Protecting Your Skin after Transplant

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Protecting Your Skin After Transplant

May 1, 2023

Presenter: Rachel Rosenstein, MD, PhD, Hackensack Meridian Health; John Theurer Cancer Center

Presentation is 25 minutes, followed by 30 minutes of Q & A

Summary: A variety of skin problems are common after a bone marrow or stem cell transplant including infections, rashes, hair loss, lesions and skin cancer. This video discusses both malignant and non-malignant skin problems, who is at risk for developing these problems, recommended skin care after transplant, and testing to prevent or diagnose skin problems early.

Highlights:

• Sun exposure can lead to rashes, skin cancer and can trigger or worsen graft-versus-host disease (GVHD).
• Patients who had a stem or bone marrow transplant using cells from a donor (allogeneic transplant) have an increased risk of developing skin cancer.
• It’s a good idea to apply a broad spectrum sunscreen with an SPF of 30 or greater, to all exposed skin when outdoors, year-round, and to reapply it every two hours.

Key Points:

(02:10): Regularly treating dry skin after transplant with a moisturized is important for maintaining skin health.

04:24): Transplant recipients should avoid bubble baths and scented salts or oils, and use mild cleansers and lukewarm, rather than hot water, when bathing or showering.

(05:46): Different types of skin infections can follow transplants. It is important to identify the type of infection to best know how to treat it.

(12:56): Rashes after transplant may be caused by a new drug the patient is receiving.

(14:47): Two types of hair loss can occur after transplant: non-scarring, which is usually reversible, and scarring, which may be permanent.

(16:45): Pre-cancerous skin lesions, such as actinic keratoses, can occur after transplant

(19:29): The most common non-melanoma skin cancers are basal cell carcinoma and squamous cell carcinoma.

(23:10): Melanoma is a cancer of the skin’s pigment cells. The “ABCDEs” of melanoma can help you recognize signs of melanoma and seek treatment promptly.

(26:07): Skin cancer screening should be done on a regular basis, both with self-exams and routine visits to the dermatologist.

Transcription of Presentation:

(00:01): [Michala O’Brien]: Welcome to the workshop Protecting Your Skin After Transplant. My name is Michala O’Brien, and I will be your moderator for this workshop.

(00:09):  It's my pleasure to introduce you to today's speaker, Dr. Rachel Rosenstein. Dr. Rosenstein is an Assistant Professor in the Internal Medicine Dermatology Division at Hackensack Meridian School of Medicine. She currently practices as an oncodermatologist, focusing on skin concerns of patients. Dr. Rosenstein's research focuses on developing a better understanding of the steps that lead to chronic GVHD (graft-versus-host disease), validating biomarkers of skin disease, and identifying new treatment targets. Please join me in welcoming Dr. Rosenstein.

(00:48): [Dr. Rachel Rosenstein]: Understanding malignant and non-malignant skin problems following stem cell transplant. Thank you so much for having me here to speak to you all today. I'm very excited to talk about protecting your skin after transplant. Following today’s presentation, I hope you will have an understanding of malignant and non-malignant skin problems that can develop after a hematopoietic stem cell transplant in the short and long-term, who's at risk for developing non-malignant and malignant skin problems after transplant, recommended skincare and sun protection post-transplant, and tests and the frequency of these tests that hematopoietic stem cell transplant patients should have for early detection of malignant and non-malignant skin problems.

(01:29): Skin problems are common after transplantation, and although many of these problems can develop in people with intact immune systems who haven't gone through transplantation, and who aren't on immunosuppressive medications, they often occur more frequently in transplant patients. Today, I'll be discussing some reasons that transplant patients benefit from regular skin exams. What I won't be focusing on today is a very common possible consequence post-transplant, which is graft-versus-host disease, or GVHD. You'll have an extensive, focused presentation on this topic on Thursday by Dr. Markova.

(02:10): Treating dry skin is very important for stem cell transplant recipients. Let's start with treatment of dry skin. Patients may complain of dry skin post-transplant due to changes in medications, changes in bathing habits, use of hospital dry skin products, and also in the setting of graft-versus-host disease. Typically, for patients with dry skin, we recommend moisturizer use twice daily. There are a wide variety of moisturizers, and we choose the type of moisturizer based on the degree of dryness at the site, the site in particular, how acceptable the consistency of a moisturizer is to a patient in particular, and the season.

(02:52): Different types of moisturizers include ointments, which are very occlusive [they create a barrier to prevent moisture loss], and they're less likely to cause burning or stinging. But to some people, the greasiness may not be acceptable.

(03:03): There are also creams, which are absorbed faster and are less occlusive. But they still are thick in comparison to lotions, which have a higher water content and are thinner.

(03:14): Many people might like the feeling of applying a lotion to the skin, but for people with dry skin, lotions can lead to burning of the skin. So, typically, I'll recommend that someone with dry skin use an ointment or a cream and not a lotion and apply it at least twice daily.

(03:32): Sometimes, for particularly problematic areas, I'll recommend that patients apply a moisturizer under occlusion, and this can be with cotton gloves on your hands. If there's a particularly problematic area where there's a fissure or a cut in the skin, this could be with a band aid overlying it. If the arms or legs are particularly dry, a moisturizer can be applied, and then the area can be wrapped with saran wrap, which can be helpful.

(04:00): Typically, when choosing a moisturizer, I'd recommend avoiding allergy-provoking ingredients, including perfumes, lanolin, herbal extracts. Look for the words fragrance-free or "free and clear". You would choose those instead of something that says unscented, because sometimes in something that's unscented, they've used chemicals to mask the underlying scent.

(04:24): Transplant recipients should use mild cleansers and avoid bubble baths and scented salts or oils, and use lukewarm, rather than hot water, when bathing or showering. Extending beyond moisturizer use, let's talk a little bit about basic skincare. For basic good skincare, I'd recommend you use mild cleansers and just focus on the soiled and sweat gland-containing areas. You don't need to use soap over the whole body surface.

(04:41): I would avoid bubble baths and scented salts or oils. I recommend bathing with lukewarm water, not hot water, in the bath or the shower, which can contribute to dryness. I would recommend that you shower no more than once daily and for a short period of time, about 10 to 15 minutes. After the shower, pat the skin dry. Do not rub roughly, and it's best to apply moisturizer within three minutes of exiting the bath.

(05:09): In the situation where dry skin is associated with redness, irritation or itch, a topical steroid may be prescribed. If that's needed, it's best to apply that first after exiting the shower, and then apply a moisturizer overlying that. If the dry skin is associated with significant itch, it's best to try not to scratch it, which can be quite difficult, as scratching can actually thicken the skin and contribute to a worse itch sensation. It can also open up the skin and predispose it to infection at the site.

Moving on to a variety of rashes that can occur post-transplant, let's first talk about infections that can occur in the skin, focusing on bacterial infections. So, bacterial infections can start with the skin as a source of the infection, and particularly in patients on immunosuppressive medications, they may develop infections in the blood, which could then lead to a rash in the skin.

(06:11): In the upper corner, you see a patient with honey-colored crust on the face. This is characteristic of a superficial skin infection called impetigo, which is often due to strep or staph. Next to that, you see a deeper skin infection on the leg called cellulitis. In the bottom corner, you can see inflammation around hair follicles, or furunculosis, where there's infection in the hair follicle and surrounding skin. Whenever there's liquid coming out of any of these rashes or pus, we'll often take that as an opportunity to do a culture to try to identify the organism causing the infection.

(06:49): On the bottom, you can also see what looks like a more severe rash, and this is a bacterial infection that actually came from the blood and ended up in the skin. Oftentimes these patients may be sicker because the bacteria are in the blood.

(07:03): Sometimes a biopsy is needed to identify the organism causing the rash or infection. Identifying the organism is very important. Sometimes these are not typical organisms to cause infections in the skin, so we may need to perform a biopsy. The type of biopsy that we'll do for a rash like this is a punch biopsy. The skin is numbed, so you'll feel a pinch and a burn with the numbing, but you won't feel the biopsy itself. A cookie cutter type device will be used to take usually about a four-millimeter piece of skin out, and this allows evaluation of the full depths of the skin. Oftentimes the site will be sutured closed afterwards.

(07:39): We diagnose the type of infection by the appearance on the skin, by doing cultures, sometimes by doing biopsies; we will typically treat bacterial infections with antibiotics. If it's very mild, a topical antibiotic may be used, sometimes oral antibiotics, in severe situations where the rash is widespread or the patient is very ill, systemically, we'll need to use intravenous antibiotics.

(08:03): A virus often seen in patients after transplant is varicella zoster or shingles. Moving on to viral infections, there are many different types of viruses, but one common family of viruses in transplant patients is the herpesvirus family, including herpes simplex, or HSV, and varicella zoster, also called shingles.

On the top, you can see grouped blisters on a red base, and this is very characteristic of HSV. You can see a similar-appearing rash below that close-up, and if you look next to it, you can see that this rash takes up a whole band on this patient's back. This is varicella zoster covering a "dermatome", an area of the skin where the nerve travels in the skin. Often, patients have been exposed to these herpesvirus members earlier on in life. So, you might be on suppressive medication post-transplant to prevent flares of these rashes. Oftentimes they come out due to reactivation, but it's also possible to get these virus infections newly by skin-to-skin contact.

(09:06): Usually, when we see these rashes, we will start treatment, but we'll also often do a scraping, sending the contents of the scraping for culture or a molecular test called a PCR to try to identify the particular virus causing the rash. Oftentimes patients will be put on antiviral medication by mouth, but if the eruption is widespread or involves sensitive organs or the patient is very immunosuppressed, they may need intravenous antivirals as well.

(09:39): Benign skin lesions and warts are sometimes seen in patients after transplant. Viruses can also produce benign skin lesions, there are two on this slide. The first, Molluscum lesions, are very common in kids, but not so common in adults who have intact immune systems, since they've already developed immunity to molluscum. Sometimes these lesions can come out in transplant patients, and this can be transmitted by skin-to-skin contact or by sexual contact. Treatment is often with cryotherapy, using liquid nitrogen to freeze the lesions; curettage, scraping the lesions; or application of topicals.

(10:20): Another viral-induced skin lesion is warts or verruca vulgaris, and these are due to human papillomavirus, or HPV. There are many different types of HPV, and we're in contact with many types of HPV all the time. Most of these HPVs contribute to warts. Some can contribute to cancers, such as cervical cancer, squamous cell carcinoma of the skin, as well as head and neck cancers. There's actually now a vaccine against many of these HPVs, but not all of them.

(10:52): On the bottom of this slide, you can see these warty lesions. Often, when transplant patients develop warts, it's due to reactivation. They've already been exposed to the virus, but due to changes in their immune system post-transplant or immunosuppressive medication, these warts may then be clinically apparent. Treatment may involve decreasing immunosuppression, and sometimes that alone can lead to the resolution of warts. Sometimes it involves treating them with cryotherapy or freezing the lesions, paring them down, or topicals. But unfortunately, sometimes warts can grow quite large and be difficult to treat in the post-transplant population.

(11:33): A variety of different organisms can cause fungal infections after transplant. Moving on to fungal infections, there are a variety of different organisms that can cause fungal infections. In the upper corner, you can see tinea, where there's a red rash with prominence around the ring. Next to that, you can see a somewhat subtle rash called tenia versicolor, where there's brown or tan or pink patches with subtle scale, due to malassezia.

(11:56): Below that, you can see a yeast infection in the mouth, Candida, that can cause thrush in the mouth. Next to that, you can see the effect of Candida on the skin, often causing a bright red rash. To the side of the main rash, you can see what are called satellite lesions, and that's characteristic of Candida.

(12:14): There are also some rarer fungal infections that can cause a problem in post-transplant patients, and these are called opportunistic infections.

(12:23): Often, we'll do a scraping to try to look for the fungus under the microscope. We might send a culture off, and in some situations, where the rash is widespread and it's difficult to distinguish from other rashes, we might do a biopsy. For localized rashes, the treatment may be topical antifungal creams or antifungal shampoos. When widespread or more serious, a systemic antifungal may be necessary, and in very rare situations, surgery or debridement might be done for a fungal infection.

(12:56): Rashes after transplant may be caused by a new drug the patient is receiving.  Moving beyond infections to other inflammatory rashes in the skin, let's talk a little bit about drug rashes. Post-transplant, patients are often put on a variety of new medications. It's a good idea to keep a drug diary, taking note of the dates that new medications are started and doses changes, as this can be helpful if rashes develop later on to try to determine which medication was the culprit that caused the drug rash.

(13:23): Above, you can see morbilliform drug rashes, which are very common drug rashes that typically occur days to weeks after starting a new medication. They can sometimes look similar to rashes from viruses or rashes from graft-versus-host disease. Sometimes a biopsy is done, which can sometimes be helpful in distinguishing these diagnoses. Typically, we try to stop the offending medication, but sometimes the rash continues its course. It can become quite widespread and red, associated with itch, but then it typically self-resolves. It can lead to darker color of the skin and scaling as the rash improves. Sometimes these rashes can be associated with systemic findings, as well, so we'll often check blood work to check the blood count and look at the kidney and liver function.

(14:14): This rash is often red and itchy, but there are also other rashes which may be associated with skin pain, burning, blistering of the skin, peeling of the skin, and these are more severe rashes or severe drug rashes, called Stevens-Johnson syndrome. They'll often involve mucosal surfaces, such as the eyes, nose, mouth, genital area; if any of these symptoms occur, you should call your doctor immediately.

(14:47): Two types of hair loss can occur after transplant: non-scarring, which is usually temporary, and scarring, which may be permanent.  Moving on to another concern, post-transplant hair loss. Hair loss is split into two different types, non-scarring hair loss and scarring hair loss. In non-scarring hair loss, there's loss of individual hairs, but the hair follicles are intact. But, in scarring hair loss, there's loss of the hairs and the follicles are scarred over. A common cause of hair post-transplant is chemotherapy and radiation; typically, this hair loss occurs two to four weeks after starting these treatments. This type of hair loss is usually reversible but can be persistent in some people.

(15:27): Medical stressors and even psychological stressors can also lead to a temporary hair loss called telogen effluvium, which typically occurs three to four months after a traumatic event and can last for three to four months. It's also typically reversible. During this time period when there's hair loss, it's good to minimize trauma to the hair and the scalp and protect the skin from the sun, as skin may be now exposed that was covered by hair previously. Sometimes hair loss is persistent, and sometimes a biopsy is done. Oftentimes this biopsy shows features of patterned hair loss or androgenetic alopecia. Sometimes treating hair loss in that way can be helpful as well.

(16:13): Moving on to the other type of hair loss, scarring hair loss. Here, you can see in the image, not only loss of hairs, but redness and scale around the hair follicles. You also see loss of hair follicles. Post-transplant, this can be due to graft-versus-host disease and infection. It's possible that a culture might be done, or a punch biopsy of the scalp, looking for the cause of the scarring hair loss. Treating scarring hair loss early is very important to prevent further scarring and further loss.

(16:45): Pre-cancerous skin lesions, such as actinic keratoses, can occur after transplant. Let's move on to skin lesions after transplant. There are many different skin lesions that can develop, but I'm going to focus today on some of the more common ones and more problematic ones.

(16:56): Here we see actinic keratoses, also called solar keratoses. These are potentially pre-cancerous skin lesions due to atypical keratinocytes, or skin cells. This is most often induced by sun damage. We treat these areas because they have the capability, in rare situations, to develop into invasive squamous cell carcinomas. It appears rough. There are scaly spots, often pink, and you can see the top of the hand and arm involved in the top photo. In the image below, you can see similar damage, but then one area where a squamous cell carcinoma has developed due to sun damage. Often, this involves the face, neck, tops of hands, forearms, and scalp. It can also involve the lips, most commonly the lower lip. In that case, it's called actinic cheilitis.

(17:55): Often, treatment of actinic keratoses occurs with treatment of individual lesions, such as with liquid nitrogen or cryotherapy. But when there are too many lesions to treat individually, we do something called field therapy. With field therapy, we'll often use topical chemotherapy, such as 5 fluorouracil cream, which leads to destruction of the pre-cancerous cells, while trying to keep the normal cells intact. This is often associated with redness and irritation. If the treatment goes very strongly, it can lead to blistering and crusting, which we do not want to happen. A close discussion with a dermatologist is important during this treatment.

(18:47): Other ways to do field therapy include chemical peels and photodynamic therapy. In photodynamic therapy, a photosensitizing medication is applied to the skin, and then light is targeted at those areas. The goal of these therapies is to control the damage from the sun, but sometimes these lesions will return, and repeat treatments may be necessary.

(19:12): Patients have an increased risk for developing skin cancer after a stem or bone marrow transplant using donor cells (allogeneic transplant). Moving on to malignant skin problems... after an allogeneic hematopoietic cell transplant [a bone marrow or stem cell transplant using donor cells], patients are at an increased risk for skin cancer. 2.6% of transplant patients will develop skin cancer, separated into two groups: non-melanoma skin cancers and melanoma.

(19:29): The most common non-melanoma skin cancers are basal cell carcinoma and squamous cell carcinoma. Basal cell carcinoma is the most common skin cancer; it is usually localized. It rarely metastasizes [spreads]. But it can be more aggressive, depending on the features of the lesion itself as well as the patient's immunosuppressive state.

(19:52): Here, you can see different examples of basal cell carcinomas. They're often described as pink and pearly bumps that can also be red and scaly. You can see, in the upper corner, that they can be pigmented, and that one's quite dark, almost black. They can sometimes bleed easily or appear scar-like; the one on the top in the middle you can barely see. So, sometimes they can be difficult to identify. These lesions are typically slow-growing, but they can become large. They may ulcerate and open up; one of these images is a patient's cheek, where it was draining for months. They can become locally destructive.

(20:36): Diagnosis of basal cell carcinoma is typically done with what is called a shave biopsy, which differs from the type of biopsy that I described before. A superficial piece of skin is cut off from the lesion and sent for evaluation. Treatment depends on pathologic features of the basal cell, the location of the lesion, and the size of the lesion. Sometimes, for superficial basal cells, we can use destructive methods, such as electrodesiccation and curettage or scraping and burning. We can also use cryotherapy or liquid nitrogen for treatment, 5 fluorouracil, as well as radiation. Most often, lesions are treated with excision, where a margin of normal skin beyond the skin cancer is removed, and then the site is often closed with stitches.

(21:24): In some situations, Mohs micrographic surgery is done, this is performed to limit the removal of normal skin. The surgeon evaluates the clinical evidence of the lesion and takes a small amount of normal skin, looks at it under the microscope, evaluates if the skin cancer has been cleared, and if it's been cleared, then the site can be closed. If it hasn't been cleared, additional sections may be taken and evaluated before the surgery ends.

(21:57): Squamous cell carcinomas have a greater potential to recur, invade, or metastasize [spread] compared to basal cell carcinomas. Moving on to squamous cell carcinomas; squamous cell carcinomas often present as scaly, pink bumps. They may cause pain, ulcerate, bleed, or crust. Sometimes they may appear, as in the bottom corner, as dome-shaped, crater-like bumps called keratoacanthomas, and they are typically believed to be well-behaved squamous cell carcinomas. Squamous cell carcinomas have a greater potential to recur, invade, or metastasize [spread] compared to basal cell carcinomas. Here you can see squamous cell carcinoma that has taken up much of the finger or the leg.

(22:32): Squamous cell carcinomas are diagnosed by skin biopsy. Treatment depends on pathologic features of the cancer, location, and size. While destructive methods can be used in some situations, more often the squamous cell carcinoma is treated with surgery, including excision and Mohs micrographic surgery. Sometimes imaging or a lymph node biopsy is deemed necessary, depending on features of the squamous cell carcinoma; sometimes radiation is necessary post-surgery.

(23:03): The two types of skin cancer that I just discussed are keratinocyte carcinomas, where the skin cells themselves become cancer.

(23:10): Melanoma is a cancer of the skin’s pigment cells. The “ABCDEs” of melanoma help you recognize signs of melanoma. Moving on to melanoma, this is a cancer of the pigment cells. There are some features of melanoma that have been distilled into ABCDEs of melanoma, and this allows you to try to recognize these lesions. A is for asymmetry. B stands for irregular borders. You can see a somewhat scalloped border here. C stands for color, where there's a variety of colors in this lesion. D stands for diameter. Larger lesions are more often melanomas, although sometimes melanomas can be quite small as well. A key feature is evolution, that they change. A patient might notice a changing lesion themselves. Melanomas are often dark brown or black, but here you can see they can sometimes be pink along with those colors or pink on their own.

(24:01): Melanoma is diagnosed by skin biopsy, and we want to get deep below the lesion with the skin biopsy, as the depth of the melanoma plays a role in determining further testing that's done. Sometimes an excisional biopsy is done. Depending on the size and the depth of the lesion, excision may be done by a dermatologic surgeon or an oncologic surgeon. It may require imaging or a lymph node biopsy, and some patients may require additional systemic therapy.

(24:33): Sun exposure is the most common risk factor for developing skin cancer. So, what are the risk factors for these different types of skin cancers? Most commonly, sun exposure for all of them. But there are some other risk factors that play a role in post-transplant patients as well.

(24:43) Other risk factors for developing basal cell carcinoma include these include a diagnosis of leukemia, lymphoma, malignant marrow disease, light skin color, younger age at transplantation, having had total body irradiation, or a history of chronic GVHD.

(25:01): Risk factors for squamous cell carcinoma, aside from sun, and, as we discussed before, include human papillomavirus, include primary diagnosis of leukemia or severe aplastic anemia, younger age at time of transplant, history of chronic GVHD, immunosuppression for greater than 24 months, and in particular, use of the medication azathioprine.

(25:23): Risk factors for developing a melanoma include a personal or family history of melanoma, a history of having many moles, having had a T-cell-depleted transplant, female sex, or having had total body irradiation. Moving on to melanoma, risk factors include a personal or family history of melanoma, a history of having many moles, having had a T-cell-depleted transplant, female sex, or having had total body irradiation.

(25:37): There have been studies done in solid organ transplant recipients who have been subjected to prolonged immunosuppression; some other features have been suggested as to the timing of skin cancer screening post-transplant. This includes history of previous skin cancer or pre-cancerous lesions, having spent more time outside daily, being greater than 50 years of age, having lived in a hot climate for a long time, having had many sunburns, or decreased pigment in the skin.

(26:07): Screening for skin cancer is very important and should be done yourself and at your dermatologist’s office. Skin cancer screening is important post-transplant and can be done with self-exams. I mentioned the ABCDEs of melanoma, which can help a patient identify melanoma on themselves. When looking for basal cell or squamous cell carcinoma, want you to look for new, growing lesions. They might have open sores. Spots might itch, might hurt, crust, scab, bleed.

When doing a skin exam, it's good to be in bright light, to be looking into a full-length mirror. You could use a hand mirror to try to look at areas that are difficult to see in the full-length mirror. You can use a blow-dryer to go through the scalp, trying to visualize the scalp and push the hair away. It's also good to ask for help, have others to take a look. You can look at the Skin Cancer Foundation website, www.skincancer.org, which has good tips on doing self-exams.

(26:58): It's also important to get skin exams with a local dermatologist, about every 6 to 12 months, depending on the factors that showed on the other slides. Anyone with a history of a prior skin cancer or a lot of pre-cancerous changes, it makes sense to get a skin check every six months. Before the exam, you can prepare by identifying lesions of concern, remove nail polish and makeup to fully be able to visualize the nails and the face, and wear hair loose to be able to see the scalp more clearly.

(27:32): Sun exposure can lead to rashes, skin cancer and can trigger or worsen graft-versus-host disease (GVHD). So, we discussed that ultraviolet radiation is a cause of skin cancer. Sun can also lead to rashes post-transplant.

Patients may be on medications such as voriconazole or hydrochlorothiazide, and antibiotics, like Bactrim™ and doxycycline, which can sensitize the skin to the sun.

(27:52): Sun can also trigger or worsen graft-versus-host disease. Some protection post-transplant is very important. It can provide skin cancer prevention; at least one in five people will be diagnosed with skin cancer. It can help prevent benign lesion development and rashes as well as improve the signs of aging.

(28:13): Sunscreen products can either provide protection against UVB light only, or can be labeled  “broad spectrum” and provide protection against both UVA and UVB light. Sunscreens limit UVB wavelengths which interact with molecules in the skin. Sunscreens are considered over-the-counter drugs and are regulated by the FDA. They are all labeled with a sun protective factor, or SPF, which refers to their protection only from UVB light. SPF is a measure of how much UVB radiation is required to produce sunburn on protected skin, compared to unprotected skin. So, someone usually burns in 10 minutes without sunscreen, but they're wearing an SPF of 10. They might burn, then, in around 100 minutes in the equivalent level of sun.

(28:53): Sunscreens may also be labeled with the term "broad spectrum", and this refers to protection from UVA and UVB. As I mentioned, the SPF only refers to UVB protection. Sunscreens also may be labeled as water-resistant.

(29:09): Here is a graph looking at the UVB filtering of different SPFs of sunscreen, and you can see an SPF of 30 filters out 96.7% of UVB and an SPF of 50, 98%.  So, the SPF has actually been capped now at 50, because it does filter out a lot of UVB light.

(29:29): What are the different mechanisms of sunscreen? Sunscreen forms a coating on the surface of the skin that filters out radiation, there are two main mechanisms. One is chemical sunscreens, which act by absorbing light. The others are physical sunscreens, called mineral or inorganic, and they scatter light energy. Chemical sunscreens often have a long list of active ingredients on the label, while physical sunscreens typically include titanium dioxide and/or zinc oxide.

(30:01): Recently there has been an appreciation for the role that visible light and LED lights can play on the skin.  So, now, iron oxide is sometimes added to sunscreens, as it can protect against UVB light and visible light. Iron oxide also provides a tint, and physical blockers may have a white appearance that's not cosmetically desirable to some patients.  Iron oxide can add this tint that makes them easier to use.

(30:30):  The reason that sunscreen sometimes does not work is because people do not apply a thick enough coat. Why doesn't sunscreen always work?  The main reason is that many people don't often apply sunscreen at the same thickness as was done in the clinical trials. In fact, most users apply 20 to 50% of the desired amount of sunscreen. To cover the skin of an adult requires two to three tablespoons of sunscreen, one to one and half ounces, about a shot glass worth.  So, strategies to improve outcomes might be to apply sunscreen twice in a row or use a product with a higher SPF.

(31:03):  Avoid direct sun exposure between 10 AM and 4 PM. Some good sun protection guidelines include avoiding direct sun exposure when possible, usually between 10:00 AM and 4:00 PM. Seek shade to shelter from direct sun.

(31:13): Wear protective clothing. There's clothing now that's rated with a UVB protective factor or a UPF, that can be worn over bathing suits. They actually make bathing suits that are UVB protective. But dark clothing can be helpful on its own, and clothing with a tighter weave can also be helpful. Sunglasses are important to protect the eyes.

(31:36): It’s a good idea to apply a broad spectrum sunscreen, with an SPF or 30 or greater, to all exposed skin when outdoors, year-round, not only when it's hot or during the summer, and to reapply it every two hours. It's good to use broad spectrum sunscreen; I always recommend an SPF of 30 or greater. As I mentioned, use up to one to two ounces of sunscreen to cover exposed skin.

(31:57): It's good to apply sunscreen 15 minutes before sun exposure. Use water-resistant sunscreen if swimming or perspiring. Plan to reapply sunscreen every two hours, and if swimming or perspiring, even more frequently.

(32:09): I typically recommend sunscreens that are lotions. Spray sunscreens can also be used, but they need to be applied liberally, and it's best to use them only outside so they're not inhaled. Over the past few years, there was a sunscreen controversy that involved identification of benzene in sunscreens. This is not an ingredient of sunscreen. It was just a consequence of production, but most of the sunscreens that they identified were spray sunscreens.

(32:39):  Unfortunately, there are some sunscreen controversies, but sunscreens have been utilized for decades and have a really great safety record. There have been some concerns suggested from animal and lab studies, and some evidence a few years ago that sunscreens may be found in the bloodstream, but that hasn't affected any recommendations in regard to their use. Overall, the risk-benefit analysis favors use of sunscreens, as they can protect us from skin cancer development.

(33:06): Major side effects of sunscreens include irritation and allergic reactions; for patients that are prone to these types of reactions, I would suggest they use a sunscreen with a physical blocker, such as titanium dioxide or zinc oxide, as they're less likely to cause a reaction.

(33:23): Sun exposure is not necessary to get vitamin D.  There are other safer sources. But what about vitamin D? Don't we need sun to generate vitamin D? Vitamin D levels in sunscreen users are lower than non-users, but within the normal range, according to studies. Vitamin D may be obtained from foods, including oily fish, fortified milk, and milk products, as well as vitamin D supplementation. I don't recommend sun exposure for the express purpose of obtaining vitamin D, as there are other ways to get vitamin D.

(33:51): Indoor tanning increases the risk of developing a skin cancer and is a “no go” for transplant recipients.  I do want to mention indoor tanning. Indoor tanning contributes to 400,000 skin cancers each year, a 75% increased risk of melanoma from one indoor tanning session before the age of 35. Any use of tanning devices is associated with two and a half times the risk of squamous cell carcinoma and one and a half times the risk for basal cell carcinoma. Women with basal cell had an average twice as many visits to tanning beds. Women younger than 30 are six times more likely to get melanoma if using indoor tanning beds.  It's really not a good idea for anyone to do indoor tanning, particularly transplant patients.

(34:29):  To summarize, transplant patients are at risk for malignant and non-malignant skin problems. There are good dry skin care techniques that can help alleviate itch and rash, and these are actually good skincare techniques for anyone to support a strong barrier function of their skin. Sun protection is very important to prevent malignant skin problems and other non-malignant skin problems. Skin cancer screening should be done regularly in the form of self-exams, as well as visits to the dermatologist, and a variety of rashes can also merit dermatologist evaluation. Thank you so much for listening today, and I'm happy to take questions.

Question and Answer Session

(35:10): [Michala O’Brien]: Thank you, Dr. Rosenstein, for this excellent presentation. Our first question is Are there any signs of nail health to watch for? For example, my nails are now rigid. Is this related to menopause, or should I be concerned?

(35:37): [Dr. Rachel Rosenstein]: Ridging of the nails is a common concern for a lot of patients. Ridging of the nails is very common and can be a sign of dryness. It is not necessarily related to the transplant, but it can be. There are many different types of nail changes. Some can be associated with graft-versus-host disease. Some can just be associated with dryness. If it truly is just ridging, it's not necessarily something to be very concerned about. But if it's concerning to you, moisturizing of the hands and the nails and the skin around the nails frequently can potentially help.

(36:19): [Michala O’Brien]: Do you have any advice about how to care for steroid-thin skin that easily bruises and scars? Is there anything to use to toughen up or thicken the skin?

(36:30): [Dr. Rachel Rosenstein]: Unfortunately, steroids are a big part of treatment for GVHD post-transplant and can lead to thinning of the skin. People often get concerned about thinning and bruising on the forearms and the hands and the legs.  Things that one can do include those dry skin care techniques I mentioned, moisturizing the skin frequently with a cream and an ointment. Often, the bruising that occurs is in areas of sun damage.  So, protecting the skin with sunscreens and clothing is also really important for the thin skin and the easily bruising skin.

(37:15): [Michala O’Brien]: Why are transplant survivors more susceptible to skin cancers?

(37:20): [Dr. Rachel Rosenstein]: There are a variety of reasons, and it depends partially on the skin cancer. But some of the medications that transplant patients are on can sensitize to light, and that light can then predispose to skin cancers.

(37:39): Some of the treatments that transplant patients have received, such as total body irradiation, can cause damage to cells that, then, may predispose to skin cancer. We don't necessarily understand why certain underlying malignancies may predispose to skin cancer, but it may have something to do with the amount of time that one has had a suppressed immune system prior to transplantation.

(38:08): We do know that certain medications to treat graft-versus-host disease can predispose to skin cancer more so than others.  Unfortunately, there are a lot of different reasons that a transplant patient may be more susceptible to skin cancer, and for patients that are on immunosuppression for many years, that risk likely increases.

(38:34): [Michala O’Brien]: This patient is almost ten years post allo stem cell transplant. Is there any amount of sun that is okay daily without having protection to be outdoors?

(38:46): [Dr. Rachel Rosenstein]: Regardless of the transplant history, I recommend that everyone has sun protection throughout the year, cloudy days, cold days, only on exposed skin. It's a continuum, and repeated sun exposure just adds to the sun damage. I'm sure not everyone is perfectly compliant with sunscreen when I recommend it, but I would never recommend not to apply it, except in certain situations.

(39:23): There are some rashes that improve with sun exposure, and sometimes we'll recommend phototherapy or narrow-band UVB light. Sometimes patients aren't able to adhere to the strict schedule needed to go to a facility that has narrow-band UVB light.  So, there are rare situations where I'll suggest that a patient use sun to improve their rash, but that's for a few minutes at a time, a few days a week. That's only in the situation that they have a rash that might improve with a little bit of sun exposure. In general, we know that sun can predispose to skin cancer and that the effects are additive.  So, I don't necessarily say, "Go outside without sun protection," but as I mentioned, a lot of people, myself included at times, don't necessarily put on enough sunscreen.  So, we are getting sun, even when we're intending not to.

(40:21): [Michala O’Brien]: Should transplant patients not use hot tubs to avoid staph infections or only if they have open wounds?

(40:31): [Dr. Rachel Rosenstein]: I don't know that there are official recommendations for that. Hot tubs can predispose to infections. Also, pseudomonas can cause an infection after hot tub use, causing folliculitis. I think patients that have graft-versus-host disease that have open skin shouldn't be in the hot tub, but someone that has done well post-transplant, where their skin is healthy and intact, I would ask that question to your oncologist. I wouldn't want to say something that differs from them, but there might be situations where a hot tub could be used.

(41:18): [Michala O’Brien]: I have both melanoma and basal cell diagnosed. Should I be seen more regularly than once a year?

(41:25): [Dr. Rachel Rosenstein]: I would recommend more regularly than once a year. I typically see patients who have had skin cancer every six months, and for patients who have had melanoma, in the period soon after the melanoma diagnosis, I would see them every three months and then space it out a little bit to every four months. But never go beyond every six months. I would suggest at least every six months or even more frequently, depending on when the melanoma diagnosis was, and depending on how the remainder of the skin looks.

(42:01): [Michala O’Brien]: I have a basal cell on the front of my face in a very visible area. Does a plastic surgeon do the Mohs procedure you mentioned?

(42:10): [Dr. Rachel Rosenstein]: Mohs surgery is typically done by dermatologists who have undergone further fellowship training in Mohs micrographic surgery. This is a specific technique that they learn, and they practice very frequently.

(42:25): Mohs surgeons are often very well-trained and very comfortable doing closures of skin cancer surgeries on the face. But there are definitely situations where certain Mohs surgeons would suggest that after they do the Mohs surgery, after they clear the skin cancer, the patient go to a plastic surgeon for closure. They may not be comfortable with the size of the lesion or the location of the site or the patient may prefer to have a plastic surgeon do it. So that collaboration between a Mohs surgeon and a plastic surgeon is quite common. I would suggest discussing this with the Mohs surgeon who's going to do the procedure and their comfort and your comfort with who's doing the closure.

(43:17): [Michala O’Brien]: Is it safe to use acne products, like retinols, after transplant?

(43:24): [Dr. Rachel Rosenstein]: I think it depends on the individual patient and if they have any skin concerns on the face. But retinols can lead to redness and irritation, and they can lead to sensitivity to the sun. Moisturizing and sun protection are particularly important in patients who are using retinols. But in the situations where there aren't side effects of retinols, or one is dealing with the possible side effects appropriately, a retinol could be used if you're able to continue sun protection while using the retinol.

(44:04): [Michala O’Brien]: Is red -light therapy safe?

(44:12): [Dr. Rachel Rosenstein]: I'm not sure what the purpose of red-light therapy is. There are situations where red- light is used as part of photodynamic therapy, and if that's the question, sometimes that is used to treat pre-cancerous skin changes and actinic keratoses. It can be helpful in that situation. In other situations, I think it would depend on the use and who's doing it and for what purpose.

(44:43): [Michala O’Brien]: This patient has longstanding lung disease from GVHD, and their breathing seems to get worse after sun exposure. Is this their imagination, or is it from a GVHD flare?

(44:57): [Dr. Rachel Rosenstein]: The sun can do different things on the skin. Sun can lead to redness. It can lead to hives. It could lead to irritation or different rashes.  So, it's hard to say in a particular patient, but sun can have an effect, potentially, systemically. It's hard to know if it's a GVHD flare, but it's definitely something to discuss with your dermatologist and oncologist.

(45:33): [Michala O’Brien]: When I'm exposed to heat, which could be indoors or outside, I get a prickly feeling, that feels like pins and needles. This does not happen in the shower, however. This damage to my sweat glands after chemotherapy, will this go away? Any suggestions?

(45:50): [Dr. Rachel Rosenstein]: I would have more questions, like, "Is this prickly sensation associated with a rash? Is there anything that you can do to make the prickly sensation get better or worse?" Neuropathy is common post-transplant, and it's possible that the prickly sensation is from the nerves. If a rash is involved, the sun can lead to hives in some people. That can be associated with itch or altered sensation.

(46:19): Graft-versus-host disease can have an effect on sweat glands.  If you're a patient with graft-versus-host disease, particularly the sclerotic form of graft-versus-host disease, that might be something to consider.  I think that's definitely something to discuss with your oncologist or dermatologist.

(46:39): [Michala O’Brien]: Does dry skin tend to improve with time, or is it permanent damage? I'm ten months post-transplant, and my skin is very fragile and dry.

(46:51): [Dr. Rachel Rosenstein]: Dryness can occur for many different reasons, and skin can also become more dry as time goes on. I think there are situations where moisturizing frequently, good weather can have an effect on someone's skin, and this might improve over time. Changes in medications might be having an effect on water content in the body. It's hard to say, in a particular situation, if the dryness will improve. But it is a complaint that people often have as they get older, regardless of the history of transplant.  So, I think it might be patient-specific.

(47:33): [Michala O’Brien]: Apparently sirolimus can cause acne-like lesions. How do you treat these?

(47:42): [Dr. Rachel Rosenstein]:  Treatment of acne can be quite variable, and there are a lot of different possibilities. Sometimes over-the-counter washes with benzoyl peroxide or with salicylic acid can be helpful. Sometimes we'll use retinoids, which is a very common treatment for acne. Depending on how bad the acne is, sometimes it will require oral antibiotics or topical antibiotics.  It depends on how bothersome it is to the patient, what's been tried before, what other medications a patient is on, and their tolerance for different possible side effects.

(48:26): [Michala O’Brien]: Do you have any advice on protecting skin from infections while somebody's on vacation?  

(48:40): [Dr. Rachel Rosenstein]:  When thinking about vacation, time in the water, pools and oceans, would be something to consider, and I would be very careful to look at your skin for openings in the skin barrier that are already there. Showering after time in the water can be helpful. Other than that, be careful with diet and the food and water that you have access to and sun protection on vacation, of course.

(49:17): [Michala O’Brien]: Should patients over 45 years-of-age, who have a re-emergence of HPV, be given the HPV immunization?

(49:27): [Dr. Rachel Rosenstein]: Sometimes the HPV vaccine is difficult to get coverage for by insurance later on. But I do have patients who have HPV-related skin cancers, and I typically do suggest that they get vaccinated, regardless of their age, if that is a concern for them as an individual. There aren't guidelines for this, but that's typically what I recommend.

(49:59): [Michala O’Brien]: Do you have any suggestions for treatment for severe skin itching, specifically scleroderma related to chronic GVHD?

(50:10): [Dr. Rachel Rosenstein]:  Skin itching can be a really difficult issue for patients. To start, I would recommend good dry skin care techniques. Sometimes antihistamines can be helpful. When they're not helpful, sometimes medications such as gabapentin or pregabalin can be helpful.

(50:32): Treating the underlying sclerotic disease with the medications that are now available to do that, including a ROCK2 inhibitor or ruxolitinib, can be helpful. But it also can be quite debilitating and difficult for patients, and sometimes requires trial and error. There are also some medications that are typically marketed as antidepressants that can also improve itch.  Trying out a variety of options, if there aren't drug interactions, may be the best course.

(51:13): [Michala O’Brien]: This is a question about clothing effectiveness. Is that a good sun barrier? Should I use sunscreen underneath protective clothing?

(51:25): [Dr. Rachel Rosenstein]:  The officially UVB-protective clothing that have a UPF, I'd say it can give you a similar effect as sunscreen, and depending on the amount of time you're outside can be quite effective. Dark clothing and tightly-woven clothing that's not officially UVB-protective can also be helpful, but lighter clothing, thinner clothing can also lead to sun exposure. I think it depends on what you're wearing and your experience with what you're wearing. If it's something light, I would be wearing sunscreen under it. But a UVB-protective bathing suit for a limited time outside, I typically am not wearing sunscreen under it.

(52:13): [Michala O’Brien]: How prevalent is skin cancer among African Americans?

(52:18): [Dr. Rachel Rosenstein]: I don't have the numbers, but skin cancer is a problem for everyone. Some skin cancers are more related to sun exposure. Others are less so. There are anecdotes of melanoma being found on the bottom of the feet and in the genital area and starting within the mouth, where sun is likely less of a factor. Patients on immunosuppressive medications, the susceptibility is higher. So, I recommend sun protection for everyone. Although people with lightly pigmented skin are likely at greater risk, I still think sun protection is important to protect from skin cancer for people with more darkly pigmented skin.

(53:07): [Michala O’Brien]: Is impetigo contagious?

(53:11): [Dr. Rachel Rosenstein]: Impetigo can be contagious, but I think of it as an infection that's typically easily controlled with topicals or sometimes oral antibiotics. But it can be contagious by contact.

(53:32): [Michala O’Brien]: Here's a CAR-T question. This patient is currently having CAR-T therapy, but they have had actinic keratosis for the last three to four years. Will having CAR-T and being immunocompromised complicate or worsen a future diagnosis?

(53:54): [Dr. Rachel Rosenstein]: I think the question is asking about the actinic keratoses post-CAR-T therapy, and potentially there could be greater concern for the actinic keratoses post-CAR-T therapy. But fortunately, in regard to actinic keratoses, protecting yourself from the sun with sunscreen can actually help the body take care of some of the actinic keratoses, and good sun protective techniques can be helpful as well. We have a lot of different possible treatments for them. So, I think awareness of the pre-cancerous changes potentially should be heightened post CAR-T therapy, but hopefully will be manageable.

(54:38): [Michala O’Brien]: This will have to be our last question. During chemotherapy and transplant, all of my skin tags went away, and they're starting to return. Is there something I can do to prevent this?

(54:53): [Dr. Rachel Rosenstein]: Unfortunately, we haven't found a way to prevent skin tags yet, although many people would be interested in that. We do see skin tags commonly form at areas of friction, so, preventing friction potentially could be helpful. Sometimes they can be related to glucose intolerance, so just making sure that your sugar levels are good can be helpful. Then depending on how problematic the skin tags are for you, they can be removed by a dermatologist. Unfortunately, it's often not covered by insurance.

(55:36): [Michala O’Brien]: Thank you. On behalf of BMT InfoNet and our partners, I'd like to thank Dr. Rosenstein for a very helpful presentation. Thank you, the audience, for your excellent questions. Please contact BMT InfoNet if we can help you in any way, and please enjoy the rest of the symposium.