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Cutaneous Disease in Solid Organ Transplant Recipients: A 5-Year Experience from a Multidisciplinary Medical-Surgical Transplant Dermatology Center
Journal Pre-proof Cutaneous Disease in Solid Organ Transplant Recipients: A 5-Year Experience from a Multidisciplinary Medical-Surgical Transplant Dermatology Center Rina Allawh, MD, Kumar S. Nadhan, MD, Mark Abdelmalek, MD, Carrie Ann Cusack, MD, Alden M. Doyle, MD, Melissa Hoffman, BS, Christina Lee Chung, MD PII:
S0190-9622(19)32793-8
DOI:
https://doi.org/10.1016/j.jaad.2019.09.045
Reference:
YMJD 13857
To appear in:
Journal of the American Academy of Dermatology
Received Date: 2 May 2019 Revised Date:
27 August 2019
Accepted Date: 8 September 2019
Please cite this article as: Allawh R, Nadhan KS, Abdelmalek M, Cusack CA, Doyle AM, Hoffman M, Lee Chung C, Cutaneous Disease in Solid Organ Transplant Recipients: A 5-Year Experience from a Multidisciplinary Medical-Surgical Transplant Dermatology Center, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2019.09.045. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
Cutaneous Disease in Solid Organ Transplant Recipients: A 5-Year Experience from a Multidisciplinary Medical-Surgical Transplant Dermatology Center Rina Allawh , MD, Kumar S. Nadhan , MD, Mark Abdelmalek , MD, Carrie Ann Cusack, MD , Alden M. Doyle, MD , Melissa Hoffman , BS, Christina Lee Chung , MD 1
2
4
3
5
3
1
1 Montgomery Dermatology/Lankenau Institute for Medical Research, King of Prussia/Wynnewood, PA 2 Department of Internal Medicine, Lankenau Medical Center, Wynnewood, PA 3 Dermatology Associates of Southeastern New Jersey, Mt Laurel, NJ 4 Department of Internal Medicine, University of Virginia, Charlottesville, VA 5 Department of Dermatology, Drexel University, Philadelphia, PA
Article Word Count: 491 Tables: 0 Figures: 1 References: 4 IRB approved Funding Sources: None Conflict of Interest Disclosure: None Declared
Address for Correspondence: Christina Lee Chung, MD 860 1st Avenue, Suite 8B King of Prussia, PA Phone: 610-265-1166 Fax: 610-265-1186 Email: [email protected]
Introduction
Solid organ transplant recipients (OTRs) are known to be at heightened risk of developing numerous cutaneous disorders. However, the overall prevalence of posttransplant cutaneous disease, spanning the spectrum of benign and malignant processes, remains incompletely characterized. We describe the rates of skin disease in a specialized transplant dermatology center set up to capture all OTRs, regardless of organ, age, or race/ethnicity. Methods A retrospective analysis was performed on 451 OTRs evaluated at Drexel Dermatology Center for Transplant Patients (CTP) from November 1, 2011 to March 1, 2017. CTP is located in Philadelphia, Pennsylvania and comprised of two medical dermatologists and one dermatologic surgeon. All cutaneous diagnoses were recorded and grouped into categories (Figure 1). Data was collected from the electronic medical record following Drexel Institutional Review Board approval. Results Of the 451 patients, 63.2% (N=285) were male and 36.8% (N=166) were female, representing all four major racial groups. The average age was 60 years, 71.8% were kidney transplant recipients and average time of immunosuppression was nine years. One hundred and thirtyeight (30.6%) OTRs were diagnosed with non-melanocytic benign growths. Fungal infections were found in 91 (20.2%) individuals. Eighty-seven (19.2%) and 52 (11.56%) subjects were diagnosed with malignancy and premalignancy (actinic keratosis), respectively. Seventy-eight (17.3%) subjects were diagnosed with acne/folliculitis, 59 (13.1%) with viral infection, 52 (11.56%) with eczematous/papulosquamous dermatitis, 41 (9.1%) with ichthyosis/xerosis, 34 (7.5%) with pigmentary disorders, 17 (3.8%) with autoimmune dermatitis, and four (0.9%) with bacterial infection.
Discussion: Our findings reveal a high prevalence and broad range of common and immunosuppression-related, malignant and non-malignant cutaneous diseases in solid organ transplant recipients. Evidence from high-risk skin cancer clinics have promoted the adoption of a variety of measures focused on skin cancer prophylaxis and management of tumors in the transplant population. However, similar advances in the approach to the development of therapeutic and management protocols for non-malignant skin disorders in OTRs have not been developed. As life expectancy continues to increase after transplantation, increased attention to the full spectrum of cutaneous disorders that affect OTRs is warranted. Further investigation into the types, prevalence, and outcomes of cutaneous disease and relation to quality of life (QoL) issues in OTRs are necessary to develop targeted surveillance and long-term management strategies. QoL issues in the organ transplant population have been shown to influence choice of immunosuppressive agents, treatment protocols, and, most importantly, compliance with medication regimens, all of which are key elements in overall graft survival. Limitations of our study include its single-center and retrospective design. The absence of routine pre-transplant evaluations precludes an accurate determination of pre-existing skin disease. In summary, OTRs demonstrate an increased prevalence of a variety of skin diseases which include but are not limited to malignancy. We suggest that dermatologic evaluation in a specialized, comprehensive medical-surgical setting of all OTRs should be considered an essential of comprehensive transpant care. References:
1. Dicle O, Parmaksizoglu B, Gurkan A, Tuncer M, Demirbas A, Yilmaz E. Skin infections in 401 renal transplant recipients in southern Turkey. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation. 2009; 7(2): 133-136. 2. Iannacone M, Sinnya S, Pandeya N et al. Prevalence of Skin Cancer and Related Skin Tumors in High-Risk Kidney and Liver Transplant Recipients in Queensland, Australia. Journal of Investigative Dermatology. 2016;136(7):1382-1386. 3. Rizvi SM, Aagnes B, Holdaas H, Gude E, Boberg KM, Bjørtuft Ø, Helsing P, Leivestad T, Møller B, Gjersvik P. Long-term Change in the Risk of Skin Cancer After Organ Transplantation: A Population-Based Nationwide Cohort Study. JAMA dermatology. 2017; 153(12):1270-7. 4. Savoia P, Ranghino A, Fava P. Characterization and Management of Cutaneous Side Effects Related to the Immunosuppressive Treatment in Solid Organ Recipients. Current Drug Targets. 2017;18(4):436-446.
S0190-9622(19)32793-8
DOI:
https://doi.org/10.1016/j.jaad.2019.09.045
Reference:
YMJD 13857
To appear in:
Journal of the American Academy of Dermatology
Received Date: 2 May 2019 Revised Date:
27 August 2019
Accepted Date: 8 September 2019
Please cite this article as: Allawh R, Nadhan KS, Abdelmalek M, Cusack CA, Doyle AM, Hoffman M, Lee Chung C, Cutaneous Disease in Solid Organ Transplant Recipients: A 5-Year Experience from a Multidisciplinary Medical-Surgical Transplant Dermatology Center, Journal of the American Academy of Dermatology (2019), doi: https://doi.org/10.1016/j.jaad.2019.09.045. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.
Cutaneous Disease in Solid Organ Transplant Recipients: A 5-Year Experience from a Multidisciplinary Medical-Surgical Transplant Dermatology Center Rina Allawh , MD, Kumar S. Nadhan , MD, Mark Abdelmalek , MD, Carrie Ann Cusack, MD , Alden M. Doyle, MD , Melissa Hoffman , BS, Christina Lee Chung , MD 1
2
4
3
5
3
1
1 Montgomery Dermatology/Lankenau Institute for Medical Research, King of Prussia/Wynnewood, PA 2 Department of Internal Medicine, Lankenau Medical Center, Wynnewood, PA 3 Dermatology Associates of Southeastern New Jersey, Mt Laurel, NJ 4 Department of Internal Medicine, University of Virginia, Charlottesville, VA 5 Department of Dermatology, Drexel University, Philadelphia, PA
Article Word Count: 491 Tables: 0 Figures: 1 References: 4 IRB approved Funding Sources: None Conflict of Interest Disclosure: None Declared
Address for Correspondence: Christina Lee Chung, MD 860 1st Avenue, Suite 8B King of Prussia, PA Phone: 610-265-1166 Fax: 610-265-1186 Email: [email protected]
Introduction
Solid organ transplant recipients (OTRs) are known to be at heightened risk of developing numerous cutaneous disorders. However, the overall prevalence of posttransplant cutaneous disease, spanning the spectrum of benign and malignant processes, remains incompletely characterized. We describe the rates of skin disease in a specialized transplant dermatology center set up to capture all OTRs, regardless of organ, age, or race/ethnicity. Methods A retrospective analysis was performed on 451 OTRs evaluated at Drexel Dermatology Center for Transplant Patients (CTP) from November 1, 2011 to March 1, 2017. CTP is located in Philadelphia, Pennsylvania and comprised of two medical dermatologists and one dermatologic surgeon. All cutaneous diagnoses were recorded and grouped into categories (Figure 1). Data was collected from the electronic medical record following Drexel Institutional Review Board approval. Results Of the 451 patients, 63.2% (N=285) were male and 36.8% (N=166) were female, representing all four major racial groups. The average age was 60 years, 71.8% were kidney transplant recipients and average time of immunosuppression was nine years. One hundred and thirtyeight (30.6%) OTRs were diagnosed with non-melanocytic benign growths. Fungal infections were found in 91 (20.2%) individuals. Eighty-seven (19.2%) and 52 (11.56%) subjects were diagnosed with malignancy and premalignancy (actinic keratosis), respectively. Seventy-eight (17.3%) subjects were diagnosed with acne/folliculitis, 59 (13.1%) with viral infection, 52 (11.56%) with eczematous/papulosquamous dermatitis, 41 (9.1%) with ichthyosis/xerosis, 34 (7.5%) with pigmentary disorders, 17 (3.8%) with autoimmune dermatitis, and four (0.9%) with bacterial infection.
Discussion: Our findings reveal a high prevalence and broad range of common and immunosuppression-related, malignant and non-malignant cutaneous diseases in solid organ transplant recipients. Evidence from high-risk skin cancer clinics have promoted the adoption of a variety of measures focused on skin cancer prophylaxis and management of tumors in the transplant population. However, similar advances in the approach to the development of therapeutic and management protocols for non-malignant skin disorders in OTRs have not been developed. As life expectancy continues to increase after transplantation, increased attention to the full spectrum of cutaneous disorders that affect OTRs is warranted. Further investigation into the types, prevalence, and outcomes of cutaneous disease and relation to quality of life (QoL) issues in OTRs are necessary to develop targeted surveillance and long-term management strategies. QoL issues in the organ transplant population have been shown to influence choice of immunosuppressive agents, treatment protocols, and, most importantly, compliance with medication regimens, all of which are key elements in overall graft survival. Limitations of our study include its single-center and retrospective design. The absence of routine pre-transplant evaluations precludes an accurate determination of pre-existing skin disease. In summary, OTRs demonstrate an increased prevalence of a variety of skin diseases which include but are not limited to malignancy. We suggest that dermatologic evaluation in a specialized, comprehensive medical-surgical setting of all OTRs should be considered an essential of comprehensive transpant care. References:
1. Dicle O, Parmaksizoglu B, Gurkan A, Tuncer M, Demirbas A, Yilmaz E. Skin infections in 401 renal transplant recipients in southern Turkey. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation. 2009; 7(2): 133-136. 2. Iannacone M, Sinnya S, Pandeya N et al. Prevalence of Skin Cancer and Related Skin Tumors in High-Risk Kidney and Liver Transplant Recipients in Queensland, Australia. Journal of Investigative Dermatology. 2016;136(7):1382-1386. 3. Rizvi SM, Aagnes B, Holdaas H, Gude E, Boberg KM, Bjørtuft Ø, Helsing P, Leivestad T, Møller B, Gjersvik P. Long-term Change in the Risk of Skin Cancer After Organ Transplantation: A Population-Based Nationwide Cohort Study. JAMA dermatology. 2017; 153(12):1270-7. 4. Savoia P, Ranghino A, Fava P. Characterization and Management of Cutaneous Side Effects Related to the Immunosuppressive Treatment in Solid Organ Recipients. Current Drug Targets. 2017;18(4):436-446.