Skin diseases in children with organ transplants

Dermatological Conditions Seen in Kidney Transplant Recipients: Prevalence and Risk Factors

OBJECTIVES

In kidney transplant, the use of immunosuppressive drugs, indispensable to avoid organ rejection, implies an increased risk of several infectious and neoplastic diseases. Cutaneous infections have a high incidence in kidney transplant recipients and are diagnosed in 55% to 97% of these patients. The objectives of this study were to identify the most frequent skin diseases and their clinical risk factors within a population of kidney transplant recipients.

MATERIALS AND METHODS

We reviewed the medical records of 200 kidney transplant recipients at Sahloul Teaching Hospital, Tunisia, between November 2007 and January 2018. We analyzed the clinical data of patients who sought skin consultations with either dermatologists or plastic surgeons within the hospital. We collected patient sociodemographic data, type of donor, and type of immunosuppressive therapy used by recipients. We also obtained history of skin lesions and examination findings.

RESULTS

Among 200 patients included in our study cohort, 131 were male and 69 were female. Age ranged from 6 to 75 years with a mean age of 30.51 ± 12 years. Patients had received kidneys from either living or deceased donors, with available data indicating 96.5% living donors and 3.5% deceased donors. The mean time interval from transplant to first skin consultation was 31 month (range, 3 months to 10 years). Prevalence of various skin conditions was 48.5%. We found that 62.9% of cases were skin infections, 59.8% were drug-induced skin conditions, and 2.9% were skin cancers. The estimated risk factors for skin lesions include use of cyclosporin and duration of immunosuppression.

CONCLUSIONS

Our study demonstrated the spectrum of skin conditions that can be expected after kidney transplant. Careful dermatological screening and long-term follow-up are needed for these patients to reduce posttransplant skin complications.

Post-transplant malignancy: Focusing on virus-associated etiologies, pathogenesis, evidence-based management algorithms, present status of adoptive immunotherapy and future directions

Modern immunosuppression has led to a decrease in rejection rates and improved survival rates after solid organ transplantation. Increasing the potency of immunosuppression promotes post-transplant viral infections and associated cancers by impairing immune response against viruses and cancer immunoediting. This review reflects the magnitude, etiology and immunological characteristics of various virus-related post-transplant malignancies, emphasizing the need for future research. A multidisciplinary and strategic approach may serve best but overall literature evidence targeting it is sparse. However, the authors attempted to provide a more detailed update of the literature consensus for the prevention, diagnosis, management and surveillance of post-transplant viral infections and associated malignancies, with a focus on the current role of adoptive immunotherapy and the way forward. In order to achieve long-term patient and graft survival as well as superior post-transplant outcomes, collaborative research on holistic care of organ recipients is imperative.

Warts in pediatric oncology patients: A single-institution retrospective study

BACKGROUND

Pediatric oncology patients undergoing cancer treatment can often have numerous and recalcitrant cutaneous warts due to their underlying immunosuppression. There are little published data on the optimal management of warts in pediatric oncology patients undergoing active cancer treatment compared to patients having completed treatment. Our objective was to analyze the clinical course of warts treated within this patient population at Boston Children's Hospital over a 10-year period.

METHODS

This was a single-institution retrospective study of 72 pediatric oncology patients from 1 September 2011 to 1 September 2021 who were treated for warts at Boston Children's Hospital. All patients had a diagnosis of cutaneous warts with at least one follow-up visit and were receiving active treatment for cancer either during or after concurrent treatment of their warts. We examined the modality and effectiveness of wart treatments while both on and offactive treatment of their cancer.

RESULTS

The median age was 12 years (range 4-18). Fifty-four percent of patients were documented to have plantar warts. Sixty percent of patients with a documented number of warts had more than five warts at presentation. For cases in which outcomes were specified, treatment resulted in complete resolution of warts in only 24.0% of patients undergoing active cancer treatment compared to 63.3% of patients not on active treatment. Warts persisted or worsened in 56.0% of patients undergoing active cancer treatment compared to only 13.4% of patients not on active treatment.

CONCLUSION

These data may help guide clinicians in evaluating and treating warts in pediatric oncology patients.

Cutaneous infections from viral sources in solid organ transplant recipients

INTRODUCTION

Solid organ transplant recipients (SOTRs) are susceptible to various dermatological complications caused by long-term immunosuppressive therapy. Of these complications, viral infections are noteworthy because of their high prevalence and the potential morbidity associated with viral carcinogenesis.

OBJECTIVES

To evaluate the occurrence of cutaneous viral infections in SOTRs and their correlation with clinical features, transplant type, and the length and intensity of immunosuppressive therapy.

METHODS

This retrospective cohort study included SOTRs followed up at the Department of Dermatology in a tertiary hospital. The outcomes analyzed were the occurrence of cutaneous viral infections, including human papillomavirus (HPV) infection, herpes simplex, herpes zoster, molluscum contagiosum, Merkel cell carcinoma, Kaposi's sarcoma, and cytomegalovirus, and the occurrence of HPV-related neoplasms. Clinical variables, such as length and intensity of immunosuppression, type of transplanted organ, and comorbidities, were analyzed as possible risk factors for cutaneous viral infections in SOTRs.

RESULTS

A total of 528 SOTRs were included in this study, among which 53.8% had one or more viral infections. Of these, 10% developed a virus-associated malignancy (HPV-associated carcinoma, Merkel cell carcinoma, or Kaposi's sarcoma). The higher risk of viral infections among SOTRs was associated with cyclosporine intake (1.40-fold higher risk) and younger age at transplantation. The use of an immunosuppressive regimen, including additional drugs, was associated with a higher risk of genital HPV infection (1.50-fold higher risk for each incremental drug).

CONCLUSIONS

The occurrence of cutaneous viral infections in SOTRs is directly associated with the duration and intensity of immunosuppressive therapy. Patients at higher risk were those taking drugs with a stronger impact on cellular immunity and/or those on an immunosuppressive regimen comprising various drugs.

Dermatologic manifestations in pediatric patients after liver and HSCT: A 20-year retrospective cohort study

LT and HSCT are now potentially curative treatments for many medical conditions. Dermatologic manifestations are one of the sequelae after transplantation. To study the prevalence and associated risk factors of dermatologic manifestations after pediatric LT and HSCT. A 20-year retrospective cohort study was conducted in children, aged ≤15 years, who received LT or HSCT from January 1, 1997, to December 31, 2017. Medical records were reviewed for data collection until December 31, 2018. A total of 70 LT and 51 HSCT recipients were included. The percentages of overall dermatologic manifestations after LT and HSCT were 64.3% and 64.7%, respectively. Viral infection was the most common manifestation in both groups, with mucocutaneous HSV infection as the most prevalent. One HSCT recipient developed leukemia cutis. GVHD was revealed in 27.5% of HSCT recipients. Impetigo and xerosis were significantly observed in patients using azathioprine and prednisolone. Approximately two-thirds of pediatric LT and HSCT recipients experienced dermatologic manifestations, potentially associated with immunosuppressive agents. Thus, regular skin examination and optimized immunosuppression would be beneficial in these recipients.

Skin cancer in children after organ transplantation

Skin cancer is the second most common complication of organ transplantation in children. The frequency of skin cancer incidence after organ transplantation is different in paediatric and adult populations. The post-transplant lymphoproliferative disease is the most common group of malignancies after organ transplantation in paediatric population. The majority of researchers who examined children with kidney, liver, heart or lungs grafts observed that the risk of skin cancer was three times higher than in the general population whereas in adults even200 times higher. The occurrence of skin cancer in children after transplantation is extremely rare during childhood. The risk increases in early adulthood. Malignancies occurring after solid organ transplantation result from many different factors. These include the immunological condition of the child, dose and time of immunosuppression, and oncogenic viruses. The increased risk of skin cancer following paediatric transplantation requires prevention and adequate education of children and their parents. These involve avoiding sun exposure and protection such as sunscreens and protective clothing. The early detection of cancer in transplant recipients is very important. Prevention of cancer includes regular dermatological examination.

Human papillomavirus infection in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These guidelines from the American Society of Transplantation Infectious Diseases Community of Practice update the epidemiology and management of human papillomavirus (HPV) infections in organ transplant recipients. HPV is one of the most common sexually transmitted infections and is associated with cancers of the anogenital region. Increasing evidence suggests an association with head and neck cancers as well. Solid organ transplant recipients have a higher risk of HPV infection than the general population. Infection manifests as premalignant lesions, warts, or cancer of the cervix, penis, vulva, scrotum, and anal canal. Most are asymptomatic initially, so diagnosis can be difficult without screening. A vaccine is available though not effective in preventing all cancer-causing strains. Organ transplant recipients should be screened for HPV-associated cancers and appropriate therapy initiated in a timely manner. Further studies are warranted to delineate the most effective screening methods and therapeutic modalities, including whether changes in immunosuppression are effective in attenuating disease.

Hyperpigmentation Due to Cyclosporine Therapy

For a myriad of immune disorders, cyclosporine has demonstrated marked efficacy in relieving clinical symptoms and reversing pathological developments. We present a case of hyperpigmentation induced by cyclosporine therapy used to treat prurigo nodularis, an extremely rare adverse effect of cyclosporine that has been reported only once, to our knowledge, in the dermatologic literature. After four months of cyclosporine therapy, our patient developed noticeable hyperpigmentation on the dorsal hands and feet and to a lesser degree on her arms and legs. Prior research has discovered a dose-dependent decrease in tyrosinase activity and pigment formation in cultured melanocytes due to cyclosporine – an effect opposite to what was observed in our case. Thus, further study into this relationship is necessary. In essence, physicians should be aware of unwanted cutaneous changes after the initiation of cyclosporine therapy and may want to counsel patients about the importance of ultraviolet (UV) radiation protection.

Innate Antiviral Immunity in the Skin

Barrier sites such as the skin play a critical role in immune defense. They must maintain homeostasis with commensals and rapidly detect and limit pathogen invasion. This is accomplished in part through the production of endogenous antimicrobial peptides and proteins, which can be either constitutive or inducible. Here, we focus particularly on the control of innate antiviral proteins and present the basic aspects of their regulation in the skin by interferons (IFNs), IFN-independent immunity, and environmental factors. We also discuss the activity and (dys-)function of antiviral proteins in the context of skin-tropic viruses and highlight the relevance of the innate antiviral pathway as a potential therapeutic avenue for vulnerable patient populations and skin diseases with high risk for virus infections.

Dermatological Complications After Solid Organ Transplantation

Organ transplant recipients (OTRs) are a population at high risk for cutaneous adverse events. Their early recognition and appropriate treatment is an important component of the clinical management of OTRs and should be optimally dealt with by dermatologists working in the context of a transplant dermatology clinic. Skin examination should be a standard procedure before performing organ transplantation to assess conditions which may be difficult to manage after the transplant procedure has been performed or which may represent a contraindication to transplantation, e.g., malignant melanoma. It also offers an opportunity to educate patients on skin care after organ transplantation. Skin infections can occur at any time after organ transplantation and include viral, bacterial, and fungal opportunistic infections. The risk of reactivation of latent viruses, such as varicella-zoster virus (VZV) and cytomegalovirus (CMV), is high. Bacterial infections are frequent and may be caused by unusual agents such Actinomyces, Mycobacteria, Legionella, or Nocardia. A large spectrum of fungal infections may occur, ranging from superficial (e.g., dermatophytes) to deeper and more severe ones (Alternaria, Aspergillus, Cryptococcus, Histoplasma). Drug-related idiosyncratic reactions usually occur early after the introduction of the causative drug, e.g., hypersensitivity reaction to azathioprine. On the long-term run, cutaneous effects due to cumulative drug toxicity, e.g., sebaceous hyperplasia from cyclosporine, may appear. Rare immunologically driven inflammatory reactions may occur in OTRs such as GVH or autoimmune disease. Tumors are particularly frequent. Kaposi's sarcoma, associated with persistent human herpes virus 8 (HHV8) infection, and cutaneous anaplastic large-cell lymphoma (ALCL) occur early after transplantation. Other cancers, such as nonmelanoma skin cancer (NMSCs), associated with persistent human papillomavirus (HPV) infections, malignant melanoma, Merkel cell carcinoma, or adnexal tumors, manifest later with an incidence which is much higher than observed in the general population. The incidence increases further after a first NMSC occurs.

Inflammatory Cutaneous Diseases in Renal Transplant Recipients

Kidney transplant recipients frequently suffer from skin infections and malignancies, possibly due to the effects of long-term immunosuppressive therapy. While the relationships between immunosuppression and these pathological conditions have been widely investigated, little is known about the relative incidence and characteristics of inflammatory skin diseases in this type of patient. In this study, we analyze the incidence of a number of inflammatory cutaneous diseases in a cohort of patients who underwent kidney transplantation. Although our study shows a relatively low incidence of these pathologies in transplanted patients-in agreement with the general action of immunosuppressant therapies in reducing inflammation-we scored a different efficacy of the various immunosuppressive regimens on inflammatory and autoimmune skin diseases. This information can be key for designing immunosuppressive regimens and devising accurate follow-up protocols.

Study of dermatoses in kidney transplant patients

BACKGROUND

The increasing in the number of kidney transplant recipients has favored, more frequently than before, the emergence of dermatoses and warranted their study through subsequent publications.

OBJECTIVES

to evaluate the frequency of dermatoses in kidney transplant recipients.

METHODS

kidney transplant recipients with suspected dermatoses between March 1st 2009 and June 30th 2010.

RESULTS

53 patients (28 males and 25 females), aged between 22 and 69 (mean age = 45 years) were evaluated. Most of them came from the cities of Ceilândia, Samambaia and São Sebastião/DF, and had already been transplanted for 5 to 10 years before (37.7%); 62.3% were recipients of living donors and 83% were prednisone-treated. The most prevalent dermatoses were of fungal (45.3%) and viral (39.6%) etiologies. Among the non-melanoma malignant neoplasms, the basal cell carcinoma prevailed (six cases), in spite of the low incidence. Concerning fungal dermatoses, 12 cases of onychomycosis, five of pityriasis versicolor and four of pityrosporum folliculitis were reported. For diagnosis, in most cases (64.2%), laboratory examinations (mycological and histopathological) were performed.

CONCLUSION

cutaneous manifestations in kidney transplant recipients are generally secondary to immunosuppression. The infectious dermatoses, especially those of fungal origin, are frequently found in kidney transplant recipients and their occurrence increases progressively according to the time elapsed from the transplantation, which makes follow-up important.

Conversion from tacrolimus/mycophenolic acid to tacrolimus/leflunomide to treat cutaneous warts in a series of four pediatric renal allograft recipients

BACKGROUND

The challenge of immunosuppression in pediatric renal transplantation is to balance preventing rejection while avoiding infectious complications. A dermatological complication of immunosuppression is viral warts, which cause significant disfigurement and increase the risk of skin malignancy.

METHODS

We present three pediatric and adolescent renal allograft recipients with multiple, recalcitrant verrucae vulgares lesions and one patient with molluscum contagiosum who were switched from mycophenolate mofetil to leflunomide. Teriflunomide metabolite levels were carefully maintained between 50,000 and 100,000 ng/mL to balance its immunosuppressive and antiviral properties. No adverse events requiring discontinuation of leflunomide were encountered.

RESULTS

Switching from mycophenolate mofetil to leflunomide successfully cleared verrucae vulgares and molluscum lesions in all four renal transplant patients.

CONCLUSIONS

The ability to minimize and even resolve warts can improve quality of life by reducing risk of skin malignancies and emotional distress in solid organ transplant patients. Leflunomide is a potential therapeutic option for posttransplantation patients with skin warts because it serves both as an adjunct to the immunosuppressive regimen and an antiviral agent.

Skin tags and acanthosis nigricans in patients with hepatitis C infection in relation to insulin resistance and insulin like growth factor-1 levels

BACKGROUND

Skin tags (ST) are papillomas commonly found in the neck, axillae of middle-aged and elderly people

AIM

Insulin and insulin-like growth factor (IGF-1) levels are affected by hepatitis C virus (HCV) infection and both of them may be implicated in the etiopathogenesis of ST and acanthosis nigricans (AN) through their proliferative and differentiating properties. So, the aim of this work was to evaluate the impact of HCV infection on ST and AN through the estimation of insulin resistance and IGF-1.

MATERIALS AND METHODS

PARTICIPANTS WERE ARRANGED INTO FOUR GROUPS: (ST +ve / HCV +ve) 23 subjects, (ST+ / HCV -ve) 19 subjects, (HCV -ve / ST-ve) 20 subjects and (ST-ve /HCV +ve) 22 subjects. Age, ST size, color, number, AN, fasting glucose, fasting insulin, insulin resistance, IGF-1, HCV-antibodies (Ab) were recorded.

RESULTS

The mean number of ST in Group 1 was half the number of ST in Group 2 (11.0±9.3 / 22.3±14.0) (P=0.005). The difference in insulin resistance between the same groups was non-significant (13.1±10.6 / 9.0±5.5) (P=0.441) while the difference in IGF-1 was statistically significant (218.6±46.2 /285.4±32.8) (P=0.002). The multivariate logistic regression for the variables revealed that insulin resistance is the only factor affecting the occurrence of ST (OR=1.096, P=0.023). Multivariate regression analysis for the variables showed that HCV was borderline but not a significant factor affecting the number of ST (Beta=-0.409, P=0.053). The number of patients with AN was doubled in Group 2 in comparison to Group 1 but this was non significant 3(13%) / 6(32%) (P=0.2800).

CONCLUSION

HCV is associated with a significant decrease in the ST number and in the serum level of IGF-1 together with an obvious decrease in the occurrence of AN. Our results may point to the entrant effect of insulin resistance and IGF-1 in ST and AN development. The current study suggests the evaluation of IGF-1-lowering agents in the control of ST and AN especially in the females with polycystic ovary and in the prevention of the recurrence of ST after surgical removal.

Dehiscence of corticosteroid-induced abdominal striae in a 14-year-old boy treated with bevacizumab for recurrent glioblastoma

Corticosteroids have been the mainstay for management of cerebral edema caused by leaky angiogenic vessels associated with high-grade brain tumors since the early 1960s. Chronic corticosteroid use can cause iatrogenic Cushing syndrome, which is associated with weight gain and abdominal striae (striae distensae). The anti-vascular endothelial growth factor therapy, bevacizumab, has recently been introduced for the management of recurrent glioblastoma. Vascular endothelial growth factor plays multiple roles in wound healing, including promoting angiogenesis, acting as a chemo-attractant for inflammatory cells, and stimulating collagen production. We report the first pediatric case of a 14-year-old boy with corticosteroid-induced abdominal striae who developed ulceration and dehiscence of the striae following the introduction of bevacizumab therapy. The combination of high-dose corticosteroids and anti-vascular endothelial growth factor therapy may cause significant complications, especially in children who are susceptible to abdominal striae and therefore should be avoided.

Nonneoplastic mucocutaneous lesions in organ transplant recipients

Nonneoplastic mucocutaneous lesions are frequent in organ transplant recipients. Many of them are caused by a direct toxicity of immunosuppressive drugs, in particular glucocorticoids and cyclosporine. The effects of these agents are dose- and time-dependent. Glucocorticoids can cause acne, Cushingoid appearance, irregular purpuric areas, friable skin, and wide and violaceous stripes. Cyclosporine can cause hypertrichosis, pilosebaceous lesions, and gum hypertrophy. Patients with esthetic changes may show poor adherence to treatment with these immunosuppressive agents that may lead to progressive graft dysfunction. Apart from this direct toxicity, vigorous immunosuppression may render the transplant recipients more susceptible to mucocutaneous infections. Fungal infection, viral warts, and bacterial folliculitis are the most frequent types of mucocutaneous infection. Some fungal infections, such as oral candidiasis and pityriasis versicolor, are relatively trivial, but other mycotic infections can cause severe or disfigurating lesions. Among viral infections, warts and condylomata caused by human papilloma virus are frequent and may favor the development of nonmelanoma skin cancer. Bacterial infections are usually trivial in the early period after transplantation, being represented almost exclusively by folliculitis. However, subcutaneous infections may cause a necrotizing fasciculitis which is a life-threatening disorder, usually sustained by polymicrobial pathogens.

Clinical characteristics of molluscum contagiosum in children in a private dermatology practice in the greater Paris area, France: a prospective study in 661 patients

BACKGROUND

Series regarding the clinical characteristics of molluscum contagiosum (MC) are retrospective and concern small defined populations seen in a hospital setting.

METHODS

We prospectively studied patients under 15 years of age with MC seen in 25 private dermatology practices in the greater Paris area during 1 year.

RESULTS

Six hundred fifty patients were included. The mean age was 6 years. Of the patients, 30.5% had had MC in the past, 53% had 5-20 MC, 43% had a history of atopic dermatitis (AD), 5% were using topical steroids, 25.5% had coexistent AD, 13% had giant MC (>5 mm), 21% had inflammatory MC, and 19% had MC surrounded by eczema. Bathing with siblings was associated with a higher number of MC. A history of AD was associated with the presence of MC surrounded by eczema. The use of topical steroids was associated with a higher risk of relapse. There was no relation between environmental factors (MC in surrounding people, going to the swimming pool, sports practice) and the number of lesions or between environmental factors and the number of recurrences.

CONCLUSION

Atypical lesions are frequent. Bathing with siblings is associated with a higher number of MC. Topical steroid use increases the risk of relapses. AD prevalence is higher than in the general population.

National athletic trainers' association position statement: skin diseases

OBJECTIVE

To present recommendations for the prevention, education, and management of skin infections in athletes.

BACKGROUND

Trauma, environmental factors, and infectious agents act together to continually attack the integrity of the skin. Close quarters combined with general poor hygiene practices make athletes particularly vulnerable to contracting skin diseases. An understanding of basic prophylactic measures, clinical features, and swift management of common skin diseases is essential for certified athletic trainers to aid in preventing the spread of infectious agents.

RECOMMENDATIONS

These guidelines are intended to provide relevant information on skin infections and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Prevalence of benign cutaneous disease among Oxford renal transplant recipients

BACKGROUND

The burden of malignant and benign cutaneous disease among renal transplant recipients (RTR) is substantial. Little attention is given to non-malignant skin problems in the literature despite their potential impact on quality of life or on aesthetics - which may contribute to poor compliance with immunosuppressive medications post-transplantation.

OBJECTIVES

The aim of this study was to examine prevalence of benign cutaneous disease in a group of RTRs and identify risk factors for individual cutaneous conditions.

METHODS

All cutaneous findings were recorded in a single full body skin examination of 308 RTRs. Data on medical, transplant and medication history were obtained from questionnaire and medical records. Odds ratios were calculated to look at associations between benign cutaneous diseases and various potential risk factors after controlling for gender, age, time since transplantation and skin type.

RESULTS

Cutaneous infections such as viral warts (38%), fungal infection (18%) and folliculitis (27%) were common and usually chronic. A range of pilosebaceous unit disorders were observed with hypertrichosis being strongly associated with ciclosporin (P<0.0001). Other iatrogenic cutaneous effects included gingival hyperplasia (27%) and purpura (41%). We identified seborrhoeic warts and skin tags in 55% and 33% respectively. Inflammatory dermatoses were rare (<2%) apart from seborrhoeic dermatitis (9.5%).

DISCUSSION

In this first comprehensive study on prevalence of benign cutaneous diseases in a UK transplant population, a wide range of skin disorders was identified. It is therefore important that RTRs have access to dermatology services post-transplantation for appropriate management of benign cutaneous conditions as well as early detection of cutaneous malignancy and education regarding risks of sun exposure.

Cutaneous warts in children before and after renal transplantation

Cutaneous warts occur in 3.9-4.9% of children in the UK. The incidence is increased in organ transplant recipients and may be increased in patients with chronic kidney disease (CKD), since uraemia reduces the immune system's function. We surveyed the records from our CKD and renal transplant clinic to ensure patients with warts were identified and appropriately treated. Data were collected by questionnaire. The presence of warts, location, treatment, levels of pain and emotional upset were recorded. Nine of 49 (18.4%) pre-transplantation patients (33 male, median age 12.1 years) were currently suffering from warts compared with 17 of 60 (28.3%) post-transplantation patients (34 male, median age 13.9 years). A further 14 pre-transplantation and 16 post-transplantation patients had previously suffered from warts which had resolved. Forty-one patients had sought treatment for warts, mainly from primary care. Five patients, all having received transplants, were seen by a dermatologist. Self-rated levels of pain and emotional upset were generally low, apart from those of four adolescent patients who expressed significant emotional upset. We concluded that cutaneous warts are more common among CKD patients. Appropriate information and treatment are required before and after transplantation. The majority of warts can be treated in primary care, but selected patients with extensive warts that cause distress need early referral for dermatology opinion.

Adverse effects of immunosuppression in pediatric solid organ transplantation

Solid organ transplantation is a life-saving treatment for end-stage organ failure in children. Immunosuppressant medications are used to prevent rejection of the organ transplant. However, these medications are associated with significant adverse effects that impact growth and development, quality of life (QOL), and sometimes long-term survival after transplantation. Adverse effects can differ between the immunosuppressants, but many result from the overall state of immunosuppression. Strategies to manage immunosuppressant adverse effects often involve minimizing exposure to the drugs while balancing the risk for rejection. Early recognition of immunosuppressant adverse effects may help to reduce morbidities associated with solid organ transplantation, improve QOL, and possibly increase overall patient survival.

Quantitation of mast cells and collagen fibers in skin tags

BACKGROUND

Skin tags are common benign skin tumors usually occurring on the neck and major flexors of elder people.

AIMS

The aim of this study is to perform quantitation of mast cells and collagen fibers in skin tags and normal skin in diabetics and nondiabetics, to find a possible correlation between mast cells and collagen fibers in the pathogenesis of skin tags.

METHODS

Thirty participants with skin tags were divided into two groups (15 diabetic and 15 nondiabetic). Three biopsies were obtained from one anatomical site: A large skin tag, a small skin tag, and adjacent normal skin. Mast cells stained with Bismarck brown were counted manually in ten different fields of each section with magnification x1000 and the average count was correlated with the percentage of mean collagen area in five fields done by the image analyzer.

RESULTS

A statistically significant correlation between mast cell count and percentage of collagen mean area was detected in both studied groups (except in large skin tags of the nondiabetic group).

CONCLUSION

The positive correlation between mast cell count and percentage of collagen mean area suggests the critical role of mast cells in the etiogenesis of skin tags through its interaction with fibroblasts.

Immunosuppression-related fibroproliferative polyps: a substantial subset of acquired pediatric mucocutaneous polyps

A distinct group of fibroproliferative polyps of the tongue arising in immunosuppressed children and often associated with chromosomal breakpoints at chromosomes 9p34 or 22q11 was recently described. Based on this finding, we reviewed fibroepithelial polyps arising in nonlingual sites in the pediatric population to investigate a possible relationship with immunosuppression. We identified 8 fibroepithelial polyps arising in 6 immunosuppressed patients (4 males and 2 females, median age 17 years) in a wide range of mucocutaneous sites. Histologic features were identical to the common fibroepithelial polyp, or skin tag, with a variably collagenous fibrovascular core covered by unremarkable squamous epithelium. No viral cytopathic changes were identified in any case. Although cytogenetic studies were not performed on any of the biopsy material, 1 patient had a constitutional deletion of chromosome 22q11. We suggest that there may be a relationship between these polyps and the previously described tongue lesions and that immunosuppression may be an important factor in their pathogenesis.

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.

[Eruptive melanocytic nevi of the palms and soles in a patient with Crohn disease]

Eruptive melanocytic nevi of the palms and soles are a rare phenomenon which has been associated with a number of different diseases. A variety of pathogenetic mechanisms have been proposed. A 22-year-old woman with Crohn disease since 1998 presented with multiple eruptive melanocytic nevi of the palms and soles. She is the second case in the literature describing the association between Crohn disease and eruptive melanocytic nevi. In contrast to the first report by Belloni-Fortina et al., in our case the melanocytic nevi appeared only on the palms and soles.

Vaccinia virus infection attenuates innate immune responses and antigen presentation by epidermal dendritic cells

Langerhans cells (LCs) are antigen-presenting cells in the skin that play sentinel roles in host immune defense by secreting proinflammatory molecules and activating T cells. Here we studied the interaction of vaccinia virus with XS52 cells, a murine epidermis-derived dendritic cell line that serves as a surrogate model for LCs. We found that vaccinia virus productively infects XS52 cells, yet this infection displays an atypical response to anti-poxvirus agents. Whereas adenosine N1-oxide blocked virus production and viral protein synthesis during a synchronous infection, cytosine arabinoside had no effect at concentrations sufficient to prevent virus replication in BSC40 monkey kidney cells. Vaccinia virus infection of XS52 cells not only failed to elicit the production of various cytokines, including tumor necrosis factor alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6, IL-10, IL-12 p40, alpha interferon (IFN-alpha), and IFN-gamma, it actively inhibited the production of proinflammatory cytokines TNF-alpha and IL-6 by XS52 cells in response to exogenous lipopolysaccharide (LPS) or poly(I:C). Infection with a vaccinia virus mutant lacking the E3L gene resulted in TNF-alpha secretion in the absence of applied stimuli. Infection of XS52 cells or BSC40 cells with the DeltaE3L virus, but not wild-type vaccinia virus, triggered proteolytic decay of IkappaBalpha. These results suggest a novel role for the E3L protein as an antagonist of the NF-kappaB signaling pathway. DeltaE3L-infected XS52 cells secreted higher levels of TNF-alpha and IL-6 in response to LPS and poly(I:C) than did cells infected with the wild-type virus. XS52 cells were productively infected by a vaccinia virus mutant lacking the K1L gene. DeltaK1L-infected cells secreted higher levels of TNF-alpha and IL-6 in response to LPS than wild-type virus-infected cells. Vaccinia virus infection of primary LCs harvested from mouse epidermis was nonpermissive, although a viral reporter protein was expressed in the infected LCs. Vaccinia virus infection of primary LCs strongly inhibited their capacity for antigen-specific activation of T cells. Our results highlight suppression of the skin immune response as a feature of orthopoxvirus infection.

Viral infections affecting the skin in organ transplant recipients: epidemiology and current management strategies

Viral skin infections are common findings in organ transplant recipients. The most important etiological agents are the group of human herpesviruses (HHV), human papillomaviruses (HPV), and molluscum contagiosum virus. HHV that are important in this group of patients are herpes simplex virus (HSV) types 1 and 2, varicella-zoster virus (VZV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), HHV-6 and -7, and HHV-8, which causes Kaposi sarcoma (KS). HSV infections are characterized by their ability to establish latency and then reactivate at a later date. The most common manifestations of HSV infection in organ transplant recipients are mucocutaneous lesions of the oropharynx or genital regions. Treatment is usually with acyclovir, valaciclovir, or famciclovir. Acyclovir resistance may arise although the majority of acyclovir-resistant strains have been isolated from AIDS patients and not organ transplant recipients. In such cases, alternatives such as foscarnet, cidofovir, or trifluridine may have to be considered. VZV causes chickenpox as well as herpes zoster. In organ transplant recipients, recurrent herpes zoster can occur. Acute chickenpox in organ transplant patients should be treated with intravenous acyclovir. CMV infection occurs in 20-60% of all transplant recipients. Cutaneous manifestations, which include nonspecific macular rashes, ulcers, purpuric eruptions, and vesiculobullous lesions, are seen in 10-20% of patients with systemic infection and signify a poor prognosis. The present gold standard for treatment is ganciclovir, but newer drugs such as valganciclovir appear promising. EBV is responsible for some cases of post-transplant lymphoproliferative disorder, which represents the greatest risk of serious EBV disease in transplant recipients. HHV-6 and HHV-7 are two relatively newly discovered viruses and, at present, the body of information concerning these two agents is still fairly limited. KS is caused by HHV-8, which is the most recently discovered lymphotrophic HHV. Iatrogenic KS is seen in solid-organ transplant recipients, with a prevalence of 0.5-5% depending on the patient's country of origin. HPV is ubiquitous, and organ transplant recipients may never totally clear HPV infections, which are the most frequently recurring infections in renal transplant recipients. HPV infection in transplant recipients is important because of its link to the development of certain skin cancers, in particular, squamous cell carcinoma. Regular surveillance, sun avoidance, and patient education are important aspects of the management strategy.

Evaluation of papillomaviruses associated with cyclosporine-induced hyperplastic verrucous lesions in dogs

OBJECTIVE

To determine whether cyclosporine A-induced hyperplastic skin lesions of dogs were associated with papillomavirus infections.

ANIMALS

9 dogs that were treated with cyclosporine A and developed hyperplastic skin lesions.

PROCEDURE

History and clinical and histopathologic data were collected. Paraffin-embedded skin biopsy specimens from hyperplastic skin lesions were immunostained for common papillomavirus genus-specific structural antigens by use of a polyclonal rabbit anti-bovine papillomavirus type 1 antiserum. Sections from each tissue block underwent DNA extraction, and polymerase chain reaction (PCR) assays were performed with several sets of primers to amplify a wide range of papillomavirus DNA from humans and other animals.

RESULTS

In 7 of 9 dogs, there were more than 10 hyperplastic skin lesions that microscopically resembled those of psoriasiform lichenoid dermatosis. In those dogs, results of testing for papillomavirus via immunohistochemical analyses and PCR assays were negative. In the other 2 dogs, there were only 1 and 3 verrucous lesions, and in those dogs, histologic evaluation revealed koilocytes and nuclear viral inclusions that were immunoreactive for papillomavirus antigens. Papillomavirus DNA was amplified from both dogs. One of the sequences was characteristic for the canine oral papillomavirus, whereas the other had similarities with the recently described canine papillomavirus 2.

CONCLUSIONS AND CLINICAL RELEVANCE

In dogs, hyperplastic skin lesions occasionally develop during treatment with cyclosporine A. Most of the lesions resemble those of psoriasiform lichenoid dermatosis, although papillomavirus can be detected in some instances.

Skin changes in pediatric transplant patients

The advent of organ transplantation identified a new group of diseases. Dermatologists are studying transplant-associated diseases along with the atypical behavior of already known dermatoses. Pediatric patients have been treated as an extension of adult population, but unique aspects of age required clarification. A prospective cohort was studied including patients from both genders up to 17 yr of age who were recipients of kidney, liver or BMT during 2003 in Porto Alegre, Brazil. Regular skin examinations were performed up to the sixth month after the procedure, and an analysis was determined by ID (i.e. = number of skin changes/number of patients-month x 100). Thirty-nine patients were examined: 20 were kidney transplant recipients; 11 were BMT recipients (10 autologous transplants and 1 allogeneic transplant); and 8 were liver transplant recipients. Skin changes result primarily from the use of medication (87.2). Individually, kidney transplant patients presented the highest ID of skin changes because of medications (104.1). BMT recipients presented the highest ID of alterations occurring on skin appendages (85.4) and liver transplant recipients had the highest ID of vascular changes (94.9). In conclusion, this study shows that cutaneous alterations in pediatric transplant recipients present some particularities not described in adult recipients, such as ichthyosiform xerosis in renal recipients and skin scaling with pellagroid appearance in bone marrow recipients. Also, dermatoses secondary to medication use were the main finding in pediatric population.

Cutaneous adverse events in renal transplant recipients receiving sirolimus-based therapy

BACKGROUND

Sirolimus is an immunosuppressive drug recently developed for organ transplantation. Its mechanism of action, independent of calcineurin, is different from that of cyclosporine and tacrolimus, two calcineurin inhibitors (CIs). Because the toxicity of CIs is partly the result of calcineurin blockade, sirolimus exhibits a different toxicity profile. In this study, we evaluated the profile, frequency, and severity of cutaneous adverse events in renal transplant recipients receiving sirolimus-based therapy.

PATIENTS AND METHODS

A systematic and in-depth evaluation of skin, mucous membranes, nails, and hair was performed in 80 renal transplant recipients receiving sirolimus-based therapy. The mean duration of the graft was 6 years and of sirolimus treatment was 18 months. Mycophenolate mofetil and steroids were combined with sirolimus for 74 patients. Sirolimus was used as first immunosuppressive therapy for 36 patients, and 44 patients were switched from CIs to sirolimus.

RESULTS

Seventy-nine patients (99%) experienced cutaneous adverse events. Twenty patients (25%) demonstrated serious adverse events, and six patients (7%) stopped sirolimus during the 3 months after the study because of cutaneous events. The most frequent of these were pilosebaceous apparatus involvement, including acne-like eruptions (46%), scalp folliculitis (26%), and hidradenitis suppurativa (12%); edematous complaints, including chronic edemas (55%) and angioedema (15%); mucous membrane disorders, including aphthous ulceration (60%), epistaxis (60%), chronic gingivitis (20%), and chronic fissure of the lips (11%); and last, nail disorders including chronic onychopathy (74%) and periungual infections (16%).

CONCLUSIONS

Skin disorders are frequent in renal transplant recipients receiving sirolimus as a long-term therapy. Despite the usually mild nature of skin events, they are often the reason for stopping sirolimus.

Skin disorders in patients transplanted in childhood

Only few data are available on skin disorders in pediatric organ transplant recipients. In order to describe the whole range of dermatological diseases in a population of pediatric organ transplant recipients, we studied a group of 217 consecutive organ transplant recipients (168 kidney, 29 heart, 19 liver, one lung) aged <18 years at transplantation followed at a single center. A total of 193 patients showed at least one skin disorder; 149 had more than one skin disease. The most common skin infections were warts (24.4%), pityriasis versicolor (20.7%), folliculitis (12.9%), intertrigo (6.5%); the most common drug side effects were hypertrichosis (69.6%), steroid acne (39.6%), gingival hyperplasia (29%) and severe xerosis (20.7%). Two patients (0.9%) developed nonmelanoma skin cancer. Our study summarizes the main skin complications in patients transplanted in childhood and underlines the necessity of regular dermatologic surveillance of these patients.