Skin infections in Egyptian renal transplant recipients

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.

Onychomycosis in immunocompromised population: Phenotypic and molecular identification

Onychomycosis is common among immunosuppressed individuals. Renal transplant recipients (RTR) and lupus nephritis (LN) patients are submitted to corticosteroid and other immunosuppressive therapy; and diabetes mellitus (DM) patients are intrinsically immunocompromised.

OBJECTIVES

The aim of this study was to characterise and identify fungal infections on the nails (feet and hands) in immunocompromised patients.

METHODS

The clinical material, nail scales (foot and/or hand), was collected from 47 RTR, 66 LN, 67 DM, and 78 immunocompetent individuals (control group). Phenotypic and molecular analyses were performed.

RESULTS

A total of 258 patients were examined. There was a female predominance, except in the RTR. The average age was 52 years old. Lateral distal subungual onychomycosis (OSDL) (75.2%), mainly affecting the hallux nail, was frequent. The predominance of dermatophyte on toenails and Candida species on fingernails was statistically significant. A higher frequency of fingernail involvement in LN and DM, and for LN, the difference was significant (p = .0456). Infections by Candida spp. were more frequent in DM. Using molecular methods, 87.2% of diagnoses were confirmed, identifying fungal agents at the species level. Dermatophytes, Trichophyton rubrum and Trichophyton interdigitale and the species of Candida, C. parapsilosis and C. albicans, were the most frequent fungal agents.

CONCLUSIONS

Molecular techniques (sequencing of ITS regions of rDNA) offer greater accuracy, although there is no difference, regarding the detection. Clinical presentation and fungal species may differ somewhat from the general population. Immunosuppression did not increase fungal detection positivity.

Novel investigational therapies for onychomycosis: an update

INTRODUCTION

Onychomycosis is an infection of the nail plate that is prevalent among the ageing population. Onychomycosis is difficult to treat with low initial cure rates, high rates of relapse, and reinfection. Present treatment options include oral and topical therapies, with oral therapies yielding better results. However, there has been a greater emphasis on the development of topical antifungal therapies as they have fewer side effects and drug interactions.

AREAS COVERED

This review summarizes new and reformulated drugs. Results from in vitro studies to Phase III clinical trials are discussed. Novel drugs include: the oral azole VT-1161, the topical azole efinaconazole, the benzoxaborole tavaborole, reformulations of terbinafine P-3058 and LI-P, novel inhibitor of succinate dehydrogenase ME1111, and off-label use of tazarotene. Enhanced permeation of the morpholine amorolfine through the nail plate is also discussed using ultraviolet (UV) curable gels, and a fractional CO2 laser.

EXPERT OPINION

Novel topical antifungals and the reformulation of current antifungals have demonstrated marked improvement in nail penetration. Current research has an emphasis on topical therapies due to their minimized risk for adverse effects and higher patient demand. Nevertheless, few topical agents have surfaced in the past few years and the investigation of efficacious combination therapies may become more important.

Improving Cure Rates in Onychomycosis

Background:

Onychomycosis is a persistent fungal nail infection that is notoriously hard to treat. Approximately 20% to 25% of patients with onychomycosis do not respond to treatment, and 10% to 53% of patients relapse. As such, successful treatment is imperative for long-term disease management.

Objective:

To identify ways to improve cure rates for onychomycosis.

Method:

The literature on onychomycosis treatment and recurrence was reviewed to summarize treatment approaches and suggest strategies to increase cure rates.

Results and Conclusion:

To improve treatment success in onychomycosis, we suggest the following measures be followed: (1) onychomycosis must be correctly diagnosed, (2) the treatment regimen should be tailored to the individual patient, (3) the efficacy of antifungals must be maximized, and (4) recurrence must be prevented.

Risk of infectious diseases and cutaneous tumours in solid organ recipients: A meta-analysis of literature

AIM: To compare the risk of cutaneous infections and tumours in kidney transplant recipients with data recently published about this topic.

METHODS: In the present work, we evaluated the incidence of bacterial, fungal and viral cutaneous infectious diseases and the development of skin cancers in a cohort of 436 patients who underwent a renal transplantation. The median age at transplantation of our patients was 50 years and the median duration of the immunosuppression was of 7.2 years. Data obtained from our cohort were compared with those obtained by a systematic review of the literature of the last 20 years about the same topic.

RESULTS: Infectious diseases were the most frequent dermatological disorders that were diagnosed after transplantation, affecting about the 16.5% of patients. Herpes virus reactivation occurs in about the 35% of patients and is more common within 6 mo from transplantation, whereas when the immunosuppression is reduced, skin infections are mainly represented by Human Papilloma Virus infections and localized mycosis, such as pityriasis versicolor and superficial candidiasis. Bacterial infections were relatively rare and occur mainly in the first months after transplantation. The cumulative risk to develop skin cancer enhance significantly over the time, as consequence of long-term immunosuppressive regiments. Endogenous and exogenous risk factors, as well as the schedule of immunosuppression can play a role and justify the different incidence of skin cancer in the various series.

CONCLUSION: Skin infections and cancer, commonly diagnosed in transplanted patients, impact on survival and life-quality, justifying the realization of follow-up programs for the early diagnosis and treatment.

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.