The incidence of immunosuppression-related skin disease in long-term transplant patients

Malignancies After Heart Transplant

Along with graft vasculopathy, malignancies comprise a major complication after heart transplant, with a rate of occurrence of 39.1% in 10 years. Skin cancers and posttransplant lymphoproliferative disorder are more common in adults, whereas lymphoma is more often shown in children. A major cause of malignancies after heart transplant is the use of increased doses of prophylactics needed during immunosuppressive therapy. Data, however, are scarce regarding the association between a particular immunosuppressive drug and a posttransplant malignancy. Compared with the general population, recipients have a higher incidence of malignancies after heart transplant, with an early onset and more aggressive disease. Solid tumors known to occur in heart transplant recipients include lung cancer, bladder and prostate carcinoma, adenocarcinoma of the oral cavity, stomach cancer, and bowel cancer, although the incidence is rare. The risk factors for development of a malignancy after heart transplant are the same as for the nontransplant population.

Recurrent non-melanoma skin cancer: remission of field cancerization after conversion from calcineurin inhibitor- to proliferation signal inhibitor-based immunosuppression in a cardiac transplant recipient

Non-melanoma skin cancers (NMSCs) are the most common malignancies after solid organ transplantation. Their incidence increases with time after transplantation. Calcineurin-inhibitors (CNIs) and azathioprine are known as skin neoplasia-initiating and -enhancing immunosuppressants. In contrast, increasing clinical experience suggests a relevant antiproliferative effect of mammalian target of rapamycin inhibitors, also named proliferation signal inhibitors (PSIs). We report the case of a cardiac allograft recipient with an impressive and consolidated reduction of recurrent NMSC, observed after conversion from CNI-therapy to a PSI-based protocol.

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.

Nail changes in kidney transplant recipients

BACKGROUND

Nail changes are common complications of end-stage renal disease, and reports of nail changes in kidney transplant recipients (KTR) are rare. Few reports have documented a higher prevalence of onychomycosis in KTR compared with controls, while others found no significant differences. In this study, we investigated the prevalence and nature of nail changes in a large series of KTR.

METHODS

Three hundred and two KTR (216 males and 86 females) were included in this study, and the mean transplant duration was 6.57 years (range 1.5 month-23 years). They were screened for the presence of nail changes. Nail clippings were collected when indicated and cultures were performed for patients with suspected onychomycosis. The patients were compared with 302 age- and sex-matched healthy controls (220 males and 82 females).

RESULTS

One hundred and twenty-one KTR (40.1%) had nail changes compared with 104 (34.4%) in controls. Onychomycosis, Muehrcke's nail and leuconychia were significantly more common in KTR [23 (7.6%), 13.3 (4.3%), 11 (3.6%), respectively] compared with controls [7 (2.3%), 1(0.3%), 2 (0.66%), P = 0.002, 0.001 and 0.02, respectively]. However, the most frequent nail change among KTR and controls was absent lunula, 90 (29.8%) and 80 (26.5%), respectively P = 0.36. Longitudinal ridging was also a frequent nail pathology among KTR and controls, 21 (6.9%) and 19 (6.3%), respectively, P = 0.74.

CONCLUSION

KTR have higher prevalence rates of onychomycosis, Muehrcke's nail and leuconychia than the healthy population. On the other hand, absent lunula could be a normal variation among Egyptian people.

Évaluation du suivi dermatologique et des tumeurs cutanées chez les greffés rénaux

BACKGROUND

Renal transplant patients are at increased risk for warts, actinic keratoses and carcinomas. A descriptive study was conducted to investigate the number and frequency of dermatologic examinations in renal transplant patients with a functional graft. The incidence and clinical factors for skin tumours were also assessed.

PATIENTS AND METHODS

We sent an initial questionnaire to 686 renal transplant patients asking whether they had consulted a dermatologist since the time of transplantation. A second questionnaire was then sent to private dermatologists in order to evaluate dermatologic follow-up and the frequency and anatomic distribution of warts and cancerous skin lesions. At the same time, the patients' medical records at the hospital were studied.

RESULTS

About two thirds of the 436 patients included in the study have seen a dermatologist at least once since the time of transplantation. Only 31.2% are being followed up regularly by a dermatologist. The incidence of warts and actinic keratoses is 48.8% and 20.6% respectively, and increases with the duration of immunosuppressive therapy. The incidence of carcinomas is 20.2%, with basal cell carcinomas being seen more frequently than other carcinomas. Risk factors identified for carcinomas are older age at transplantation, duration of immunosuppressive therapy, fair skin, presence of warts and actinic keratoses. All these skin lesions arise predominantly on highly sun-exposed surfaces. Nevertheless, squamous cell carcinomas are more often confined to sun-exposed skin than Bowen's diseases and basal cell carcinomas.

DISCUSSION

Dermatologic follow-up of transplant recipients has rarely been investigated and our study shows that monitoring of skin cancer is probably inadequate. It also confirms the high incidence of carcinomas among renal-transplant recipients in a temperate climate, although basal cell carcinomas are more frequent than squamous cell carcinomas.

Azathioprine in dermatology: The past, the present, and the future

For several decades, dermatologists have utilized azathioprine to treat numerous debilitating skin diseases. This synthetic purine analog is derived from 6-mercaptopurine. It is thought to act by disrupting nucleic acid synthesis and has recently been found to interfere with T-cell activation. The most recognized uses of azathioprine in dermatology are for immunobullous diseases, generalized eczematous disorders, and photodermatoses. In this comprehensive review, the authors present recent advancements in the understanding of azathioprine and address aspects not covered in prior reviews. They (1) summarize the history of azathioprine; (2) discuss metabolism, integrating information from recent publications; (3) review the mechanism of action with attention paid to the activities of azathioprine not mediated by its 6-mercaptopurine metabolites and review new data about inhibition by azathioprine of the CD28 signal transduction pathway; (4) thoroughly examine thiopurine s-methyltransferase genetics, its clinical relevance, and interethnic variations; (5) review prior uses of azathioprine in the field of dermatology and grade the level of evidence; (6) discuss the use of azathioprine in pregnancy and pediatrics; review (7) key drug interactions and (8) adverse effects; (9) suggest a dosing and monitoring approach different from prior recommendations; and (10) explore the future of azathioprine, focusing on laboratory considerations and therapeutic application.

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.

Review article: practical management of inflammatory bowel disease patients taking immunomodulators

Azathioprine, mercaptopurine, methotrexate, ciclosporin and tacrolimus all have their respective niches in the treatment of inflammatory bowel disease. These immunomodulators are potent and effective medications; however, they potentially have serious toxicity. To maximize benefit and minimize risk, clinicians must understand the mechanism of action, appropriate indications, range of toxicity and proper dosing of these medications. Furthermore, once initiating therapy, patients need to be monitored appropriately for evidence of efficacy and toxicity. This review includes the rationale behind recommendations for the management and monitoring of patients using immunomodulators. For the purine antagonists--azathioprine and mercaptopurine--the evidence for utility of thiopurine methyltransferase testing and mercaptopurine metabolite monitoring is addressed. The roles of liver biopsy and screening for methylenetetrahydrofolate reductase mutations in patients taking methotrexate are reviewed. With appropriate monitoring, the calcineurin inhibitors--ciclosporin and tacrolimus--can be used safely and effectively. Immunomodulators are important agents for the treatment of Crohn's disease and ulcerative colitis, and prescribing clinicians should be comfortable recognizing both their value and their limitations.

Skin cancer in renal allograft recipients - experience in different ethnic groups residing in the same geographical region

Cancer is a recognized long-term complication of kidney transplantation. Skin cancer is the most common post-transplant malignancy in developed countries but information is limited on the nature of skin cancer in allograft recipients from developing countries followed up over an extended period. The records of all patients (n = 542) who had received kidney transplants (n = 623) at our institution over a 23-yr period were reviewed and those with skin cancer were identified. Demographic, clinical, and pathologic details were collected. After a mean follow up of 6.3 yr 11 (5.9%) white patients had skin cancer of whom nine (82%) were male. No non-whites had skin cancer. In white patients skin cancer accounted for 68% of all post-transplant malignancies. Squamous cell carcinoma was the most common malignant skin lesion and 84% of all lesions occurred in sun-exposed areas. Specific immunosuppression did not appear to influence the number of lesions or the interval from transplantation to cancer development. Patients responded well to treatment with no mortality related to the skin cancer. Skin cancer is relatively unique to patients of European origin.

Multiple giant molluscum contagiosum in a renal transplant recipient

Atypical presentations of molluscum contagiosum (MC) infection can be expected in renal transplant recipients, as a result of long-term immunosuppression. However, giant MC has rarely been reported in this population. We present a 28-year-old female renal transplant recipient receiving immunosuppressive therapy who developed multiple giant MC lesions on her axillary folds. The lesions were treated successfully with curettage and electrocauterization.

Nail disorders in hemodialysis patients and renal transplant recipients: a case-control study

BACKGROUND

There is one published case-control study of nail disorders in hemodialysis patients. The nail changes that occur in renal transplant recipients have not been investigated specifically.

OBJECTIVE

The aim of this study was to determine prevalence rates of nail disorders in hemodialysis patients and renal transplant recipients, and to investigate whether these nail pathologies are related to hemodialysis and renal transplantation.

METHODS

One hundred and eighty-two hemodialysis patients and 205 renal transplant recipients were screened for the presence of nail disorders. The findings in these groups were compared with findings in 143 healthy individuals.

RESULTS

One hundred and twenty-seven patients (69.8%) in the hemodialysis group and 116 patients (56.6%) in the renal transplant recipients had at least one type of nail pathology. Absence of lunula, splinter hemorrhage, and half-and-half nails were significantly more common in the hemodialysis patients than in the renal transplant recipients. Leukonychia was significantly more frequent in the renal transplant recipients than in the hemodialysis patients and controls.

CONCLUSION

Hemodialysis patients and renal transplant recipients have higher rates of nail disease than the healthy population. Renal transplantation may reduce the frequencies of splinter hemorrhage and half-and-half nails. Interestingly, leukonychia increases significantly after renal transplantation.

Skin cancers in renal-transplant recipients occur more frequently than previously recognized in a temperate climate

BACKGROUND

Renal-transplant recipients are at increased risk of developing skin cancers, especially squamous cell carcinoma. We have carried out a comprehensive epidemiologic review of skin cancers occurring in a population receiving transplants in Oxford over a 21-year period, where nearly all patients have remained under the care of the Oxford Transplant Centre.

METHODS

Between 1975 and 1996, 1,360 renal transplants were performed in 1,115 patients. Skin cancer data were reviewed in 979 patients from this group who remained under the care of the Oxford Transplant Centre. The lesions included in the analysis were histologically confirmed basal cell carcinoma, Bowen's disease, squamous cell carcinoma, keratoacanthoma, malignant melanoma, Merkel cell tumor, and sebaceous carcinoma.

RESULTS

One hundred eighty-seven (19.1%) transplant patients developed at least one skin malignancy. The rate of skin cancer was 141 per 1,000 person years at risk. Sixty-four percent of patients with skin cancer had multiple lesions (maximum 50). Squamous cell carcinoma was the most common skin cancer to develop and the most common first skin cancer to present. The mean time to presentation of the first skin cancer was 8 years. Six patients developed nodal metastases, and two patients died secondary to skin cancer. Risk factors identified were increasing age at transplantation, recipient sex, total time of exposure to immunosuppression, increased creatinine levels at 1 year, and graft relation. The cumulative incidence of skin cancer reached 61% at 20 years after transplantation.

CONCLUSION

The data from this study suggest that more patients develop skin malignancies than previously reported from Europe. It is important to advise patients before transplantation in regard to skin complications, provide regular dermatological follow-up, and tailor immunosuppressive regimen to minimum doses to be compatible with good graft function.

The pattern of mucocutaneous infections and infestations in renal transplant recipients

Immunosuppression-related mucocutaneous lesions are a significant problem in renal transplant recipients. Infections account for the majority of these manifestations. The aim of this study was to determine the spectrum of mucocutaneous infections and infestations in renal transplant recipients. Over a period of three years, all the renal transplant recipients presenting with mucocutaneous lesions (only with infectious etiology) were included in the study. Diagnosis was based on the clinical appearance and appropriate investigations like scraping for KOH, Tzanck smear, cultures, and skin biopsies whenever necessary. In order to study the temporal effect of immunosuppression on these mucocutaneous infections, the patients were divided into six groups -with durations of graft survival ranging from 0-2, 2-6, 6-12, 12-24, 24-60, and more than 60 months in Groups A-F, respectively. A total of 104 renal transplant recipients presented with 117 infections and infestations. The mean age at presentation was 35.9 +/- 1.2 years (15-65 yrs), and the mean duration after the transplant was 23.3 +/- 3.5 months (1-175). The mean serum creatinine level at the time of clinical presentation was 1.4 +/- 0.07 mg/dl (0.7-6). Twenty-seven patients were on a two-drug regimen, prednisolone and azathioprine, and the rest were on a three-drug regimen with cyclosporine in addition. Out of the total of 117 infections in 104 patients, 57 were viral, 49 were fungal, and 8 were bacterial. Two patients had scabies and one had cysticercosis. The mean time interval for the occurrence of infections after the transplant was earlier in patients on three-drug immunosuppression (12.4 +/- 2.3 months) than in those on the two-drug regimen (51.3 +/- 1.8 months), (p<0.01). The viral infections had the shortest mean time interval for presentation following transplant, 15.8 +/- 1.2 months (p<0.05). We did not find any statistically significant difference with regard to age or sex of the patients, duration after the transplant, or the pattern of infection. Careful examination of transplant patients is essential for early detection and proper treatment, because the mucocutaneous infections can have atypical morphologies and are likely to become extensive if not treated early.

Fungal skin infections in organ transplant recipients

Transplantation is now currently and increasingly performed for the treatment of various acute and chronic diseases. Today the kidney, heart, lung, heart-lung, liver, pancreas, kidney-pancreas, small bowel and bone marrow are being transplanted. The immunological status of patients receiving such transplants exposes them to the risk of developing bacterial, viral and fungal infections. The etiological agents of mycotic diseases involving the skin of transplant recipients range from the common dermatophytes through yeasts such as Candida spp., Malassezia spp. and dimorphic fungi to the emerging molds Fusarium spp. and Pseudallescheria boydii. The very wide spectrum of fungi causing cutaneous disease produces equally varied clinical aspects. Lesions may be typical, but are very often aspecific or ambiguous. Cutaneous lesions may be the sign of a trivial mycotic disease or the marker of a disseminated, potentially lethal fungal illness, so great attention should be given to their early recognition. Cutaneous manifestations due to Candida spp., Aspergillus spp., dematiaceous fungi and Pityrosporum folliculitis are usually observed early after transplant, cryptococcosis more than 6 months later, while the frequency of dermatophytoses increases as time goes by. Coccidioides immitis, Histoplasma capsulatum and Blastomyces dermatitidis may appear any time after transplantation. The management of the more severe forms of cutaneous mycosis in transplant recipients is difficult. Besides the fact that early recognition is not easy, there are also problems regarding the effectiveness and the toxicity of the therapy and drug-drug interactions. Prophylactic measures to avoid fungal contamination must be performed during hospitalization; patients should be taught how to avoid contamination, not only during the first period after transplantation, when high dosage immunosuppressive drugs are given, but also later when a normal lifestyle is resumed.

Azathioprine for atopic dermatitis

For adults with atopic dermatitis (AD) refractory to topical treatment, the choices of second-line therapy are limited. Furthermore, there are concerns about the long-term safety of treatments such as cyclosporin. Limited open studies suggest that azathioprine may be effective, although controlled trial data is lacking. Nevertheless, many UK dermatologists use azathioprine to treat patients with severe AD, despite the potential risk of serious toxicity. Azathioprine myelotoxicity and drug efficacy are now known to be related to the activity of a key enzyme in azathioprine metabolism, thiopurinemethyltransferase (TPMT). Recently, the facility for TPMT measurement has become more widely available, providing the possibility to optimize the therapeutic effect of azathioprine, yet minimise the risk of toxicity. We review the evidence concerning the use of azathioprine for AD, and have identified 128 cases in eight open studies, including our own prospective trial. Improvement in the majority was noted in seven studies, although objective measures of disease activity were used in only one trial. Measurements of TPMT activity were performed in the two most recent studies only. These data underscore the requirement for a prospective randomised controlled trial, and highlight the need to further investigate the role of TPMT measurement in azathioprine usage.

Skin diseases in children with organ transplants

BACKGROUND

Skin diseases are frequent in organ transplant recipients, but studies concerning children are sparse.

OBJECTIVE

We assessed skin diseases in children who had received organ transplants.

METHODS

A total of 145 children referred to our dermatologic consultation were studied.

RESULTS

Steroid-induced striae distensae and acne occurred only in adolescents; severe cyclosporine-related side effects were more frequent in younger children. The most common findings were warts (53.8%), tinea versicolor (14.5%), herpes simplex/zoster (9.6%), molluscum contagiosum (6.9%), and impetigo contagiosum and folliculitis (6.2%). Other notable disorders included a diffuse hyperpigmentation with a "dirty" appearance of the skin, pyogenic granulomas, melanocytic nevi proliferation, and skin tags. Two of 20 further adult patients who received transplants during childhood had squamous cell carcinomas.

CONCLUSION

Children who have received organ transplants frequently present side effects of immunosuppressive drugs and infectious diseases. Most disorders are related to the age of the patients rather than to the length of immunosuppression, whereas others are favored by the reinforcement of immunosuppression. Skin cancers were not encountered, but the risk of carcinomas in early adulthood should be considered.

Skin Cancer in Heart Transplant Recipients

Background —The frequency of skin tumors of all types and specifically of squamous cell carcinoma (SCC) is increased in heart transplantation (HT), but the predisposing risk factors are controversial.

Methods and Results —We studied 300 patients (age 49±15 years, 258 men, mean follow-up 4.6 years, follow-up range 1 month to 12 years) who were receiving standard double (cyclosporin plus azathioprine) or triple (cyclosporin plus azathioprine plus prednisone) therapy. The first-year rejection score was calculated for endomyocardial biopsy samples (International Society for Heart and Lung Transplantation grade 0=0, 1A=1, 1B=2, 2=3, 3A=4, 3B=5, and 4=6) and used as an indirect marker of the level of immunosuppression. Multivariate analysis (Cox regression) included age at HT, sex, skin type, first-year rejection score, presence of warts and solar keratosis, lifetime sunlight exposure, and first-year cumulative dose of steroids. The incidence of skin tumors of all types increased from 15% after 5 years to 35% after 10 years after HT according to life-table analysis. Age at HT of >50 years ( P =0.03, RR=5.3), skin type II ( P =0.05, RR=2.6), rejection score of 19 ( P =0.003, RR=5.7), solar keratosis ( P =0.001, RR=6.9), and lifetime sunlight exposure of >30 000 hours ( P =0.0003, RR=7.6) were risk factors for SCC.

Conclusions —Older age at HT, light skin type, solar keratosis, greater sunlight exposure, and high rejection score in the first year were independently associated with an increased risk of SCC. The progressive increase in cancer frequency during follow-up and the association with high rejection scores suggest that both the length and level of immunosuppression may be relevant. Because cumulative immunosuppressive load is cumbersome to calculate, a high rejection score in the first year may provide a useful predictor for patients at risk.

Skin cancer in heart transplant recipients: frequency and risk factor analysis

BACKGROUND

The frequency of skin cancer is increased among organ transplant recipients, but the predisposing risk factors are controversial. It is also unclear whether heart transplant patients face an increased risk compared to recipients of other organs, e.g. kidney transplants.

METHODS

We performed univariate and multivariate analysis of risk factors for skin cancer in 252 heart transplants and in a control series of 228 kidney transplants followed up at a single center. An extensive dermatologic examination was carried out; baseline features, type of immunosuppression, number of 3A rejection episodes, extent of sunlight exposure and skin type were recorded. Multivariate analysis (Cox regression) included: age at transplantation, sex, skin type (Fitzpatrick's criteria), presence of solar keratosis, presence of warts, type of organ, sunlight exposure.

RESULTS

During follow up skin cancer was more common among heart transplants (40, 16 %) than in kidney transplants (16, 7%, p = 0.004). The cumulative incidence of skin cancer by life table analysis increased from 16% after 5 years to 33% after 10 years in heart transplant patients and from 6% to 17% in kidney transplants (p 10000 hours (relative risk = 2.8), but not organ type were significant risk factors.

CONCLUSION

Age at transplant, skin type and sunlight exposure, but not type of organ and type of immunosuppressive regimen, are associated with increased risk of skin cancer in heart transplantation.

Awareness of skin cancer by kidney transplant patients

BACKGROUND

Skin cancer is the most common malignancy occurring after kidney transplantation.

OBJECTIVE

Our purpose was to identify the skin problems of kidney transplant recipients, the extent of their awareness of skin cancer, and interest in skin cancer screenings.

METHODS

One hundred twenty-two patients were administered an oral questionnaire during regular follow-up at a renal transplant clinic.

RESULTS

The average time from transplantation was 3.1 years. Thirty-nine percent of patients reported skin problems, including warts, fungal infection, and skin cancer. Forty-one percent of patients were unable to recall specific skin cancer education, and 52% expressed an interest in skin cancer screening. Twenty-seven percent of patients had seen a dermatologist since their transplant, but only 14% were followed up regularly by a dermatologist.

CONCLUSION

We believe the need for continuing skin cancer education and early detection and treatment of skin lesions establishes an important role for the dermatologist on the transplant recipient's health care team.

Comparative epidemiologic study of premalignant and malignant epithelial cutaneous lesions developing after kidney and heart transplantation

BACKGROUND

Cutaneous carcinomas are the most frequent cancers in organ transplant recipients.

OBJECTIVE

Our purpose was to compare the epidemiologic data of cutaneous premalignant and malignant epithelial lesions in kidney and heart transplant recipients.

METHODS

A total of 580 kidney and 150 heart transplant recipients were examined for the presence of premalignant and malignant epithelial lesions.

RESULTS

A twofold increase in incidence of premalignant and malignant epithelial lesions was found in heart compared with kidney transplant recipients. Heart transplant recipients were older at transplantation, received more intense immunosuppressive treatment, and had a shorter delay from transplantation to the development of the first lesion. The squamous cell carcinoma/basal cell carcinoma ratio was 2.37:1 in kidney and 1.08:1 in heart transplant recipients. The extracephalic location represented 60% of the premalignant and malignant epithelial lesions in kidney and 30% in heart transplant recipients.

CONCLUSION

Cutaneous premalignant and malignant epithelial lesions in kidney and heart transplant recipients show epidemiologic differences that can tentatively be explained by the older age and the more intense immunosuppressive treatment of heart transplant recipients.

Skin cancer in heart transplant recipients

BACKGROUND

The frequency of skin cancer in organ transplant recipients is high, up to 15%.

OBJECTIVE

Our purpose was to determine the incidence of skin cancer in patients who underwent immunosuppression after heart transplantation and to determine the factors important in the appearance of skin cancer.

METHODS

We studied the frequency of skin cancer in 92 of 111 patients after they underwent heart transplantation between January 1984 and December 1993.

RESULTS

At least one cutaneous neoplasm (squamous cell carcinoma and/or basal cell carcinoma) developed in 14 patients (15.2%). The basal cell carcinoma to squamous cell carcinoma ratio was 1:1.5. The skin cancer appeared an average of 31.5 months after transplantation; the average was 36 months for squamous cell carcinoma and 25.3 months for basal cell carcinoma. Cumulative risk rose from 4.3% at 1 year up to 43.8% at 7 years after transplantation. The overall incidence of both types of skin cancer was 45.3 per 1000 posttransplant person-years, with an incidence of 25.8 for basal cell carcinoma and 29.1 for squamous cell carcinoma. Most skin cancers developed between 2 and 3 years after transplantation. All patients were exposed to a significant amount of ultraviolet radiation and had skin type II or III. We did not find a significant association between skin cancer and haplotype HLA-A3, HLA-A11, HLA-DR, and the number of mismatches for HLA-B.

CONCLUSION

We found an increased progressive cumulative incidence of skin cancer in heart transplant recipients for two reasons: (1) immunosuppression and increased exposure to ultraviolet radiation in some patients, and (2) the skin type of certain patients. We emphasize the need for photoprotection in this group of patients and regular skin cancer screening examinations.

Involvement of canine oral papillomavirus in generalized oral and cutaneous verrucosis in a Chinese Shar Pei dog

Severe papillomatosis developed in the oral cavity and spread throughout the haired skin of the trunk and limbs of an 8-month-old female Chinese Shar Pei dog. The dog had received corticosteroids prior to referral, which was associated with the onset of demodecosis and papillomatosis. Papillomavirus structural antigens were detected in biopsies by immunohistochemistry using a panel of monoclonal and polyclonal antibodies. An 8.2-kilobase papillomavirus-specific DNA molecule was detected in the cutaneous lesions by high stringency Southern blot hybridization using a cloned canine oral papillomavirus DNA probe. Restriction enzyme analysis revealed that the virus in the cutaneous lesions was identical to the canine oral papillomavirus. Discontinuation of the steroids combined with the use of a mitocide, antibiotics, and an autogenous vaccine resolved the demodecosis and papillomatosis. This case report suggests that corticosteroid-induced immunosuppression can expand the tissue tropism of papillomaviruses.

Relationship between the ability of sunscreens containing 2-ethylhexyl-4'-methoxycinnamate to protect against UVR-induced inflammation, depletion of epidermal Langerhans (Ia+) cells and suppression of alloactivating capacity of murine skin in vivo

The UVB sunscreen 2-ethylhexyl-4'-methoxycinnamate was evaluated in hairless albino mouse skin for its ability to inhibit UVR-induced (i) oedema, (ii) epidermal Langerhans cell (Ia+) depletion and (iii) suppression of the alloactivating capacity of epidermal cells (mixed epidermal cell-lymphocyte reaction, MECLR). The sunscreen, prepared at 9% in ethanol or a cosmetic lotion, was applied prior to UVB/UVA irradiation. In some experiments there was a second application halfway through the irradiation. Single applications in both vehicles gave varying degrees of protection from oedema and Langerhans cell depletion but afforded no protection from suppression of MECLR. When the sunscreens were applied twice there was improved protection from oedema and Langerhans cell depletion and complete protection was afforded from suppression of MECLR. There was a clear linear relationship between Langerhans cell numbers and oedema with and without sunscreen application. The relationship between Langerhans cell numbers and MECLR was more complex. These data confirm published discrepancies between protection from oedema (a model for human erythema) and endpoints with immunological significance, but show that 2-ethylhexyl-4'-methoxycinnamate can afford complete immunoprotection, although protection is dependent on the application rate and vehicle.

Association of skin malignancies with various and multiple carcinogenic and noncarcinogenic human papillomaviruses in renal transplant recipients

BACKGROUND

Organ transplant recipients receiving immunosuppressive treatment are prone to skin carcinomas on sun-exposed areas, and the frequency of such carcinomas in the long term reaches 40%. These carcinomas primarily are squamous cell carcinomas (SCC), which often are preceded by viral warts and premalignant keratoses. Human papillomaviruses (HPV) with other cocarcinogenic factors have been reported to play a role in the development of carcinomas in these patients.

METHODS

Five hundred renal-graft recipients referred to our department were examined for the presence of warts, precancerous keratoses, Bowen disease, keratoacanthomas, and basal and squamous cell carcinomas. Adequate material for histologic and virologic examination was obtained from 24 patients. An in situ molecular hybridization technique was performed using biotinylated DNA probes for HPV types 1a, 2a, 5, 16, and 18 under stringent conditions.

RESULTS

HPV DNA was detected in 44 of 86 specimens, including 14 of 17 warts, 4 of 17 premalignant keratoses, 1 of 4 Bowen disease lesions, 8 of 12 keratoacanthomas, 3 of 4 tumors in which distinction between keratoacanthomas and SCC was difficult, and 14 of 30 SCC. Twenty-six of 44 positive specimens contained several HPV types, whereas 30 specimens contained oncogenic types. Benign types 1 or 2 were detected alone in five SCC. HPV types 16 and 18 (usually detected in genital lesions) were found in 26 samples from sun-exposed areas.

CONCLUSIONS

Our results show that oncogenic and benign HPV often are detected within premalignant keratoses and SCC in organ transplant recipients, which suggests that HPV may play a role in the development of cutaneous malignancies.

Sunlight, keratotic skin lesions and skin cancer in renal transplant recipients

In a retrospective follow-up study, 36 renal transplant recipients with, and 101 without, skin cancer, who had received their first transplant before January 1981 and who were still alive with a functioning graft on 1 August 1989, were assessed to determine the risk of non-melanoma skin cancer in relation to exposure to sunlight during childhood and adolescence. The contribution of the number of keratotic skin lesions to the skin cancer risk was also assessed. The estimated relative risks (odds ratios) of skin cancer in relation to exposure to sunlight and the presence of keratotic skin lesions were calculated by maximum likelihood estimation in a logistic model. The majority of skin cancers and keratotic skin lesions were confined to sun-exposed skin. After adjustment for possible confounding variables, the odds ratios of skin cancer for moderate and high cumulative life-time exposure to sunlight, respectively, compared with low exposure, were 2.4 (95% confidence interval [CI] 0.64-9.3) and 47.6 (95% CI 5.4-418). Exposure to sunlight before the age of 30 contributed more to the risk of developing skin cancer later in life than exposure after the age of 30. No association was found between cumulative life-time exposure to sunlight and the number of keratotic skin lesions. Nevertheless, these lesions behaved as a strong independent risk factor in the development of skin cancer. The adjusted odds ratio of skin cancer for 50-99 lesions compared with < 50 lesions was 4.5 (95% CI 1.1-18.2); the adjusted odds ratio for > or = 100 lesions compared with < 50 lesions was 20.8 (95% CI 5.3-81.7).(ABSTRACT TRUNCATED AT 250 WORDS)

Development of human papillomavirus-associated Buschke-Löwenstein penile carcinoma during cyclosporine therapy for generalized pustular psoriasis

Buschke-Löwenstein-type giant penile condyloma developed in a human immunodeficiency virus-negative, 25-year-old man after 4 years of intermittent cyclosporine therapy (5 mg/kg/day) for pustular psoriasis. Microscopic examination showed multifocal areas of invasive squamous cell carcinoma. Dot blot analysis of amplified polymerase chain reaction products with primers directed at the L1 region demonstrated signals for several human papillomavirus genotypes, including human papillomavirus type 16, that correlated with different histologic patterns consisting of verrucous and bowenoid changes and invasive carcinoma. This case conforms to the enhanced risk of cutaneous carcinogenesis from either papillomavirus infection or chronic actinic damage that has become evident in patients with organ allografts and cyclosporine therapy.

Quantitative and morphometric analysis of Langerhans cells in non-exposed skin in renal transplant patients

Renal transplant recipients have a high incidence of cutaneous complications such as neoplasia and viral or fungal infections. Morphologic alterations of epidermal Langerhans cells (LC) have furthermore been described in these patients. Since these changes have been mainly found in sun-exposed skin, a direct effect of immunosuppressive therapy remains a matter of discussion. A quantitative and morphometric study of epidermal LC in non-exposed skin was performed in 28 renal transplant patients (RTP). RTP were divided in two groups according to immunosuppressive treatment: group A; azathioprine + prednisone (14 cases) and group B; cyclosporine + prednisone (14 cases). Twenty sex-age matched non-immunosuppressed patients acted as controls (group C). Epidermal sheets were obtained by incubation in EDTA and stained for ATPase activity and with the monoclonal antibody T6 (CD1) using the avidin-biotin peroxidase method. Langerhans cells were counted using a calibrated graticule (400x) and expressed as the mean number of LC/mm2. The mean area of the LC and the number of primary dendrites (pd) and secondary dendrites (sd) were determined with a morphometer adapted to an Apple II computer. The mean number of positive cells in controls was: ATPase, 677 +/- 157; T6, 695 +/- 164. Patients in group A had the maximum reduction in both ATPase and T6 LC density (ATPase, 339 +/- 142; T6, 402 +/- 194). Patients in group B had an intermediate reduction in the number of LC (ATPase, 494 +/- 121; T6, 529 +/- 112).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and clinical spectrum of skin diseases in kidney transplant recipients

Cutaneous lesions can be a significant problem in kidney transplant recipients. Factors such as climate and skin types have been implicated as modifiers of these clinical manifestations. With the purpose of determining the prevalence and clinical spectrum of skin diseases in a group of Hispanic kidney transplant recipients in a tropical climate, 82 serial unselected patients were examined. Seventy-eight were found to have some type of skin disease. Infections of the skin were the most common, followed by drug-induced changes and malignant or premalignant cutaneous tumors. Except for the preponderance of superficial mycotic infections, the overall results in our population are in agreement with other series.

Langerhans cells and epithelial cell modifications in cervical intraepithelial neoplasia: correlation with human papillomavirus infection

The study of a series of 18 cervical intraepithelial neoplasia (CIN) grade II and III was aimed at determining the distribution and phenotype of immunocompetent cells (Langerhans cells, T and NK cells) and the alteration in the expression of EGF receptors and beta 2-microglobulin in correlation with human papillomavirus (HPV) infection (viral antigen and DNA typing with biotinylated probes). These lesions were characterized by a reduced number of Langerhans cells and a dense infiltrate. HPV infection did not induce HLA-DR expression in the infected epithelial cells. We observed an enhanced expression of epidermal growth factor (EGF) receptors by epithelial cells and a reduced beta 2-microglobulin reactivity by both epithelial and immunocompetent cells. Most of CIN showed foci of infected cells. No significant differences were observed in immunological markers of CIN harboring benign HPV 6/11 DNA or oncogenic HPV 16/18 DNA. Viral antigen was not detected in these lesions. These changes in the epithelial cells of CIN and their microenvironment associated to the lack of HLA-DR expression in the infected cells hamper the squamous epithelial cells to function as antigen presenting cells. This may facilitate a decrease in the immunological surveillance and may contribute to the severity of such lesions.