Dermatologists play important team role in care of pediatric transplant recipients

Charleston, S.C. - Skin diseases are common among pediatric solid organ transplant recipients, and so dermatologists play an important role in the management of these children, said Maria C. Garzon, M.D., at the 2004 annual meeting of the Society for Pediatric Dermatology here.

"The cutaneous disorders that occur range in severity from mild to life-threatening, and include problems that emerge in the acute period post-transplantation as well as those that present over the longer term. Therefore, dermatologist involvement is essential in the early and ongoing care of these patients," says Dr. Garzon, associate professor of clinical dermatology and clinical pediatrics, Columbia University, New York.

Infections from immunosuppression Early after transplantation, when immunosuppressive drugs to prevent organ rejection are being administered at the highest doses, careful surveillance is needed to detect any sign of serious infection. The development of any erythematous nodules or plaques should raise a red flag and prompt culture and biopsy for timely diagnosis, because the lesions may be a sign of a systemic mycosis, including aspergillosis, cryptococcosis, mucomycosis or Fusarium infection.

"Spontaneous regression is uncommon and achieving clearance can be very challenging," Dr. Garzon says. "Furthermore, these lesions are concerning because of the link between squamous cell carcinoma and infection with certain HPV subtypes associated with warts."

Not well studied The problem of skin cancer in pediatric organ transplant recipients has not been as well studied as it has in the adult population. However, available data show that as are adults, children are at particularly increased risk for developing squamous cell carcinoma and squamous cell carcinoma of the lip.

In addition, the risk of melanoma is elevated compared to the general population. A study of adult organ transplant recipients found factors increasing the risk of skin cancer include increasing age and longer periods of immunosuppression.

"Those features are very relevant to the pediatric transplant population, as patients are now commonly surviving for a decade or longer post-transplantation," Dr. Garzon says. "However, there has also been a shift in medications used for immunosuppression, and ongoing study is needed to see if that change affects skin cancer rates in pediatric transplant patients."

Given the risk of skin cancer, the importance of prevention and early diagnosis, with instructions about sun protection and frequent skin examinations, should be incorporated into the earliest counseling of pediatric transplant patients and reiterated periodically over the longer-term course of their care.

Cosmetic complications important As these patients recover after transplantation and begin to resume more normal lives, a number of other immunosuppressive medication-related cutaneous side effects can also be concerning. Such side effects as acne, striae distensae, gingival hyperplasia, hypertrichosis and hyperpigmentation may be medically benign, but are important to address because they are cosmetically disfiguring and adversely affect quality of life.

"Often, children and their families are told some of these problems will diminish as immunosuppressive medication is decreased further, and not all of them can be managed satisfactorily," Dr. Garzon explains. "However, because they can be so emotionally troubling, these drug-induced side effects should not be disregarded as inconsequential."

Transplant rates, survival increase The need for multidisciplinary management of pediatric solid organ transplant patients is a growing challenge as both the number of young transplant recipients and the duration of their survival is increasing. Unfortunately, the role of the dermatologist may sometimes be overlooked.

"In one recent review article on the care of childhood and adolescent solid organ transplant patients, dermatologists were not even mentioned for their involvement in patient care," Dr. Garzon says.