organ transplant recipients.
Methods  One hundred and twenty-one paraffin-embedded skin tumours (27 actinic keratosis, 41 intraepidermal carcinoma, 53 squamous cell carcinoma) and 11 normal skin samples were analysed for the presence of betaPV by a polymerase chain reaction–reverse hybridization assay designed to detect the presence of the 25 known betaPV genotypes.
Results  In IC patients, betaPV was detected in 30 of 59 (51%) tumours and two of 11 (18%) normal skin samples ( P  =   0·046). In IS patients, betaPV was found in 27 of 62 (44%) tumours; no normal skin samples were available for comparison. The most frequently found genotypes were HPV-24, HPV-15 and HPV-38. Of those tumours infected with betaPV, 28 of 57 (49%) were infected with more than one genotype (range 2–8). Tumours from IS patients were from a younger age group (mean age 57·4 years) than IC patients (mean age 73·8 years). Multiple infections were more common in tumours from IC patients (21 of 30; 70%) compared with those from IS patients (seven of 27; 26%) ( P  <   0·001). In the IC group, age did not appear to influence the distribution of single and multiple infections whereas in IS patients the proportion of multiple infections to single infections increased with age. There were no multiple infections in normal skin.
Conclusions  A wide spectrum of betaPV types was detected in our samples. Further characterization of betaPV in vivo is needed in order to determine the mechanisms by which the virus contributes to cutaneous carcinogenesis.     

Skin cancer chemoprophylaxis in renal transplant recipients: 5 years of experience using low-dose acitretin

Renal transplant recipients have an increased risk of developing skin cancers, which are often multiple and aggressive. Frequently, these tumours develop on a background of widespread epidermal dysplasia. Systemic retinoids are known inhibitors of skin cancer but reports of their use in renal transplant patients are limited. We describe our experience using 0.3 mg/kg daily of acitretin in 16 patients over a 5-year period. Overall, there was a significant reduction in the number of new tumours excised in 12 of 16 patients during treatment compared with the same pretreatment interval. A significant chemoprophylactic effect was shown for up to 4 years of treatment. Patients with five or more tumours prior to acitretin benefited most. Two patients discontinued treatment because of side-effects and two patients developed hyperlipidaemia. Two patients with end-stage graft failure proceeded to haemodialysis. The introduction of low-dose acitretin proved to be a useful strategy in the long-term reduction of skin cancer in renal transplant recipients with multiple skin cancers and extensive epidermal dysplasia.     

Prevalence of gold contact hypersensitivity in the West of Scotland

373 patients unending for routine patch testing were tested with 0.5% gold sodium thiosulfate (GST), 8(2.1%) patients had a positive patch test, and a further 4 (1.0%) patient reactions which were interpreted as irritant. 2 out of 8 patients with a positive patch test to GST suspected gold allergy prior to testing, and both of these patients reported that their eczema resolved if they avoided gold jewellery. This is the lowest prevalence of hypersensitivity to GST reported and suggests that gold contact allergy may not he as widespread as has been recently proposed.     

Skin infections in organ transplant recipients

In contrast to the well‐described high risk of skin cancer in organ transplant recipients, skin infections in these patients are not as well explored.Skin infections caused by viruses, bacteria or fungi represent a growing diagnostic and therapeutic challenge in the dermatological aftercare of organ transplant recipients. Differing immunosuppressive drugs and their variable dosage in chronologic sequence after transplantation probably influence the type and appearance of skin infections. The typical chronology of skin infections are wound infections, pyoderma or the reactivation of herpes viruses in the first month post‐transplant;the main problems in months 2–5 are opportunistic infections and reactivation of varicella‐zoster virus.After 6 months as immunosuppression is reduced, the spectrum of causative organisms approaches that of the general population; mycoses and human papilloma virus (HPV) infections dominate. A causal connection exists between infection with oncogenic viruses such as HPV, Epstein‐Barr virus and human herpesvirus 8 and specific skin cancers (squamous cell carcinoma, Kaposi sarcoma and post‐transplant lymphoprolif‐erative disorders). Dermatological care of organ transplant recipients using appropriate diagnostic methods adapted to the modified clinical pattern may lead to early adequate treatment.     

Skin manifestations associated with tumours of the brain

In a 4-year period seventy-seven patients with tumours of the brain were investigated for skin manifestations. These were observed in twenty-four (31-2%) and fall into three main groups: Pruritus. Thirteen patients complained of pruritus. Most characteristic is the pruritus of the nostrils, which was observed in six patients. It can be extremely severe and is a sign of an advanced tumour. Pigmentary disorders were observed in seven patients. In two, vitiligo appeared simultaneously with the brain tumour symptoms. In the others, hyperpigmentation appeared on the face later in the course of the disease. Hyperkeratotic changes were manifest in four patients. Two had a mild hyperkeratosis of the palms and soles. The other two developed in addition an ichthyosiform atrophy of the skin. The possible pathogenesis of the skin manifestations associated with brain tumours is discussed.     

Skin manifestations in solid organ transplant recipients

The clinical spectrum of the most significant dermatological complications of solid organ transplantations is presented in an attempt to enhance the awareness among dermatologists and other physicians of the importance of careful dermatological monitoring of organ transplant recipients for early diagnosis and prompt treatment of these manifestations.     

Skin cancers and other cutaneous diseases in renal transplant recipients: a single Italian center observational study

Kidney transplant recipients frequently suffer from skin infections and malignancies, due to the effects of long-term immunosuppressive therapy. Herein, a dermatological screening was performed to evaluate the relationship between risk factors, cutaneous tumours and other skin diseases in a group of 282 kidney transplant patients. Infectious diseases (16.7%) were the most frequent dermatological disorders, whereas cutaneous inflammatory and autoimmune diseases were relatively rare, probably due to an indirect therapeutic role of immunosuppressive regimens. Thirty patients experienced cutaneous side effects from immunosuppressants, mainly when receiving corticosteroids (p?=?0.0372). We identified 99 patients (35.1%) who developed cutaneous tumours after transplantation. Cumulative tumour incidence was observed during long-term immunosuppressive therapy; no relationships were identified between skin cancer risk and single class of drug or combination regimens. When we evaluated the eventual relevance of other risk factors for skin cancers, we demonstrated a statistical significance in univariate analysis for male gender, more advanced age at transplantation, long duration of immunosuppressive regimens, no sunscreen usage, outdoor job, absence of cherry angiomas and presence of actinic keratoses (AKs). Age at transplantation (p?=?0.0174), presence of AKs (p?=?0.0005) and duration of immunosuppression (p?=?0.0011) also confirmed their significance in multivariate analysis.