The organs and the skin
Immunosuppressant treatments can lead to cutaneous skin concerns in transplant patients.
Organ transplants are becoming more common each year as surgical technology advances and contemporary immunosuppression regimens lead to longer life expectations for patients. Dermatologists are key players in managing the cutaneous complications that can arise from immunosuppressive medications.
In Friday’s session, U009 – Opportunistic Infections and Drug Rashes Oh My – Managing the Cutaneous Complications of Solid Organ Transplantation, Melodi Javid Whitley, MD, PhD, FAAD, said dermatologists should learn about these new immunosuppressive treatments.
Specifically, the past 10 to 15 years have seen the approval of two different classes of immunosuppressants for organ transplant recipients: mTOR inhibitors (everolimus and sirolimus) and the CTLA-4 analogue belatacept. Even though they are not as commonly used as traditional immunosuppressants, Dr. Whitley said dermatologists should be on the lookout for potential adverse events.
“One of the major side effects of mTOR inhibitors that is especially relevant to dermatologists is poor wound healing,” she said. “Dermatologists should be aware of this and discuss potential drug holidays or alternatives with their transplant physician colleagues when planning surgical procedures for their patients.”
Dr. Whitley, who is assistant professor of dermatology at Duke University School of Medicine in Durham, North Carolina, said she commonly sees acne and folliculitis among patients on mTOR inhibitors.
“Belatacept seems to be quite well tolerated, however there have been some cutaneous side effects reported,” she said. “These patients will benefit from expert care from a board-certified dermatologist.”
Common cutaneous triggers
Stephanie M. Gallitano, MD, FAAD, director of yesterday’s session, said there are opportunistic cutaneous infections that are overrepresented in the solid organ transplant community for several reasons, including decreased cell-mediated immunity among this patient group.
“Cell-mediated immunity is essential for recognizing and targeting viruses. Common viral infections, such as human papillomavirus (HPV) and molluscum contagiosum, are overrepresented in these patient populations due to their impaired immune response,” she said.
Dr. Gallitano, who is assistant professor of clinical dermatology at Columbia University Irving Medical Center in New York City, said HPV infections such as common warts and genital warts can become extensive and recalcitrant. They can also potentially play a role in the development of skin cancers.
“Up to 80% of keratinocyte carcinomas in transplanted patients have HPV DNA, suggesting a role in the development of keratinocyte carcinomas,” she said. “Beta-HPV subtypes can cause acquired epidermodysplasia verruciformis in solid organ transplant recipients. These cutaneous lesions may progress to squamous cell carcinoma.”
Human polyomaviruses may also trigger cutaneous infections in solid organ transplant patients. Dr. Gallitano said trichodysplasia spinulosa virus and human polyomaviruses 6, 7, and 9 can all cause cutaneous infections.
“These viruses are detected with no clinical disease on healthy skin but may cause pathologic disease in [organ transplant patients],” she said. “Additionally, patients with immunosuppression are at greater risk of developing reactivation of human herpes virus infections, including varicella zoster and herpes simplex viral infections.”
Ultimately, Dr. Gallitano said the key to diagnosing and treating these infections is high clinical index of suspicion and appropriate testing.
“Patients can be diagnosed with skin biopsies that demonstrate characteristic features,” she said. “Trichodysplasia spinulosa virus and human polyomavirus 6 and 7 can also be detected through Karius testing, which is a blood test using next generation sequencing to detect and identify pathogens in the blood stream. VSV and HSV can be detected by routine viral polymerase chain reaction (PCR) tests.”
