Managing skin cancer in the transplant population

Key Points

Buenos Aires, Argentina - Transplant patients have a significantly higher risk of developing skin cancers, due the immunosuppression they experience as a result of the drugs they must take. However, some patients are more at risk than others.

One expert outlines the risk factors and how to approach these patients in order to minimize, and even prevent, their potential skin cancer disease.

"The risk in transplant patients is hugely different, depending on who you are dealing with. Certain ethnic groups almost have no risks, and others have huge risks. Risks are also determined by the age and gender of the person.

Risk factors

Dr. Murphy says transplant patients with skin types I and II have the greatest risk for nonmelanoma skin cancer, particularly squamous cell carcinoma (SCC), with a reversal of the ratio seen in the normal population.

The risk of melanoma is increased six to eight times in transplant patients with skin types I and II.

According to Dr. Murphy, the duration of immunosuppression is another major risk factor for developing skin cancers. Transplant patients as a whole can have risks running up to 250 times that of the normal population.

"A patient who has been long-term transplanted - say 20 to 25 years - has a much higher risk than someone who is not. However, someone who received a transplant six months ago has not yet developed the risks of long-term immunosuppression compared with someone who is not transplanted, because they are not immunosuppressed long enough," Dr. Murphy tells Dermatology Times.

"The older you are, the longer you are on immunosuppressant drugs, and the paler your complexion, the greater your risk," she says.

Dr. Murphy says there is a cumulative risk of skin cancer with age, irrespective of whether you are a transplant patient.

If immunosuppression is added on top of that, there will be an intensification of that risk.

Also, male gender seems to be independently related to an increased risk.

According to Dr. Murphy, the geographical location of the patient is an important risk factor, too, specifically in terms of the amount and intensity of sun exposure.

Approximately 90 percent of skin cancers occur on sun-exposed sites; therefore, those people in sunny countries may have higher risks if they are outside.

"It is crucial to evaluate the risk profile and then try to detect those who are at particular risk, and eradicate lesions that confer racial risk. We try to eradicate the precursor lesions that might predispose patients to skin cancer in so far as it is possible," Dr. Murphy says.

Dr. Murphy prefers to treat her transplant patients proactively. She individualizes treatment for each of her patients, depending on the extent of their problem, as well as patient preference, and uses treatments such as cryotherapy, Efudex (Valeant), imiquimod, topical diclofenac as well as PDT.

She also actively treats viral warts, as the HPV virus infection is intimately bound with the development of skin cancer in these patients, such as SCC.

Furthermore, there seems to be an interaction between UV radiation and the presence of proliferating HPV in terms of risk of nonmelanoma skin cancer.

It is paramount in transplant patients to practice prevention as much as possible, including using sunscreens, behaving appropriately in respect to sun exposure and wearing proper clothing.

Dr. Murphy says early detection and timely surgical eradication of early lesions to try to prevent their progression is crucial, and the main pillars of management in these patients.

She instructs her patients to watch for any new lesions that may develop, because in these immunosuppressed patients, little lesions can rapidly increase in size in a matter of a few days.

"We also use retinoids such as Neotigason (Hoffman-LaRoche), which can successfully cut the rate of cancer development in half in these patients. As it is sometimes difficult to reduce immunosuppression by reducing the dose of the immunosuppressive drugs, treating with retinoids is sometimes very helpful," Dr. Murphy says.