Cutaneous manifestations in renal transplant recipients

Atypical clinical presentation of an Arthroderma gypseum infection in a renal transplant recipient

Dermatophytes are known as a common cause of superficial mycosis, but atypical presentations in immunosuppressed patients make the diagnosis more challenging. Here, we report a case of a 39-year-old patient, a renal transplant recipient from a living donor, who presented with atypical cutaneous lesions of lower extremities caused by Arthroderma gypseum (Nannizzia gypsea), four months after receiving a renal transplant. It is important to highlight the importance of the early detection of fungal infections in immunosuppressed patients. Clinicians should have a high degree of suspicion for the early detection and treatment of the cases.

Superficial fungal infections in renal transplant recipients

BACKGROUND

Renal transplant recipients (RTRs) are predisposed to fungal infections because of long-term graft-preserving immunosuppressive therapy.

METHODS

We prospectively enrolled 223 consecutive adult RTRs. Patients were transplanted at 1 of 2 transplant centers in Poland. The group consisted of 97 women (43%) and 126 men (57%). The control group consisted of 100 patients (39 women and 61 men) randomly selected from the outpatient dermatology clinic and from hospital personnel. All RTRs and the control group were screened for the presence of superficial fungal infections. All patients were examined by the same dermatologist. The oral mucosa and the entire body surface were fully examined. Mucosal swabs were obtained from all patients in both the examined and control groups. Skin scrapings and swabs were obtained from any clinically suspicious lesions. Nail clippings were collected in the case of any nail changes.

RESULTS

Superficial fungal infections have been detected in 133 RTRs (60%)and 27 controls (27%; P = .00001). One hundred eight RTRs (62%) developed superficial fungal infections in the first year after transplantation (P < .008). The most common site for superficial fungal infections in the RTRs group was the oral cavity. Candida albicans was the most frequently isolated species in the oral cavity.

CONCLUSIONS

Superficial fungal infections in RTRs are statistically more common among RTRs than in the general population. Whether the drug was used separately or administrated under immunosuppressive combinations had no influence on the occurrence of fungal infections. The final results showed no correlation between patient age and the occurrence of fungal infections. Dermatologists who care for transplant patients should be aware of the clinical course of fungal species in RTRs compared with the general population.

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.

[Skin diseases in hemodialysis and kidney transplant patients]

Recently, the world is facing an escalate in the incidence of chronic kidney disease (CKD). Databases containing information about patients in end stage renal disease (ESRD), especially in the United States, were the sources of initial information about it. Brazil has the third largest population on dialysis in the world, and there are about 680 dialysis centers, spread across all units of the federation in the present, providing treatment to an estimated population of almost 90,000 patients. Cutaneous involvement in the chronic renal failure is characterized by a number of manifestations, which may be related to three processes: the primary renal disease, the uremic state, or the therapeutic measures used in their handling. The skin changes in these two classes of patients, dialysis and transplant recipients, have been the subject of several studies. n recent years, however, great progress has been achieved in these two therapeutic modalities, which may have changed not only the type of the dermatologic disorders associated with these two conditions, but also their intensity or frequency. This article aims to yield an update as to the topic skin diseases in hemodialysis and kidney transplant patients.

Histopathological variants of cutaneous squamous cell carcinoma: a review

Nonmelanoma skin cancer (NMSC) is the most common form of cancer in the Caucasian population, with squamous cell carcinoma (SCC) accounting for the majority of NMSC-related metastases and death. While most SCC lesions are indolent tumors with low malignant potential, a wide diversity of SCC subtypes exist, several of which are associated with markedly more aggressive behaviors. Distinguishing these high-risk variants from their counterparts is possible through microscopic analysis, since each subtype possesses unique histopathological features. Early identification of high-risk lesions can allow for more rapid therapeutic intervention, reducing the likelihood of metastasis and death. The authors review specific histopathological features and associated clinical outcomes of the primary subdivisions of SCC.

Skin infections in Egyptian renal transplant recipients

BACKGROUND

The risk of skin infections in renal transplant recipients (RTRs) has been described previously; however, it differs markedly by ethnic groups, skin type, and geographical location. We investigated the prevalence and nature of skin infections in a large series of RTRs in our locality in Egypt.

PATIENTS AND METHODS

A total 302 RTRs (216 males and 86 females) were included in this study. They were screened for the presence of bacterial, fungal, and viral skin infections depending on clinical signs, Woods lamp examinations, culture, and biopsy if indicated. The patients were compared with 300 healthy controls matched for age and sex (200 males and 100 females).

RESULTS

We found 191 (63.25%) RTRs had some kind of skin infection. Folliculitis (10.3%), tinea versicolor (30.1%), dermatophytosis (19.5%), and onychomycosis (7.6%) were statistically significantly more common in RTRs compared with control subjects.

CONCLUSION

Our RTRs have higher prevalence rates of folliculitis and superficial fungal infections than the healthy population and they should be searched for in every patient with renal transplantation to ensure early treatment and avoid complications. Low-dose ketoconazole should be considered in renal transplant populations with high rates of superficial fungal infections, as it may reduce risk of such infections.

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.

Pustular Psoriasis After Renal Transplantation

Cutaneous manifestations in renal transplant recipients are frequently represented by infections and cancerous lesions. However, dermatologic lesions secondary to autoimmune diseases are rare. We report a case of pustular psoriasis occurring after renal transplantation in a 31-year-old woman with a history of vitiligo. The patient was on hemodialysis for 2 years for undetermined chronic nephropathy. She received an HLA identical live related transplant from her brother. She was maintained on an immunosuppressive regimen of corticosteroids, azathioprine, and cyclosporine, which was replaced with mycophenolate mofetil because of neurotoxicity and azathioprine was stopped. Thirty-one months after renal transplantation, she developed pustular psoriasis which was treated with retinoids; she experienced a relapse and resistance to treatment despite the reintroduction of cyclosporine.

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.

Racial and ethnic variations in incidence and pattern of malignancies after kidney transplantation

Malignancies are a well-recognized complication of renal transplantation. Although the problem is well studied in developed countries, less is known about it in developing countries. Although geographic and ethnic variations have been alluded to in several reports, to our knowledge the subject has not been investigated formally. From April 1976 through March 1999, 41 (7.6%) patients were diagnosed with cancer among a heterogeneous population of renal allograft recipients treated at our institution in Cape Town, South Africa. The incidence of malignancies was comparable in white and nonwhite patients. However, squamous cell cancer and basal cell cancer of the skin (in that order) were the most common cancers in white patients, in whom they occurred exclusively. On the other hand, Kaposi sarcoma was the most common cancer in nonwhite renal allograft recipients, in whom it accounted for almost 80% of all cancers. Review of the world literature suggests that posttransplant cancers are less common in developing countries; Kaposi sarcoma is the most common lesion, with few exceptions. Malignant lymphomas are also more common in developing countries. The impact of different immunosuppressive regimens is controversial. In general, cyclosporine is not associated with a significant increase in the incidence of cancer after renal transplantation, although the time to the first cancer may be reduced. In our experience, the pattern of posttransplant cancers in white and nonwhite patients living in the same geographic region epitomizes the world experience of the disease and suggests that genetic factors, rather than geography, are the more important determinants of cancer development after renal transplantation.

Mucocutaneous lesions in transplant recipient in a tropical country

Dermatological manifestations are common in renal transplant patients, but differ markedly with ethnic group and geographical location. We studied mucocutaneous lesions in 54 renal allograft recipients (related donors = 30; unrelated donors = 24) living in tropical atmospheres. Their gender was 50 males, and 4 females ranging in age between 15 and 63 years (mean = 37.84 years). The mean duration of follow-up was 124 months (range = 4 to 173 months). All patients received kidneys from living donors and were kept on immunosupression with mean daily doses of prednisolone, azathioprine, and cyclosporine of 10.2 mg, 68.6 mg, and 252 mg, respectively. The mean trough concentration of cyclosporine was 185 ng/mL. The mucocutaneous lesions were divided into four groups: drug-induced (n = 24, 44.4%), fungal (n = 18, 33.3%), viral (n = 9, 16.6%), and bacterial (n = 10, 18.5%). Cushingoid features, gum hypertrophy, and hypertrichosis were seen in 7 (12.9%) patients. Steroid acne was seen in three cases. Pityriasis versicolor was the most common (20.3%) fungal infection of the skin. In addition, Tinea unguium and mucocutaneous candidiasis were noted in four and three cases respectively. Herpes virus infection (Herpes zoster 5; Herpes simplex 2) was noted in 7 (12.9%) cases. Chicken pox at 5 years posttransplant and cutaneous vasculitis associated with cytomegalovirus disease at 6 months posttransplant were seen in one case each. We have not seen warts in our patients. Pyogenic bacterial infection of skin in the form of abscess (n = 6), cellulitis (n = 3), and pyoderma (n = 1) were observed in 10 (18.5%) patients. Thus, drug-induced mucocutaneous side effects and skin fungal infections are the most common dermatological manifestations among renal transplant recipients living in a tropical country.

Superficial fungal infections in 102 renal transplant recipients: a case-control study

BACKGROUND

Renal transplant recipients are predisposed to superficial fungal infections caused by graft-preserving immunosuppressive therapy. Reports have documented a wide range of prevalence rates for superficial fungal infections in this patient group.

OBJECTIVE

The aim of this study was to determine the prevalence and clinical and mycological features of superficial fungal infections in renal transplant recipients at our center.

METHODS

One hundred two consecutively registered renal transplant recipients (34 women, 68 men) and 88 healthy age- and sex-matched persons acting as controls (30 women, 58 men) underwent screening for the presence of superficial fungal infection. Skin scrapings and swabs were obtained from the dorsum of the tongue, upper part of the back, toe webs, and any suspicious lesions. Nail clippings were also collected. All samples were examined by direct microscopy and were stained with calcofluor white. The samples were cultured in Sabouraud dextrose agar, mycobiotic agar, and dermatophyte test medium. Candida species were identified on the basis of germ-tube production, spore formation in cornmeal agar, and results of biochemical testing. Dermatophytes were identified on the basis of colonial and microscopic morphologic features in conjunction with results of physiologic evaluation (in vitro hair perforation test, urease activity, temperature tolerance test, and nutritional test).

RESULTS

Sixty-five (63.7%) of the 102 renal transplant recipients had cutaneous-oral candidiasis, dermatophytosis, or pityriasis versicolor, whereas only 27 (30.7%) of controls had fungal infection. Pityriasis versicolor was the most common fungal infection in the patient group (36.3%), followed by cutaneous-oral candidiasis (25.5%), onychomycosis (12.7%), and fungal toe-web infection (11.8%). Pityriasis versicolor and oral candidiasis were significantly more common among the renal transplant recipients, whereas the frequency of dermatophytosis in patients and controls was similar. Candida albicans was the main agent responsible for oral candidiasis, and Trichophyton rubrum was the most common dermatophyte isolated. Analysis showed that age, sex, and duration of immunosuppression did not significantly affect the prevalence of superficial fungal infection. Cyclosporine treatment and azathioprine therapy were identified as independent risk factors for superficial fungal disease.

CONCLUSIONS

The prevalence of opportunistic infections with Pityrosporum ovale and C albicans is increased among renal transplant recipients, probably owing to the immunosuppressed state of this patient population. However, renal transplant recipients are not at increased risk of dermatophytosis.

Freqüência de dermatoses infecciosas em 208 pacientes transplantados renais

FUNDAMENTOS: Nos pacientes transplantados renais, a imunossupressão crônica acarreta maior suscetibilidade às dermatoses infecciosas. OBJETIVOS: avaliar a freqüência de dermatoses infecciosas em 208 pacientes transplantados renais no período de 12 meses e verificar a relação entre sua ocorrência e o período de tempo transcorrido desde o transplante. MÉTODO: 208 transplantados renais de uma população de 720 pacientes foram submetidos a exame dermatológico no período de um ano, tendo sido realizados exames anatomopatológico micológico, bacteriológico e/ou cultural das lesões suspeitas. RESULTADOS: a freqüência de dermatoses infecciosas nessa população foi de 89,4%. As infecções fúngicas, virais, bacterianas e parasitárias mais freqüentes foram pitiríase versicolor (17,8%), verruga vulgar (32,2%), foliculite (4,3%) e escabiose (3,8%). CONCLUSÃO: as dermatoses infecciosas são freqüentes nos pacientes transplantados renais, e sua ocorrência aumenta progressivamente conforme o tempo transcorrido a partir do transplante, sendo importante o acompanhamento dermatológico desses pacientes.

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.

Skin infections in renal transplant recipients

BACKGROUND

Skin infection is a frequent complication in renal transplant recipients. The purpose of the study was to acquire long-term, period-specific incidence data on the most commonly occurring skin infections in renal transplant recipients.

METHODS

A retrospective analysis was performed using medical records of 134 patients, covering a period between 10 and 29 yr. Cumulative incidences of the skin infections were calculated by counting the infections per patient for different time periods and were expressed as a percentage of the total group of patients. The incidence of the skin infections was determined for different post-transplant time periods.

RESULTS

A total of 340 skin infections in 105 out of 134 patients were recorded. Some infections, such as candidal infection, herpes simplex infection, and impetigo were most prominent during the first post-transplant year and did not affect many new patients after the first year. Other infections, such as dermatomycoses, herpes zoster, and folliculitis were also affecting a substantial number of new patients after the first post-transplant year.

CONCLUSIONS

This study confirms that skin infections among renal transplant recipients are very common and that the spectrum of skin infections differs according to the post-transplant time period.

Clinical risk factors associated with nonmelanoma skin cancer in renal transplant recipients

A single-center, cross-sectional, longitudinal study was conducted to determine the prevalence, annual incidence, and clinical risk factors for skin cancer in a white renal transplant population. One hundred eighty-two white patients (95% of population) with functioning allografts, a mean age at transplantation of 38.9 +/- 15. 6 (SD) years, and a mean follow-up of 8.5 +/- 6.3 years were interviewed and examined between May 1997 and June 1999. All case notes were carefully reviewed. Since transplantation, 16.5% of the patients had developed nonmelanoma skin cancer; 15.4%, actinic keratoses (AK); 53%, viral warts; and 1.6%, lentigo maligna melanoma (n = 3). Thirty-nine percent of the tumors were detected as a consequence of this study, and 20% of these occurred on covered body sites. The squamous cell (SCC)-basal cell carcinoma (BCC) ratio was 3.8:1. Eighty-two percent of the patients were examined a second time 12 months after the initial assessment. Using these data to identify new lesions, the annual incidence was calculated at 6.5%, increasing to 10.5% at more than 10 years posttransplantation. Duration of immunosuppression, older age at transplantation, presence of AK, male sex, and outdoor occupation were significantly associated with both SCC and BCC; SCC alone was associated with a history of having smoked tobacco. Early identification of those at greatest risk using a clinical risk profile may allow the development of more structured preventative and surveillance strategies than currently exist.

Sudden onset of disseminated porokeratosis of Mibelli in a renal transplant patient

Porokeratosis is a disorder of epidermal keratinization of uncertain cause. Five clinical variants of porokeratosis have been described. These include porokeratosis of Mibelli, punctate porokeratosis, linear porokeratosis, porokeratosis palmaris plantaris et disseminata, and disseminated superficial porokeratosis. Disseminated superficial porokeratosis and single plaque porokeratosis of Mibelli have each been documented to occur in association with immunosuppression. To our knowledge, only 5 cases of disseminated porokeratosis of Mibelli in transplant recipients have been reported. We present a patient who developed explosive onset of disseminated porokeratosis of Mibelli shortly after renal transplantation. It is important to differentiate this unusual variety of porokeratosis from other cutaneous manifestations in transplant patients so that appropriate therapy can be instituted.

Lymphocyte subsets and Langerhans cells in sun-protected and sun-exposed skin of immunosuppressed renal allograft recipients

BACKGROUND

Patients who have received renal allografts experience early aging of the skin, opportunistic infections, and an increased incidence of skin cancer.

OBJECTIVE

We compared the density of lymphocyte subsets and Langerhans cells in normal-appearing skin of renal allograft recipients without skin cancer at 5 to 6 years (group 1) and 14 years after transplant (group 2) with a matched normal control group.

METHODS

Biopsy specimens of sun-protected and exposed areas from 18 white, kidney allograft recipients (10 in group 1 and 8 in group 2) with normal renal function and from 10 healthy volunteers were semiquantitatively analyzed for dermal lymphocyte subsets and Langerhans cells.

RESULTS

There was a statistically significant decrease in all dermal cell elements in the sun-protected skin of both groups of patients who had received grafts. The sun-exposed skin of group 2 also showed a significant decrease of dermal CD4+ and CD8+ lymphocytes, and group 1 had a significant decrease in dermal CD8+ lymphocytes. The dermal CD1a+ cell population in the sun-exposed skin from both grafted groups did not differ from the control group.

CONCLUSION

Kidney transplant recipients showed dermal depletion of cells related to immune surveillance against tumors even before skin cancer occurred, and this depletion seemed to become more marked with the duration of immunosuppression.

Subcutaneous phaeohyphomycosis in a renal transplant recipient: a case report and review of the literature

Subcutaneous phaeohyphomycosis caused by dematiaceous fungi has rarely been described in immunocompromised patients. We report a case of subcutaneous infection caused by Phialophora parasitica in a renal transplant recipient. The role of early identification of the offending fungal species followed by a wide local excision in the management of such patients has been discussed.

Epidermal dysplasia and neoplasia in kidney transplant recipients

BACKGROUND

Established data confirm an increased incidence of skin cancer, mainly squamous cell carcinoma (SCC), in long-term kidney transplant recipients (KTRs).

OBJECTIVE

Our purpose was to investigate prospectively the type and frequency of neoplastic and preneoplastic skin lesions in KTRs during the first 3 years of immunosuppression, as well as the influence of potential risk factors.

METHODS

Eighty-one consecutive KTRs were examined every 6 months during the first 3 years after transplantation. All survival analyses were performed with the EGRET statistical software package.

RESULTS

After a median follow-up of 34 months, 25 skin cancers developed in 12 patients; the basal cell carcinoma (BCC)/SCC ratio was 3.1:1. The cumulative risk of skin cancer developing after 3 years of graft survival was 18.1%. Only age at the time of transplantation (p = 0.005) and occupational sun exposure (p = 0.048) had statistical significance as risk factors.

CONCLUSION

In carefully supervised KTRs, a high incidence of cutaneous malignancy, mainly BCC, exists in the early posttransplant period. Sun exposure and the patient's age at the time of transplantation seem to be the most important risk factors.

Skin cancer and warts in immunosuppressed renal transplant recipients

Non-melanoma skin cancer (NMSC) is increasingly recognised as a complication of long-term immunosuppression and has been particularly studied in renal transplant recipients (RTR). A population study of renal transplant recipients has been performed with analysis of those features contributing to a high rate of detection of NMSC, such that 40% patients with fair skin have NMSC 5 years after transplantation. 90% of the total patient population have warts 5 years after transplantation, many being atypical and in sun-exposed sites. Therefore, contributory factors in these patients include not only the global immunosuppression, ultraviolet radiation (UVR)-induced mutagenesis and photoimmunosuppression, but also the widespread presence of human papillomavirus (HPV) infection, including the unusual epidermodysplasia verruciformis (EV)-associated cutaneous oncogenic HPV.

Porokeratosis of Mibelli: rapid recurrence of a large lesion after carbon dioxide laser treatment

Porokeratosis of Mibelli was diagnosed in a 9-year-old Afro-American girl. The lesion was rather large (4.1 x 2.0 cm) and had developed rapidly over the course of six months. Considering the potential for malignant transformation without neglecting the importance of cosmesis, carbon dioxide laser vaporization with curettage was chosen to ablate the lesion. Within two months the entire treated area revealed recurrent porokeratosis. Due to the aggressive nature of this lesion, complete excision was performed.

Non-melanoma skin cancer in renal transplant recipients: the extent of the problem and a strategy for management

Over the past 2 years, we have examined all patients with a functioning renal allograft attending a regional nephrology unit. A total of 291 patients were examined. 172 (59%) were found to have cutaneous warts, and 64 (21.9%) had non-melanoma skin cancer (NMSC). The proportion of patients with both warts and NMSC increased with time from transplantation: 40% of patients who had been transplanted for more than 9 years had NMSC. Fifteen patients had extensive dysplastic change in all sun-exposed areas, particularly the dorsal aspect of the hands. This subgroup of patients develop large numbers of tumours, particularly squamous cell carcinomas (SCC), and require close surveillance and frequent surgery. One patient has died as a result of rapidly evolving metastases from an SCC on the dorsum of the hand. Excision and grafting of the backs of the hands in four patients, and long term etretinate therapy in 6 patients have led to a marked reduction in the frequency of surgery to remove tumours. The very high rate of NMSC, frequently multiple, found in this study of UK residents is a source of concern and indicates the need for close dermatological monitoring of allograft recipients, with intensive surveillance of patients with extensive dysplasia, who may develop tumours requiring surgery every few weeks.

Porokeratosis in immunosuppressed and nonimmunosuppressed patients

Porokeratosis is an uncommon, inherited, autosomally dominant disorder. In the last decade association of porokeratosis and immunosuppression has been observed. In this study we carried out a comparative study between immunosuppressed and nonimmunosuppressed porokeratosis cases. We found that 9 out of 20 cases of porokeratosis were associated with organ transplantation/immunosuppression. Clinicopathologic study revealed that the pattern of disease is alike both in immunosuppressed and nonimmunosuppressed patients. Our observations indicate that immune modulation could be a factor in the genesis of porokeratosis.

Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection

We reviewed all studies since 1940 on the prognosis of squamous cell carcinoma (SCC) of the skin and lip. The following variables are correlated with local recurrence and metastatic rates: (1) treatment modality, (2) prior treatment, (3) location, (4) size, (5) depth, (6) histologic differentiation, (7) histologic evidence of perineural involvement, (8) precipitating factors other than ultraviolet light, and (9) host immunosuppression. Local recurrences occur less frequently when SCC is treated by Mohs micrographic surgery. This local recurrence rate differential in favor of Mohs micrographic surgery holds true for primary SCC of the skin and lip (3.1% vs 10.9%), for ear SCC (5.3% vs 18.7%), for locally recurrent (previously treated) SCC (10% vs 23.3%), for SCC with perineural involvement (0% vs 47%), for SCC of size greater than 2 cm (25.2% vs 41.7%), and for SCC that is poorly differentiated (32.6% vs 53.6%).

Porokeratosis of Mibelli following heart transplant

A 59-year-old white man with a history of Sydenham's chorea received a mitral valve prosthesis in 1962. He sustained an anterolateral myocardial infarction in 1983. In 1984, he received a heart transplant. To prevent heart rejection, he was initially treated with cyclosporine 12 mg/kg/day and prednisone 90 mg b.i.d. In 1987, azathioprine 100 mg daily was added. In 1989, at the time of our evaluation, his medications included cyclosporine 80 mg b.i.d., prednisone 10 mg b.i.d., and azathioprine 75 mg/day. Since his heart transplant surgery he had not taken any thiazide medication. The patient noted a lesion on his right thigh; the lesion appeared in 1986, 2 years after his heart transplant. On examination in 1989, the lesion was a 2 cm wide annular plaque with a shiny atrophic center and raised border. Both the clinical appearance and pathology were consistent with a diagnosis of porokeratosis of Mibelli. No family history of porokeratosis was elicited.

Linear and punctate porokeratosis associated with end-stage liver disease

A periodic eruption of porokeratosis developed in a 31-year-old black woman with chronic idiopathic hepatitis requiring liver transplantation. The clinicopathologic features were chiefly those of linear and punctate porokeratosis but overlapped those of porokeratosis plantaris, palmaris et disseminata and hyperkeratotic or verrucous porokeratosis. Typical cornoid lamellae were visible on histologic examination. Outbreaks of the lesions occurred during exacerbations of the liver disease. The skin condition rapidly improved after operation, with concomitant improvement in liver function.

Cutaneous and oral lesions in 32 children after renal transplantation

A variety of skin and oral mucosal lesions appearing in patients after renal transplantation have been reported in the literature. Because most of these data pertain to adults, we studied a group of children with kidney transplants to investigate the occurrence of skin and/or oral mucosal lesions, compare them with those observed in adults, and contribute to the knowledge of the pathogenesis of these disorders. Our series consisted of 32 patients aged 5 to 18 years, all of whom had skin and/or oral mucosal lesions that were classified as being either drug induced, probably related to uremia, or due to other causes. A possible relationship between drug-induced lesions and the therapeutic immunosuppressive regimen in use was investigated. In addition, two formerly unreported lesions were seen in these patients: hypertrophy of lingual fungiform papillae and onychoschizia. The former occurred only in children receiving cyclosporine. Compared with adults, the frequency of gingival hypertrophy was higher and that of infectious disease was lower.

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.

Skin cancer in renal transplant recipients

Skin cancer was found in 31 of 598 patients transplanted in Oxford. No cases occurred during the first 3 years after transplantation but the prevalence rose after 12 years to 18.2 per cent. The main risk factors predisposing to skin cancer were the time after transplantation and male sex. Comparison with data from other centres suggests that exposure to ultraviolet light is a major aetiological factor in the speed of development of skin cancer. As the incidence of new cases rose progressively with time in our patients, it would seem that skin cancer is likely to become a major clinical problem as more patients enjoy prolonged survival after renal transplantation. Preventative and screening measures should be taken by transplant units both in the UK and in other countries with similar temperate climates.

Cutaneous manifestations of immunosuppression in organ transplant recipients

Skin disease is a significant cause of morbidity in chronically immunosuppressed patients, including organ transplant recipients. Cutaneous drug reactions may be caused by immunosuppressive therapy that commonly includes corticosteroids, cyclosporine, azathioprine, and antithymocyte and antilymphocyte globulins. Immunosuppressive drugs can also potentiate the effects of other carcinogens, such as ultraviolet radiation, that cause premalignant lesions and squamous cell carcinoma. The risk of Kaposi's sarcoma is increased in these immunosuppressed patients, particularly in renal transplant recipients. Oncogenic viruses such as the Epstein-Barr virus have been associated with the development of non-Hodgkin's lymphoma in transplant recipients. In transplant patients human papillomavirus infections may be predisposed to malignant transformation, particularly at genital sites. Opportunistic infections caused by bacteria, fungi, viruses, or protozoa are the most common cause of death in transplant recipients. Skin manifestations of infection in immunosuppressed patients may be an important clue to their presence.

Epidermal dysplasia and cyclosporine therapy in renal transplant patients: a comparison with azathioprine

The prevalence of dysplastic cutaneous lesions was determined in a group of 68 renal transplant patients whose immunosuppressive therapy included cyclosporine but not azathioprine. The mean age of the patients was 41 years (range 17-67), and the mean transplant time was 44 months (range 24-75). Dysplastic cutaneous lesions were found in 14 out of 68 patients, a prevalence of 20.6%. Although the lesions arose on sun-exposed sites, there was no apparent correlation with previous sun-exposure. The cumulative prevalence of dysplastic cutaneous lesions in 64 patients who had received cyclosporine for between 24 and 72 months was compared with 33 renal transplant patients who had been treated with azathioprine over a similar period of time. The overall prevalence of cutaneous dysplasia was 22% in the cyclosporine group and 9% in the azathioprine group. The cumulative prevalence of cutaneous dysplasia in the cyclosporine group was greater at all time points studied. In contrast to previous reports, we have found no evidence that the risk of cutaneous malignancy in patients treated with cyclosporine is less than that found in patients maintained on azathioprine.

Kaposi's sarcoma in kidney transplant recipients treated with cyclosporin

We report the clinical and histological features and the course of Kaposi's sarcoma in three transplant patients treated with cyclosporin. Four months after cyclosporin treatment was stopped the lesions in all three patients had completely healed.

T6+ and HLA-DR+ cell numbers in epidermis of immunosuppressed renal transplant recipients

The increased susceptibility of the skin of chronically immunosuppressed individuals to viral infections and sunlight-induced malignancies suggests specific drug-induced, dysfunction of local immune mechanisms within the sun-exposed skin of these individuals. To help understand the effect of immunosuppressive therapy alone in the absence of ultraviolet light on the immune system of skin, biopsies were collected from non-sun-exposed buttock skin of control, healthy volunteers and kidney transplant recipients immunosuppressed with either azathioprine/prednisone or cyclosporin A/prednisone and examined for incidences of T6+, and HLA-DR+ cells. No significant differences in the incidences of these 2 cell types were found (a) between control individuals and transplants recipients, (b) between transplant recipients receiving either of the immunosuppressive drug regimes, or (c) between transplant recipients who either had or had not developed skin cancer.

Cancer, warts, and sunshine in renal transplant patients. A case-control study

94 renal transplant patients were examined for the presence of cutaneous malignancies, actinic keratoses, warts, and cutaneous fungal infection, and a history was taken of infection with herpes simplex and herpes zoster. Each patient had a control matched for age, sex, and sun exposure. Of the 17 patients with high exposure to sunshine (more than 3 months in a tropical or subtropical climate or more than 5 years in an outdoor occupation), 2 had squamous cell carcinoma and 7 actinic keratoses. These lesions did not occur in the other renal transplant patients or the control group. The immunosuppressive effect of ultraviolet radiation in the sunburn spectrum (290-320 nm) in man and animals may be related to the increased incidence of cutaneous malignancy, actinic keratoses, and warts. Transplant patients should be under regular surveillance for the early detection and treatment of premalignant cutaneous lesions, and they should receive advice on avoiding sun exposure.