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Khurana A, Saxena S. Immunosuppressive agents for dermatological indications in the ongoing COVID-19 pandemic: Rationalizing use and clinical applicability. Dermatol Ther 2020; 33:e13639. [PMID: 32436617 PMCID: PMC7280701 DOI: 10.1111/dth.13639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
The ongoing COVID-19 epidemic has brought to the fore many concerns related to use of immunosuppressive agents (ISAs) in dermatology. While it is unclear whether the patients on ISAs for skin conditions are more prone to develop COVID-19, and what impact the ISA may have on the clinical outcome if a patient does get infected, rationalizations based on the specific immune effects of each drug, and existing literature on incidence of various infections with each, are possible. In this review, we provide the readers with practically useful insights into these aspects, related to the conventional ISAs, and briefly mention the clinical outcome data available on related scenarios from other patient groups so far. In the end, we have attempted to provide some clinically useful points regarding practical use of each dermatologically relevant conventional ISA in the current scenario.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
| | - Snigdha Saxena
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
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Rueter L, Ramadori P, Ulrich M, Jung S, Kardorff B, Lademann J. Reflectance confocal microscopy for noninvasive examination of nonmelanocytic tumors and virus-associated skin lesions in organ transplant recipients. Skin Res Technol 2019; 26:376-389. [PMID: 31802548 DOI: 10.1111/srt.12813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/20/2019] [Accepted: 11/09/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Drug-induced immunosuppression is necessary to prevent rejection of the foreign organ in transplanted patients, but neoplastic and virus-associated skin diseases are frequent complications. Reflectance confocal microscopy (RCM) recently emerged as a promising tool for the early diagnosis of skin lesions. MATERIALS AND METHODS A total of 61 skin lesions, among them 20 basal cell carcinomas, six Bowen's diseases, 23 actinic keratoses, and 12 verrucae, were analyzed. All lesions were clinically evaluated followed by RCM evaluation by two independent dermatologists and histological examination. RESULTS For the diagnosis of basal cell carcinoma, a sensitivity of 100% by both investigators (INV I + II) and a specificity of 100% by INV I and 80% by INV II were achieved. The sensitivity average rate for RCM features reached by both investigators ranged between 60% and 100%, and the specificity between 55% and 90%. For the diagnosis of actinic keratosis, a concordant sensitivity of 94.4% and a specificity of 80% (INV I) and 60% (INV II) were detected. The sensitivity average rate of specific RCM criteria ranged between 72.3% and 97.2%, whereas specificity ranged between 20% and 90%. Regarding verrucae, RCM confirmed the histological diagnosis with a sensitivity of 85.7% (INV I) and 100% (INV II), while specificity was 100% and 80%, respectively. CONCLUSION Reflectance confocal microscopy resulted to be a reliable tool for the noninvasive diagnosis of neoplastic and virus-associated skin changes in organ transplant recipients. Nevertheless, given the frequency and diagnostic complexity of the hyperkeratotic lesions occurring post-transplantation, larger cohorts of patients are required to confirm and consolidate these findings.
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Affiliation(s)
- Lena Rueter
- Department of Dermatology, Venerology and Allergology, Berlin Institute of Health, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Pierluigi Ramadori
- Division of Chronic Inflammation and Cancer, German Cancer Research Center, Heidelberg, Germany
| | | | - Sora Jung
- Department of Dermatology, Venerology and Allergology, Berlin Institute of Health, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Kardorff
- Gemeinschaftspraxis für Dermatologie, Allergologie, Phlebologie und Umweltmedizin Mönchengladbach, Mönchengladbach, Germany
| | - Juergen Lademann
- Department of Dermatology, Venerology and Allergology, Berlin Institute of Health, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
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Wiehe A, O'Brien JM, Senge MO. Trends and targets in antiviral phototherapy. Photochem Photobiol Sci 2019; 18:2565-2612. [PMID: 31397467 DOI: 10.1039/c9pp00211a] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Photodynamic therapy (PDT) is a well-established treatment option in the treatment of certain cancerous and pre-cancerous lesions. Though best-known for its application in tumor therapy, historically the photodynamic effect was first demonstrated against bacteria at the beginning of the 20th century. Today, in light of spreading antibiotic resistance and the rise of new infections, this photodynamic inactivation (PDI) of microbes, such as bacteria, fungi, and viruses, is gaining considerable attention. This review focuses on the PDI of viruses as an alternative treatment in antiviral therapy, but also as a means of viral decontamination, covering mainly the literature of the last decade. The PDI of viruses shares the general action mechanism of photodynamic applications: the irradiation of a dye with light and the subsequent generation of reactive oxygen species (ROS) which are the effective phototoxic agents damaging virus targets by reacting with viral nucleic acids, lipids and proteins. Interestingly, a light-independent antiviral activity has also been found for some of these dyes. This review covers the compound classes employed in the PDI of viruses and their various areas of use. In the medical area, currently two fields stand out in which the PDI of viruses has found broader application: the purification of blood products and the treatment of human papilloma virus manifestations. However, the PDI of viruses has also found interest in such diverse areas as water and surface decontamination, and biosafety.
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Affiliation(s)
- Arno Wiehe
- biolitec research GmbH, Otto-Schott-Str. 15, 07745 Jena, Germany. and Institut für Chemie und Biochemie, Freie Universität Berlin, Takustr. 3, 14195 Berlin, Germany
| | - Jessica M O'Brien
- Medicinal Chemistry, Trinity Translational Medicine Institute, Trinity Centre for Health Sciences, Trinity College Dublin, The University of Dublin, St. James's Hospital, Dublin 8, Ireland.
| | - Mathias O Senge
- Medicinal Chemistry, Trinity Translational Medicine Institute, Trinity Centre for Health Sciences, Trinity College Dublin, The University of Dublin, St. James's Hospital, Dublin 8, Ireland.
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Berth-Jones J, Exton LS, Ladoyanni E, Mohd Mustapa MF, Tebbs VM, Yesudian PD, Levell NJ. British Association of Dermatologists guidelines for the safe and effective prescribing of oral ciclosporin in dermatology 2018. Br J Dermatol 2019; 180:1312-1338. [PMID: 30653672 DOI: 10.1111/bjd.17587] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 02/06/2023]
Affiliation(s)
- J Berth-Jones
- Department of Dermatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, U.K
| | - L S Exton
- British Association of Dermatologists, Willan House, London, W1T 5HQ, U.K
| | - E Ladoyanni
- Department of Dermatology, Dudley Group NHS Foundation Trust, Dudley, DY1 2HQ, U.K
| | - M F Mohd Mustapa
- British Association of Dermatologists, Willan House, London, W1T 5HQ, U.K
| | - V M Tebbs
- formerly of George Eliot Hospital, College Street, Nuneaton, CV10 7DJ, U.K
| | - P D Yesudian
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, LL13 7TD, U.K
| | - N J Levell
- Dermatology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, U.K
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Oh CC, Lee HY, Tan BK, Assam PN, Kee TYS, Pang SM. Dermatological conditions seen in renal transplant recipients in a Singapore tertiary hospital. Singapore Med J 2019; 59:519-523. [PMID: 30386860 DOI: 10.11622/smedj.2018126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Lifelong immunosuppression after renal transplant exerts effects on the recipients' skin, including skin infections, skin cancers and drug-induced skin disorders. Our study aimed to determine the epidemiology of skin conditions among renal transplant recipients in the largest tertiary hospital in Singapore. METHODS We reviewed the medical records of kidney transplant recipients at Singapore General Hospital, Singapore, between 1 January 2003 and 31 December 2013. Among these patients, the clinical data of patients who sought skin consultations with either dermatologists or plastic surgeons within the hospital was captured. RESULTS A total of 178 patients were included in our study. There were 88 (45.6%) skin infections, 23 (11.9%) drug-induced skin conditions, 9 (4.7%) skin cancers and 73 (37.8%) other skin conditions. Skin infection was the predominant reason for consultation, with viral warts (15%, n = 29) being the most common. Of the nine cases in our cohort with skin cancer, there were three cases of basal cell carcinoma, three cases of Bowen's disease, two cases of extramammary Paget's disease and one case of squamous cell carcinoma. Drug-induced skin conditions, mainly attributable to long-term steroids and cyclosporin use, were represented by acne (9.3%, n = 18) and sebaceous hyperplasia (2.6%, n = 5). CONCLUSION 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.
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Affiliation(s)
- Choon Chiat Oh
- Department of Dermatology, Singapore General Hospital, Singapore
| | - Haur Yueh Lee
- Department of Dermatology, Singapore General Hospital, Singapore
| | - Bien Keem Tan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
| | | | | | - Shiu Ming Pang
- Department of Dermatology, Singapore General Hospital, Singapore
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Güleç AT. Natural Thermal Spa Water Versus Hyperthermic Tap Water for Treatment of Recalcitrant Hand Warts in Organ Transplant Recipients: A Patient-Blinded, Comparative Preliminary Study. EXP CLIN TRANSPLANT 2018. [PMID: 29528025 DOI: 10.6002/ect.tond-tdtd2017.p59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Cutaneous warts represent a major problem in organ transplant recipients because of their extensive involvement and persistent course. Current therapeutic modalities often fail to achieve a successful response in patients with warts. We experienced a case involving an organ transplant recipient with recalcitrant mosaic warts who presented with complete clearance of lesions in 3 days after thermal spa bathing. Here, we evaluated the efficacy of natural thermal water versus hyperthermic tap water for treatment of recalcitrant hand warts in organ transplant recipients. MATERIALS AND METHODS In this preliminary study, the right hands of 5 organ transplant recipients with hand warts were immersed in thermal water, while the left hands were soaked in tap water at 44°C to 47°C. Treatment involved three 45-minute sessions per week for 1 month. The total number and size of the warts and the hyperkeratosis severity grade were noted. RESULTS After 12 sessions, none of the patients exhibited any marked improvement in the size or number of warts, although 3 patients had a slight decrease in their hyperkeratosis severity grade. CONCLUSIONS Our preliminary data indicate that neither thermal spa water nor hyperthermic tap water is effective for treatment of recalcitrant hand warts in organ transplant recipients. However, new trials using thermal water supplied from different geographical locations should be performed before this observation can be generalized.
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Affiliation(s)
- A Tülin Güleç
- Department of Dermatology, Baskent University Faculty of Medicine, Ankara, Turkey
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Perez HC, Benavides X, Perez JS, Pabon MA, Tschen J, Maradei-Anaya SJ, Lopez L, Lozano E. Basic aspects of the pathogenesis and prevention of non-melanoma skin cancer in solid organ transplant recipients: a review. Int J Dermatol 2016; 56:370-378. [DOI: 10.1111/ijd.13409] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 04/29/2015] [Accepted: 06/06/2016] [Indexed: 01/27/2023]
Affiliation(s)
- Héctor C. Perez
- Organ and Tissue Transplant Group; Department of Surgery; Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
| | - Xiomara Benavides
- Organ and Tissue Transplant Group; Department of Surgery; Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
| | - Juan S. Perez
- Fundación Universitaria de Ciencias de la Salud; Bogotá Colombia
| | - Maria A. Pabon
- Organ and Tissue Transplant Group; Department of Surgery; Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
| | | | - Silvia J. Maradei-Anaya
- Organ and Tissue Transplant Group; Department of Surgery; Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
| | - Luis Lopez
- Organ and Tissue Transplant Group; Department of Surgery; Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
| | - Eyner Lozano
- Organ and Tissue Transplant Group; Department of Surgery; Faculty of Medicine; Universidad Nacional de Colombia; Bogotá Colombia
- Organ Transplantation Division; Hospital Universitario San Ignacio; Bogotá Colombia
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Ulrich C, Arnold R, Frei U, Hetzer R, Neuhaus P, Stockfleth E. Skin changes following organ transplantation: an interdisciplinary challenge. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:188-94. [PMID: 24698074 DOI: 10.3238/arztebl.2014.0188] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 01/07/2014] [Accepted: 01/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The immunosuppressants used in transplantation medicine significantly elevate the incidence of neoplasia, particularly in the skin. The cumulative incidence of non-melanocytic skin cancer (NMSC) in renal transplant recipients was 20.5% in a study carried out in German centers. Data on more than 35 000 renal transplant recipients in the USA document a cumulative NMSC incidence of over 7% after 3 years of immunosuppression. METHOD The authors selectively review publications obtained by a PubMed search to discuss the incidence of, and major risk factors for, skin tumors and infectious diseases of the skin in immunosuppressed patients. RESULTS The main risk factors for skin tumors are age at the time of transplantation, light skin color, previous and present exposure to sunlight, and the type and duration of immunosuppressive treatment. Squamous-cell carcinoma (SCC) is the most common kind of skin tumor in immunosuppressed patients. Human herpesvirus 8 and Merkel-cell polyoma virus also cause neoplasia more often in immunosuppressed patients than in the general population. Surgical excision is the treatment of choice. Actinic keratosis markedly elevates the risk that SCC will arise in the same skin area (odds ratio 18.36, 95% confidence interval 3.03-111). Patients with multiple actinic keratoses can be treated with photodynamic therapy or with acitretin. To lower the skin cancer risk, organ transplant recipients should apply medical screening agents with a sun protection factor of at least 50 to exposed skin areas every day. 55% to 97% of organ transplant recipients have skin infections; these are treated according to their respective types. CONCLUSION Squamous-cell carcinoma of the skin adds to the morbidity and mortality of transplant recipients and is therefore among the major oncological challenges in this patient group. Structured concepts for interdisciplinary care enable risk-adapted treatment.
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Affiliation(s)
- Claas Ulrich
- Outpatient Clinic for the Follow-up Care of Immunosuppressed Patients, Skin Tumor Center, Charité - Universitätsmedizin Berlin, Department of Hematology, Oncology, and Tumor Immunology Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medical Director, Charité - Universitätsmedizin Berlin, Department of Cardiac, Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Department of General, Visceral, and Transplant Surgery, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin
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Schopf R. Ingenol mebutate gel is effective against anogenital warts - a case series in 17 patients. J Eur Acad Dermatol Venereol 2015; 30:1041-3. [DOI: 10.1111/jdv.13097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- R.E. Schopf
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
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Savoia P, Cavaliere G, Fava P. Risk of infectious diseases and cutaneous tumours in solid organ recipients: A meta-analysis of literature. World J Meta-Anal 2015; 3:11-19. [DOI: 10.13105/wjma.v3.i1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/08/2014] [Accepted: 11/19/2014] [Indexed: 02/05/2023] Open
Abstract
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.
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Orlicka K, Barnes E, Culver EL. Prevention of infection caused by immunosuppressive drugs in gastroenterology. Ther Adv Chronic Dis 2013; 4:167-85. [PMID: 23819020 PMCID: PMC3697844 DOI: 10.1177/2040622313485275] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Immunosuppressive therapy is frequently used to treat gastrointestinal diseases such as inflammatory bowel disease, autoimmune hepatitis, IgG4-related disease (autoimmune pancreatitis and sclerosing cholangitis) and in the post-transplantation setting. These drugs interfere with the immune system. The main safety concern with their use is the risk of infections. Certain infections can be prevented or their impact minimized. Physicians must adopt preventative strategies and should have a high degree of suspicion to recognize infections early and treat appropriately. This article reviews the risk factors for infections, the mechanism of action of immunosuppressive therapy and proposes preventive strategies.
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Affiliation(s)
- Katarzyna Orlicka
- Division of Gastroenterology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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[Precancerous tumors and carcinomas in situ of the skin]. Internist (Berl) 2013; 54:671-82. [PMID: 23657620 DOI: 10.1007/s00108-012-3216-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Precancerous skin lesions and carcinomas in situ of the skin represent the early stages of epithelial skin tumors. There is no invasive tumor growth, so the basement membrane is completely intact. These lesions show a wide variation of clinical and histological appearances on the skin or mucosa. The precancerous and carcinoma in situ lesions that are described in this text are actinic keratosis, actinic cheilitis, cutaneous horns, arsenical keratosis, tar-induced dermatosis, X-ray irradiation-related keratosis, Bowen's disease, erythroplasia of Queyrat, bowenoid papulosis, intraepithelial neoplasia (vulvar, penile and anal). Because they all can progress into invasive carcinoma, therapy is mandatory. Many noninvasive therapeutic approaches exist nowadays in the form of gels, creams, photodynamic therapy and invasive techniques such as laser therapy and cryotherapy, curettage and excision of lesional skin. Depending on the treatment process, different rates of general clearance and recurrence of the lesions are discussed in this article.
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Abstract
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.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Istituto Scientifico Humanitas, Rozzano, Milan, Italy.
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