By Fiona O'Reilly Zwald, MD
I was working at a kidney transplant center in Dublin, in my native Ireland, and I was on my way — I thought — to a career in internal medicine and nephrology. But as I worked with patients who had undergone drastic, yet life-saving, solid organ transplant procedures, one thing began to stand out: The toll it took on their skin.
An intense regimen of immunosuppressant drugs kept their bodies from rejecting life-giving donor organs, but it left their skin vulnerable to various infections, and even cancers. With time, I began to feel like I could almost tell which procedures patients had undergone and which medications they were taking just by looking at their skin. It was a medical history recorded in dermatological signs.
Transplant patients are subject to an increased risk of any number of skin diseases. Owing to their medically suppressed immune systems, they are vulnerable to fungal and viral infections, and can also develop pigmentation disorders and steroid-induced acne.
It is the role of the transplant dermatologist to not only treat these problems, but also monitor the patient’s overall health as revealed in the skin. Dermatological problems often result from oversuppression of the immune system, and the dermatologist may work closely with other members of the transplant team to dial in the optimum dosage of medication.
Skin cancer is a primary concern. Recipients of solid organ transplants have a skin cancer risk up to 65 times greater than those of people without transplants. The ongoing use of immunosuppressants, a history of exposure to sunlight, and a fair, easily burned skin type can be a lethal combination.
Problems tend to arise about 7 to 10 years after the transplant procedure, but skin cancers can develop even sooner. As with all cancers, timing is critical in determining outcomes. In the Atlanta metropolitan area, wait times to see a medical dermatologist can approach three to four months, an interval that could mean the difference between life and death for some patients.
With a dermatologist as an active member of the transplant team, however, a patient gains speedy access to care. The transplant dermatologist can screen the patient for skin cancer before and after the transplant procedure.
The dermatologist can also educate patients to better prepare them to mitigate risks. Patients can be taught how to protect themselves from harmful exposure and what to look for in examining the skin for potentially troublesome lesions.
The number of transplant centers that provide patients with a high level of routine, meaningful access to a transplant dermatologist is small, but growing. Such centers have begun to establish fruitful collaborations. The International Transplant Skin Cancer Collaborative (ITSCC), started in 2001, connects about 250 medical dermatologists and surgeons who have an interest in skin cancer care for transplant recipients.
Recipients of solid organ transplants have skin cancer risks up to 65 times greater than those of people without transplants.
The Academy has also put forth a call for applications to host the Transplant Skin Cancer Network
. The chosen institution will become the nexus through which contributing sites will gather data on the incidence of and metastasis and mortality due to squamous cell carcinoma among transplant recipients.
This project will aid in the development of preventive guidelines and therapeutic strategies. The hope is that the establishment of such a network will foster collaboration, promote public awareness about the need for transplant dermatology, and aid in securing future funding for similar studies.
I personally welcome this effort to further the development of transplant dermatology. I encourage anyone who is interested in transplant dermatology to apply for these types of efforts and to become involved with the ITSCC. The need for appropriate dermatological care for transplant patients is dire. It’s written in the skin, for those who know how to read the signs.
Fiona Zwald, MD, is president-elect of the International Transplant Skin Cancer Collaborative and is actively involved with the American College of Mohs Surgery (ACMS), and is the Chair of the Scientific Committee for ACMS 2014. She is the author of more than 20 research articles, review articles, and book chapters, and has given many presentations in the field of transplant dermatology, both nationally and internationally.
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