Protecting Your Skin after Transplant

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Protecting Your Skin after Transplant

Presented Thursday, May 5, 2022

Presenter: Sharon Hymes MD, Clinical Consultant at MD Anderson Cancer Center; former Medical Director of MD Anderson Center Melanoma and Skin Clinic and member of the GVHD Clinic

Presentation is 38 minutes long with 19 minutes of Q & A.

Summary: Transplant recipients have an elevated risk of skin problems after transplant that require ongoing surveillance, early detection, and prompt treatment. This presentation describes some of the potential skin problems after transplant, and how to maintain good skin health long-term.

Highlights:

• Chemotherapy, radiation, stress and other illnesses can contribute to skin problems after transplant including hair loss, rashes, bacterial and viral infections and skin lesions.
• It can often be difficult to easily determine whether the cause of a rash is a drug reaction, an infections or graft-versus-host disease (GVHD)
• Transplant recipients have a higher risk of developing skin cancer than the general population. Routine skin screening by a qualified dermatologist, as well as minimizing exposure to the sun is important

Key Points:

(02:19): Dry skin is a major complaint after transplant. Transplant recipients should use hypoallergenic unscented creams and ointments, rather than lotions, to treat dry skin because lotions may actually burn.

(04:18): Hair loss is common after transplant.  In most cases, hair will grow back.  If it is caused by damage to the hair follicles, hair loss may be permanent.

(09:38): Rashes are common after transplant and are often related to drugs people receive. It’s important to keep a log of when you start medications to help determine the cause of a rash.

(15:21): Warts are common, particularly among people on immunosuppressive drugs. Warts are contagious and some warts may become pre-cancerous and must be removed.

(17:33): Some skin lesions, such as actinic keratoses (aka solar keratoses) can develop into skin cancer.

(21:45): Basal cell skin cancer can develop after transplant. Risk factors include lighter skin, lots of sun exposure, radiation, some chemical exposures, genetic syndromes, which are rare, and immunosuppression.

(23:43): Squamous cell carcinoma is more aggressive than basal cell carcinoma and often requires surgery to treat. Risk factors are similar to those for basal cell skin cancer, plus human papilloma virus.

(26:41): Routine skin screenings as well as self-examination are essential to detect and treat melanoma. Risk factors for developing melanoma include a family history of melanoma; many moles; light skin and eyes; use of tanning beds; radiation therapy; immunosuppression; and older age.

(29:28): Ultraviolet radiation can cause sunburn, lasting sun damage, and skin cancer. Physical sun protection with clothing is of foremost important. However, sun blocks and sunscreens also play a very important role.

(33:12): Sunscreens are only effective if the SPF is 30 or higher, the right amount is applied (which can be lot), and if it’s applied every few hours. Mineral sunscreens with inorganic filters are the safest choice,

Transcript of Presentation:

(00:01): [Steve Bauer] Introduction. Hello, welcome to the workshop, Protecting Your Skin After Transplant. It is my pleasure to introduce you to Dr. Sharon Hymes. Dr. Hymes is a nationally recognized expert on skin problems after transplant and a clinical consultant at the University of Texas and MD Anderson Cancer Center in Houston, Texas. Recently retired, she spent most of her career at the MD Anderson Cancer Center serving as the Associate Medical Director of the Melanoma and Skin Center. In addition, Dr. Hymes has been an integral member of the MD Anderson Chronic GVHD Clinic. Dr. Hymes' work has focused on skin GVHD, as well as all skin problems that occur in the setting of stem cell transplantation. Please join me in welcoming Dr. Hymes.

(00:58): [Dr. Sharon Hymes] Overview of Talk. Thank you very much. I'm very pleased to be here. I'm going to talk a little bit about protecting your skin after transplant and we'll get started right now. I have no relevant disclosures. So, the learning objectives of my talk are threefold.

(01:17): Number one, we're going to talk about some potential skin problems that can develop after a hematopoietic stem cell transplant. And I had a lot of these to choose from, but I decided to go with the questions that are asked to me most often. One of them is about dry skin after transplant, hair loss, photo sensitivity, or sensitivity to sunlight, drug rashes, viral rashes. And I'm not going to spend a lot of time on Graft Versus Host Disease, since I just spoke about that on Tuesday.

(01:48):  The second area I'm going to address is benign pre-malignant and malignant skin lesions that can be seen after stem cell transplantation. And the third is strategies that we can use to reduce the risk of developing skin cancers. So, again, in summary, the first thing I'm going to talk about is potential skin problems after transplantation. And this is the order that I'm going to talk about them in.

(02:19): Dry skin is a major complaint after transplant. So, dry skin, lots of complaints about dry skin after transplantation. That can be related to a lot of things, including the medications that you receive, hospital soaps or soaps you're using at home, or even changes in bathing habits. And it often presents with itchy skin, scaling or dryness. And occasionally you can kind of see the red skin that I'm showing in the picture on the right, amidst all this scaling and dryness of the skin.

(02:52): So, what's the treatment of this? So, in dermatology, we have sprays, we have lotions, we have creams, and we have ointments. And especially with the lotions, the creams, and the ointments, those terminologies are dependent on the amount of water incorporated in the product that you're using.

(03:16): Transplant recipients with dry skin should try creams and ointments under wraps but avoid lotions which may burn. Anyone with normal skin can use lotions. There's a lot of water incorporated in it. It feels good when you put it on, but when you start having problems with very dry, red skin, lotions can actually burn. And we'll tell patients to go ahead and proceed with creams and ointments. We ask them to use usually hypoallergenic and non-scented creams.

(03:39): Topical steroids may be another option for dry skin. Occasionally, if skin is very dry, we'll say, "Apply the creams or ointments under occlusion," which means under wraps. And that could be putting gloves on your hands after you put the creams on, or even putting some kind of cellophane wrap around the area to make sure that, that cream or ointment is incorporated in. And when we start seeing the red skin, like we're seeing in my picture to the right, that may respond to a variety of topical steroids. So, if you're not getting better with plain creams, you might consider talking to your physician about using topical steroids.

(04:18): Hair loss after transplant can be scarring or non-scarring. The next topic I'm going to talk about is hair loss. I get a lot of questions about hair loss. This is a little cartoon diagram of the skin. The very top layer is the stratum corium, which is the scaly area of the skin, followed by the epidermis, which is the brownish area in this balloon diagram. Where I have the arrow, it's pointing to the dermis and in the dermis are most of our hair follicles. Underneath this, even thin people have a layer of fat. It's the fatty layer. So, when we see hair loss, it's usually something impacting the hair follicle that's sitting in the dermis. And we divide it into two types of hair loss. We divide it into a non-scarring hair loss, which means you're not losing your hair follicles, versus a scarring hair loss, where you're actually losing your hair follicles.

(05:14): Chemotherapy, radiation, stress, and illness can cause non-scarring hair loss but it usually comes back with time. Well, what are the most common causes of a non-scarring, alopecia just means hair loss. Chemotherapy and radiation are very common causes of non-scarring alopecia. It usually commences about two to four weeks after starting chemotherapy or radiation treatment. And it usually is completely reversible, although some people say, "My hair is a different color, it's curly and it had been straight before" probably because of the impact on the hair follicle. But the hair usually comes back. There's a small subset of people where the hair does not completely come back and a little bit more on that later.

(05:59): Stress and illness can sometimes cause a temporary loss of hair. So, of course, post-stem cell transplant, there are a lot of stressors. And a few months after these stressors happen, either you had a high fever or a systemic illness, you can temporarily thin or lose hair. And that also, almost always comes back again.

(06:23): If you get this kind of hair loss, which is very common, basically it's a matter of watchful waiting to make sure the hair comes back again. Make sure you have minimal hair trauma. So, you're not pulling on your hair, using hot combs, minimal scalp trauma. And because you then you have lost your hair, we try to prevent excessive UV exposure or sun exposure to areas that don't have hair, but usually the hair will come back almost normally after this happens.

(06:59): Scarring hair loss means the follicles are lost and hair won’t grow back. So, scarring alopecia is another kind of hair loss. Scarring alopecia is characterized by actual loss of the hair follicle. And if you look at this diagram that I have, this picture I have on the right, you'll see that there isn't the typical density or distribution of hairs in this area. It may be characterized by scale. It may be characterized by scar that's visible only by pathologic examination, by taking a biopsy. And when we see this post-transplant, we start looking specifically for infection. So, we may do some cultures of the hair or the hair follicle, or it may be secondary to graft-versus-host disease. And I spent a lot of time talking about that on Tuesday, So, I won't belabor that.

(07:51): It's important for us to diagnose and treat this early, because once you scar the hair follicle, it's like a scar elsewhere. You lose the integrity of that hair follicle, and you won't always grow hair. I know people are going to have a lot of thoughts about alopecia, because I know this is something most people go through, but we're going to move on because I have a broad variety of things to talk about.

(08:18): Increased sensitivity to sun and light can occur after transplant. And the next thing we're going to talk about is photosensitivity. And this slide really should say photosensitivity. Be aware that after transplant, you might have increased sensitivity to sunlight, and that can be manifested by exaggerated sunburn or rashes in sun exposed areas. And factors that can exacerbate, or make this worse, is if you're a light-skinned individual. So, I call that skin pigment, but lightly skinned pigmented individuals tend to sunburn more easily. And if they've got on board other factors that make them photosensitive, they may get pretty severe burns.

(09:00): There are multiple medications that you receive post-transplant that can make you more for photosensitive. And so, you'll be asked to use photoprotection. And I'm going to address that at the end of the talk. And then medical issues like graft-versus-host disease can make you more photos sensitive, or connected tissue disease, like lupus erythematosus. And we can't always prevent the photosensitivity, but it's key that you use photoprotection. And we'll talk more about that at the end.

(09:38): Rashes are common after transplant. People should keep a drug diary to help identify the cause of rashes. Let's talk a little bit about rashes that we see after transplant. So, rashes are more common after transplant and especially drug-related rashes. Stem cell patients are often on multiple new medications. It's important to know that drug rashes start usually, with some exceptions, days to weeks after starting a new medication. Therefore, I think it's very important to keep a drug diary of all the start dates of your medications. And people will say, "Oh, I've had that medication before. I shouldn't get a rash," but re-exposure to a medication can absolutely be associated with a drug rash. So, even if you weren't allergic, say to penicillin, you haven't had it for a while, you get put in on it again, you may develop a drug rash to that penicillin.

(10:33): The rashes are often red and itchy and they can become very widespread. So, even if we identify the right drug, "Oh, you have a penicillin drug rash," for example, they tend to go through their complete cycle. So, even if we stop it within days, you still may get worsening the rash for several weeks after stopping the medication.

(10:58): So, on the right over here you'll see two drug rashes. The rash on the upper right shows red bumps that are becoming joined together or confluent. The rash down below looks more serious, but really isn't. If your platelets are low, you may actually bleed into the skin, bleed into these drug rashes, So, you get these red areas that don't disappear when you press on them. So, drug rashes may simply be a nuisance, but some clearly become more serious.

(11:34): Nuisance rashes merely itch but more serious ones can blister and become painful. Most drug rashes itch, but more serious drug rashes become painful. You may develop blisters, and any blister you develop in this setting should be recognized and should be related to your physician. They may also involve the mouth, the eyes or other mucosal surfaces. And if that happens, that also should be related to your physician.

(12:01): Rashes may be caused by drugs, viruses or graft-versus-host-disease (GVHD). Drug rashes may be very difficult to distinguish from the rashes caused by viruses or by graft -versus-host disease. And that's very important because when I see a rash like this, I will ask your drug history, but I may tell you that without further investigation, I cannot tell if that's a drug rash or a rash related to graft -versus-host disease. And sometimes we'll even ask for a biopsy to see if we can help distinguish it.

(12:31): So, I'm going to move on to rashes caused by viruses, and in the bottom, right, you can see a very faint red rash. That could be a viral rash, and it was in this case. That also could be GVHD. That also could be a drug rash. So, it's very important to be able to relate the history, and for us sometimes to biopsy, to see if we can identify what caused that rash.

(12:59): Herpes simplex or herpes zoster viruses are a common cause of rashes. One of the most common viral rashes and easily recognizable ones we see are related to herpes simplex and herpes zoster viruses. So, herpes simplex viruses cause cold sores, what's commonly called fever blisters or cold sores. And they're very distinct. So, look on the top left and that is grouped blisters on a red base. And that's very classic of a herpes simplex infection. Many of you who will be placed on prophylaxis medications to prevent these from breaking through. When these group blisters follow a linear skin line, that's very characteristic of herpes zoster, or shingles. And again, very important to relate to your provider, because these are treatable infections.

(13:56): Bacterial infections can also cause rashes. I'm going to move along from rashes related to viruses to rashes related to bacteria. So, when you are immunosuppressed after transplant, you are more likely to get infections, and bacterial infections in the skin can be demonstrated in two ways. Immunosuppressed patients can develop these infections that start in the blood and go to the skin. And the top picture is a picture of an infection that's in the blood and then is causing little dark areas on the skin, where it's actually killing the top layer of skin. So, when we see something like this, we're going to be looking in the blood to make sure there's not an infection. And we may actually take a biopsy of that skin, to see if we can identify what microorganism is causing that.

(14:51): Immunosuppressed people may have infections that go into the blood and require early treatment. Sometimes immunosuppressed people and non-immunosuppressed people develop infections in the skin primarily. And the bottom picture is some honey yellow crusting that's characteristic of impetigo, which is an infection of Streptococcus and Staphylococcus. And sometimes if you're immunosuppressed, those infections can go into the blood. So, we tend to try to identify those early and treat them early.

(15:21): Warts are common after transplant, particularly for people on immunosuppressive drugs.  So, that's my infectious part of my talk. I'm going to go on now to skin lesions that are non-cancerous seen after transplantation. So, there are multiple non-cancerous skin lesions that are more common after transplantation, but I wanted to bring up a very common one. And that's warts. Warts are actually caused by a virus, they're caused by the human papilloma virus. And they're probably more frequent when you're immunosuppressed. And on the left upper picture, I'm showing a hand with multiple light-colored bumps. Those are all warts. And the bottom picture is showing the peri-rectal lesion, which is also a peri-rectal wart. Sometimes these will spontaneously resolve as the immune system reconstitute.

(16:21): Warts can occur anywhere on skin. They are contagious. So, we tell people don't pick, or squeeze, or mess with them. They're often multiple and occasionally we'll biopsy a wart to make sure there's no malignant potential.

(16:37): Warts caused by genital human papilloma viruses can develop into cancer. There are some kinds of human papilloma virus, especially with genital human papilloma virus, which have pre-malignant potential for developing squamous cell carcinoma. So, sometimes we'll actually biopsy those.

(16:50): How do we treat them? We treat them by usually destruction. We'll often use cryotherapy with liquid nitrogen, which is at minus 320 degrees, we'll actually freeze them off. The patients perceive them as being burnt off and they may recur after that freezing. There are other ways to destroy them with heat. Sometimes we use topical creams, but they often recur, especially in patients that are immunosuppressed. So, that's a non-cancerous lesion we see after transplantation. There are others, but in the interest of time, I'm trying to take the most common ones.

(17:33): Some skin lesions, such as actinic keratoses (aka solar keratoses) can develop into skin cancer. Let's talk a little bit about pre-malignant lesions. The pre-malignant means they have a possibility, a higher possibility than a normal lesion, of developing into a skin cancer. So, the one I'm going to spend some time on is called an actinic keratosis. Some people call them solar keratoses. I have my little diagram of the skin and these solar keratoses develop in the base of the epidermis, the top layer of skin. And they're characterized by the proliferation of atypical keratinocytes. Keratinocytes are the cells that make up the epidermis.

(18:14): How do we see them? We see them as scaly red spots on the skin. And if you look at the hand in the diagram, you see lots of scaly red spots over the dorsal of the hand. If we see them on the lip, and you can see the bottom layer of the lip, and this is very common in men, to see it in this area, we call it actinic cheilitis. Now a small percent of these progress to squamous cell carcinoma of the skin. And so, therefore we try to treat them and I'll talk a little bit about that in a minute.

(18:49): Sun damage, radiation or light-colored skin or hair increases the risk of pre-cancerous lesions. What puts you at risk for this? Sun damage. People who have outdoor occupations, goes along with sun damage. People who have received radiation, people who are older and individuals basically with light colored skin and hair.

(19:10): Liquid nitrogen is often used to destroy actinic keratoses.  How do we treat these actinic keratoses? Well, on the top left, you see individual lesions that are red and scaly. We usually try to destroy those. And the most common thing that dermatologists use to destroy them is the liquid nitrogen cryotherapy that I mentioned earlier.

(19:30): Topical creams, such as 5 Flouracil cream, are used to treat actinic keratoses that affect a large area of the skin. Now look at the side of the face on the far right? That whole area is an actinic keratosis. So, I cannot freeze a whole area of the face. So, we treat a larger area or field of skin. We use what we call field therapy. There are multiple topical creams that we use for field therapy. The most common one is a topical chemotherapeutic drug, but topical means we just use it on the skin, and that's 5 Fluorouracil cream. When we apply it, if you look at the hands on the bottom, it is like a smart bomb. It goes after the abnormal cells, leaves the normal cells alone. It turns them red. It causes crusting and then they peel off. And we can get rid of a lot of them by using this field therapy. However, the predisposing causes for developing actinic keratosis are still in effect, So, we don't say you're cured of them. We say, "We've got them under control, and we may use this again."

(20:37): Photodynamic therapy, also called blue light therapy is sometimes used to treat actinic keratoses. Sometimes we use topical chemical peels, and sometimes we use something called photodynamic therapy or blue light therapy, which involves putting a cream on the area that gets activated by a blue light. And in Europe, it's a red light. In United States, it's a blue light and it peels those pre-cancers off. And that's called photodynamic therapy.

(21:08): Several types of skin cancer can occur after transplant. Let's move on to cancers. So, this is what we're trying to prevent. And I'm going to talk about basal cell skin cancers, squamous cell skin cancers, and melanoma. The basal cell skin cancers develop from the basal cells of the epidermis. They're the most common skin cancers that we see. They usually do not metastasize. They're just locally invasive. And the aggressive behavior of these tumors is dependent on what we see in the pathology and also, sometimes on how immunosuppressed the patient is.

(21:45): Risk factors for basal cell skin cancer. What are the risk factors for basal cell skin cancer? Lighter skin, lots of sun exposure, radiation, some chemical exposures, genetic syndromes, which are rare, and immunosuppression.

(22:01): So, what does a basal cell skin cancer look like? It can look like a lot of things. And I have a picture here. The most common way they look is the upper right, which is a pearly shiny bump with little blood vessels called telangiectasis that you can see on the surface. The inner left one shows a persistently red scaly area. The one on the forehead is, actually, white. So, sometimes they can look like scars, but this one was scaly and bleeding and prompted a biopsy. Or they can even be dark colored, like the one on the bottom right. So, they can look in a lot of different patterns.

(22:44): They're usually very slow growing, but you don't want to just watch these, because they can become very large, like the one on the back on the left. And they can also become very deep and destructive to the skin, like the lesion on the scalp on the right. So, we try to diagnose these and treat them early.

(23:04): How is basal cell skin cancer diagnosed and treated? How do we diagnose them? We skin biopsy them in many different forms. This is called a punch biopsy, where we take a little core of skin and we do it right at the bedside. And we put a little stitch in there, or we just let the area heal and we can make the diagnosis.

(23:21): How do we treat it? It really depends on the size of it, where it's located and what the pathology shows. Sometimes we destroy them by freezing, or burning, or lasering, or chemicals, or even the 5 Fluorouracil cream that I showed you. But often we cut these out with surgery.

(23:43): Squamous cell carcinoma can be more aggressive and require surgery. I'm moving on to squamous cell carcinoma. And I won't enumerate this. Very similar risk factors to basal cell carcinoma, only adding human papilloma virus, which there's certain kinds of human papilloma viruses that make you more prone to squamous cell skin cancer.

An invasive squamous cell skin cancer is usually in a sun exposed area. It can present as a red bump or a plaque, which is a large, raised area like the picture on the far right. It can present on the lip and this patient has many actinic keratosis on the bottom right, but that's a skin cancer on the lip. And it can actually present as an ulcerated nodule, like the lesion in the ear that you see on the bottom left.

(24:40):  We do a skin biopsy for diagnosis and the treatment, again, depends on the size, the location, and pathology. We more commonly do surgery because these can be more aggressive than the basal cell carcinomas.

(24:57): Melanomas diagnosed by looking at the asymmetry of the lesion, irregular borders, the color, the diameter and size, and the evolution. I know I'm going a little quickly, but I want to cover a lot of things for you. So, we're going to talk a little bit about melanoma. Melanomas arise from the pigment cells that sit in the base of the epidermis at the dermal, epidermal junction. And we identify them, we always talk about the, A, B, C D, E's of identifying melanoma.

(25:22): A stands for asymmetry, which means that if I look at this lesion on the thumb and I fold it in half, I don't see a symmetrical outline on both sides. The borders tend to be irregular. And if you can look at this lesion, you can see that there's little rounded areas that are extruding from the lesion. The color. The color doesn't seem to be uniform, as you can see in this lesion. The diameter, which is the softest of all signs, which doesn't always apply, usually is greater than six millimeters. And the most important thing I think for melanoma is E, evolution or enlargement. So, even if you have a small lesion, if it's changing, you ought to get it checked.

(26:09): I'm going to just spend a minute more in evolution, because I think it's So, important. So, evolution means if you have a new spot, the patient on the bottom had a brand new brown, black spot. That really is not asymmetric, is not very large, is not irregular, but it was new. And this was a melanoma. The lesion on top also evolved. It became itchy. It was burning and it was starting to bleed. And this was also a melanoma.

(26:41): Routine skin screenings as well as self-examination are essential to detect and treat melanoma. So, how do we screen for melanoma? I think that everyone should disrobe at routine provider visits, So, your provider can look at your skin. Consider, especially after transplant getting routine skin screening. The American Academy of Dermatology offers a free annual screening event all across the country, which you can look for if you don't have a private dermatologist. There are many community events that offer skin screening. And it's very important to do your own examination of your skin. Self-examination picks up many melanomas, basal cell and skin cancers.

(27:25): There are several risk factors for melanoma including use of tanning beds or excessive ultraviolet light exposure. Who is at risk for melanoma? If you have a family history of melanoma, and this is a small risk, not a huge risk, but these are risk factors. If you have many moles, if you have a personal risk of melanoma, you've had one, you're more likely to get another one. Patients who have light skin and eyes are more at risk. However, darker skin individuals absolutely can develop melanomas. People who have gone to tanning beds or have excessive ultraviolet light exposure. People who have atypical looking moles, patients with radiation therapy, immunosuppression, or who are older.

(28:06): And be aware that melanoma doesn't just occur on sun exposed areas. It can occur elsewhere, especially in darker skin individuals. There is melanoma of the toe in the top left diagram, melanoma of the scalp in the top right diagram. And this melanoma in the bottom was actually inside the mouth. And that's where it started and then spread to the outer lip. So, when in doubt, you have a new skin lesion, see your provider, or your doctor, or your dermatologist.

(28:41): Sun protection or photoprotection is crucial after transplant. I'm going to close by talking a little bit about how you can protect your skin. And I think photoprotection is exceedingly important post-transplant. So, I'm going to spend a little time on this.

(28:56): So, important. At least one in five people will be diagnosed with skin cancer and this is without the setting of stem cell transplant. The annual incidence of skin cancer in the U.S. is over three million. Ultraviolet radiation, including indoor tanning is an initiator and a promoter of non-melanoma skin cancer and melanoma.

(29:28): Ultraviolet radiation can cause sunburn, lasting sun damage and skin cancer. So, let's talk a little bit about ultraviolet radiation. The two types of ultraviolet radiation pertinent to my talk are UVA, ultraviolet A radiation, which is 320 to 400 nanometer and ultraviolet B radiation, which is 290 to 320 nanometers. Ultraviolet B radiation is the type of sunlight that gives you the sunburn. It can give you hyper pigmentation or dark pigmentation of your skin. It causes skin cancers, which is what photo carcinogenesis means. And it also causes photo aging, wrinkles, et cetera. It's partially absorbed by the ozone layer, but about 5% of UV light reaches the skin surface. If you look at my diagram on the right, it reaches pretty ... it goes through the epidermis and just reaches to the top part of the dermis.

(30:26): Ultraviolet A light on the other hand reaches much deeper. It's responsible for hyperpigmentation, which means darker pigment, causing skin cancers and photoaging. Interestingly, if you go to tanning beds, they're giving you UVA radiation because you don't sunburn, but it causes definite sun damage. If we photo protect, we anticipate we're going to see fewer sun skin cancers.

(30:55): Everybody needs photoprotection , particularly light-skinned people, those with a history of pre-cancerous or cancerous skin lesions and children.  So, who needs photoprotection? Really everybody needs photoprotection. Light-skinned individuals who easily sunburn probably need it even more. If you have a history of precancerous or cancerous skin lesions, you need it. Children should get photoprotection. People who are immunosuppressed and on chemotherapy, because they're more prone to get skin cancers and pre-cancer, should use photoprotection. Same with patients who have had radiation therapy.

Photoprotection is important in patients with graft-versus-host disease, because they tend to be more photosensitive. Patients with lupus and connected tissue diseases. There are some rare patients that have genetic photosensitivity disorders, and there are some medications that you receive like Voriconazole post-transplant that can make you more prone to photosensitivity.

(31:50): Sunscreens, protective clothing, and limiting sun exposure are all important. So, I have to emphasize that it's really just the easy, common-sense things that are important. Avoid midday sun. Cloudy days have significant photo exposure, So, protect your skin even on cloudy days. Use protective clothing. That means sunglasses and hats, and your hat should have at least a three-inch brim. Use clothing with a tighter clothing weave. Darker clothing, although I know it's hotter, tends to have better photoprotection. There are substances you can add to your wash cycle that make your own clothing more photo protective.

(32:30): I think physical sun protection with clothing is of foremost important. However, sun blocks and sunscreens also play a very important role. So, we're going to talk about sun blocks and sunscreens. And I know that there have been a lot of questions about those. So, when you have, and I'm speaking in the United States, the labeling's a little different in Europe, but when you see SPF, that means sun projective factor. And all it's telling you is it compares the time of redness of your skin with sunscreen applied versus redness of skin without sunscreen.

(33:12): Sunscreens are only effective if you apply the right amount before going out in the sun and reapply it every few hours. So, for example, if you go out and you burn in 10 minutes, then an SPF of 10 will theoretically keep you from burning for a hundred minutes. That's all SPF means. And it's only referring to UVB light. In the States it does not usually refer to UVA light. And that SPF is only accurate if you apply the correct amount of sunscreen. That's a lot of sunscreen, at least one ounce or shot glass of sunscreen is what they're measuring. You're supposed to apply at 15 to 30 minutes before sun exposure, and you're supposed to apply it every two hours. And it also means that you're not swimming or sweating, hard to do, and that it's not outdated. There's an expiration date on sunscreen. And that it's applied correctly.

(34:08): Use an SPF of least 30. Again, keep in mind, SPF refers to UVB protection, not UVA protection. So, when you buy a sunscreen, you're going to look for something on there that says broad spectrum SPF. What that means is somewhat protective against UVA light. And we know UVA lights is important in causing photodamage and promoting skin cancers. Try to use an SPF of at least 30. Look at the expiration date on your tube. Don't store it in the sun. And remember, no sunscreen is waterproof, only water resistant or very water resistant.

(34:51): There are many different types of sunscreen on the market. What kind of sunscreens are on the market? Well, we have chemical sunscreens, which are also called organic filters .and these absorb the sun rays. And I'm not going to go through all the ingredients in the interest of time, but there are about 14 different chemical sunscreens approved in the United States. And then we have physical sunscreens, which are the mineral sunscreens or inorganic sunscreens, and they act like a shield. They deflect the sun rays. They're usually either titanium, dioxide or both. They tend to be hypoallergenic, but unfortunately older formulations were cosmetically inferior. They're white and sticky and people don't like them.

(35:36): Mineral sunscreens with inorganic filters are the safest choice. The question people always ask me, "Are sunscreen safe?" The mineral sunscreens, or the inorganic filters, have excellent safety profiles. The chemical or organic filters...randomized trials show some absorption, but for now, recommendations for their use remain the same. And I put this in for completeness that some of the UV filters are found to have estrogenic effects in animal models. It's not clear if it's applicable to humans, some cause coral reef bleaching. And so, they recommended not to be used. Very often you'll see organic and inorganic sunscreens combined. And I would caution you about combining sunscreens and other things, like insect repellents.

(36:25): Bronzers don’t protect against sunburn. I'm not sure if we have time. I think I'll just mention this, that there is sunless tanning and you've probably seen bronzers on the market or sunless tan lotions. They have dihydroxyacetone in them. Just be aware that they don't protect against sunburn and a small amount will be absorbed. Bottom line is it is very important post-transplant to use sunscreen. I think you could tell ... use sunscreen or photoprotection. So, let me end right now.

(37:02): Conclusion. I went through the types of skin problems that might develop after stem cell transplant, including dry skin, hair loss, photosensitivity, and rashes. Didn't spend a lot of time on graft-versus-host disease, because we spoke about that on Tuesday. I spoke a little bit about the pre-malignant and skin malignant lesions you can see after transplant and some strategies that reduce your risk of skin cancer. And I spent most of the time on photoprotection. So, I'll end there and answer any questions and thank you very much.

Question and Answer Session

(37:41): [Steve Bauer] Thank you, Dr. Hymes for this excellent presentation. We will now take questions.

Our first question is, "I have GVHD of other organs, but not skin. Do I have to find a dermatologist that specializes in GVHD or can I just find any good dermatologist? I am eight years out and have not been to any dermatologist in probably 30 years."

(38:19): [Dr. Sharon Hymes] Great question. If you do not have GVHD of the skin, I think any qualified board certified dermatologist is where you should go. I would tell them you've been immunosuppressed. You need a complete skin examination. And then depending on what they find on your skin, they will make recommendations for how often to follow up.

(38:40): [Steve Bauer] All right, thank you. Next question is, "SPF at all times of the year, or can you avoid it in winter in colder climates? Is any vitamin D made with SPF 70? If not, how often should vitamin D levels be checked?"

(39:00): [Dr. Sharon Hymes] That's an excellent question. And I knew somebody was going to answer that, because we've had an ongoing discussion with our endocrinologists whether we forbid some exposure or not. So, as far as the intensity of the ultraviolet, it's clearly more intense in some seasons than in others. Cold is not the factor. It's really the intensity of the UV exposure. So, we recommend at least photoprotective clothing all year round, including winter. Now, do you have to put any kind of SPF sunscreen on areas that are not exposed? Absolutely not.

(39:41): There are some dermatologists and some endocrinologists that'll say, "If you go out twice a week for 20 minutes, that's enough sun exposure. You don't need more." I certainly don't think 20 minutes twice a week is going to make any difference, as far as skin cancers, et cetera. But I think people don't go out for 20 minutes. They don't realize how long they've been out. They get a lot more sun exposure than that. That being said, I live in Houston. I recommend year-round sun protection, and I really emphasize protective hats, protective clothing for that kind of thing.

(40:19): How often should your vitamin D level be checked? Depends on the person and the age of the person. We know as we get older, our vitamin D levels go down. We also know you don't have to get very much sun to get those vitamin D levels up, but I would suggest getting a baseline and then your primary care physician continue from there, how often it needs to be checked. And we also know that vitamin D is easily replaced with oral supplementation. So, I don't think going out and sunning yourself is the way to get vitamin D.

(40:58): [Steve Bauer] Thank you. "In your slide photo, you showed warts on a hand. Can you have HPV warts on your hand? Does this mean HPV appears because one's immune system is not fighting off the HPV?"

(41:14): [Dr. Sharon Hymes] So, that's a great question too. So, I want to tell you that we see so, many warts, non-immunosuppressed people and kids. Kids have warts all the time. And most adults have had a wart at some time. So, we see more of them that are difficult to treat in patients who are immunosuppressed, but non immunosuppressed people can absolutely get warts. And I think of it kind of like the wart's not doing any harm, it's just living with you and that's what it does in children. It just kind of lives with you not doing any harm.

(41:49): It's just that they're much harder and more persistent, often, if you're immunosuppressed. And that's why sometimes when the immunosuppression is reversed, they tend to go away by themselves.

So I hope that answers your question. And warts are, by definition, caused by human papilloma virus. And most human papilloma viruses are not pre-malignant. Most of them are not. Occasionally they are and that's why with genital warts, sometimes we're biopsying them to make sure that they don't have a pre-malignant form of the genital wart.

(42:27): [Steve Bauer] Thank you. Next question is, "What is the difference between sunblock and sunscreen and which do you recommend?"

(42:36): [Dr. Sharon Hymes]  So, usually the sun blocks refer to the physical blockers, which are zinc and titanium. The sunscreens refer more to the chemical sunblock that I showed you, but some people use those two terms interchangeably. There are advantages to both. At this point in time, because of them being more hypoallergenic, I tend to like the sun blocks better.

Many people don't like the blocks, the titanium and the zinc, because they still tend to be kind of white and pasty, and you really have to rub them in. There are some combinations, there are sun blocks, sunscreens that are combinations of the two entities. I hope that answers it.

(43:36): [Steve Bauer]  Okay. Next question. "What role does menopause and lack of estrogen play in skin cancers and issues? How can I best take care of these issues without resorting to hormone replacement therapy?"

(43:50): [Dr. Sharon Hymes] So, I would never say that you have to resort to hormone replacement therapy to prevent skin cancers. As we get older, and of course, as we get older, we go through menopause, we are also more prone to get skin cancers, but it doesn't mean that one's causal of the other. So, using hormonal replacement is not indicated to prevent skin cancer.

(44:17): [Steve Bauer]  It says, "Rashes on the mouth, eyes and mucosal areas of any idiopathic origin also include genital areas of women, such as vaginal or labia."

(44:30): [Dr. Sharon Hymes] I'm not sure I understand that question. I think they're referring to mucosal rashes. So, mucosal rashes, usually our eyes, inside the mouth and it can be inside the vagina too. So, when we have, I think you're referring back to my section on drug rashes, when I said sometimes the more severe drug rashes can be on mucosal surfaces. I'm guessing that's what you're referring to and graft-versus-host disease can also occur in those areas.

(45:02): [Steve Bauer] "My biopsies indicate that I have GVHD of the skin and a skin disorder. It's been difficult to find the best treatment. I am undergoing UVB narrowband using topical steroids and vitamin D cream. And the healing has been really slow and uneven, causing reoccurring inflammation. Are there any other therapies that can help?"

(45:26): [Dr. Sharon Hymes] So, again, I don't know your particular case. I'm assuming that you have chronic graft-versus-host disease, not acute graft-versus-host disease. And it also then matters what type of skin GVHD you have. So, GVHD can be very superficial, involving the epidermis and the dermis, and it can be deeper and sclerotic like a scleroderma type GVHD. So, your treatment's really going to depend on the type of GVHD you have. I'm assuming if you're getting narrow band, you have the more superficial kind of GVHD and there are many different ways to treat that. However, sometimes when your doctor resorts to narrow band UVB, it's because they're trying to avoid further immunosuppression.

(46:23): [Steve Bauer] Thank you. "I've had horrible, chapped lips since my first series of chemo in August and before transplant, which was in November. I've tried Vaseline as well as other ChapStick, nothing seems to work. What would you recommend?"

(46:41): [Dr. Sharon Hymes] So, although it can happen that you get very chapped lips, and what happens when people get chapped lips is they tend to become lip lickers. They tend to always try to moisten up their lips and lick it. And it makes the chapped skin worse.

Sometimes chapped lips aren't just dry lips. There are a couple of other possibilities that come to mind, and it may be that you need to go to your dermatologist to see. There are some people who actually develop a contact dermatitis on their lip from the things they're putting on it to treat the original chapped lip. So, you want to make sure that you're not actually making it worse by putting ChapStick on or whatever compound you're putting on there.

Very rarely you can get graft-versus-host disease that presents as chapped lips. And sometimes if you have chapped lips, especially in men, in the lower lip, we're looking at actinic or sun produced changes and it's not chapped lips at all. So, for this one, I think I would go to your dermatologist, with these different diagnoses in mind, and have them tell you which one they think it is.

(47:53): [Steve Bauer] Okay. "As a result of transplant, I have hospital acquired infection causing blisters on my head. I control it with [inaudible 00:48:03] and alcohol, both ethanol and isopropyl, but cannot get rid of it now after a year. Any advice?"

(48:13): [Dr. Sharon Hymes] So, I'm going to have to kind of extrapolate from the question. So, I'm thinking that what you're asking is that you have these areas of blisters are actually caused, are the infection. So, if they are the infection, it becomes important to identify the organism that's causing the infection. And once the organism is identified, then I think you can specifically treat for that organism. So, it sounds like you're using antibacterial therapy, which is of course plays a huge role. But the question is, is there actually an organism that can be addressed?

(49:01): [Steve Bauer] Okay. "Some facials for beauty purposes use laser treatments. Are these safe to have without triggering GVHD or risking skin cancer?"

(49:11): [Dr. Sharon Hymes] That's an excellent, excellent question. I get asked about a lot of cosmetic procedures after transplant. So, there are many, many different kinds of lasers and many different skill levels in the individuals using the laser. So, we tend to prefer the lasers that are not ultraviolet light. I personally, if you have a dermatologist, would speak to your dermatologist about what lasers or whomever is giving you the laser treatment, what lasers are being used. And I would avoid ultraviolet lasers. I also tend to avoid any lasers while somebody's still immunosuppressed.

(49:59): [Steve Bauer] Okay, next question. "I have a dark skin. How do I know if I'm overexposed with a risk of sunburn?"

(50:08): [Dr. Sharon Hymes] Well, it has to do with your own history. You know yourself when you go outside, do you always burn? Do you never burn? Does your skin darken, but not burn? So, after transplant, you'll stay true to that pattern, except if you're given photosensitizing drugs. And that's why I spoke about photosensitivity, or you develop graft-versus-host disease. So, you should stay true to that pattern. And pretty much everybody, I think who's immunosuppressed after transplant should practice some photoprotection.

(50:49): [Steve Bauer] Okay. "Should leukemia patients avoid skin products with benzene, because benzene causes leukemia? Is white petrolatum safe?"

(51:00): [Dr. Sharon Hymes] So, I knew somebody was going to ask me that question, because of the news about sunscreens containing benzene, probably as a manufacturing contamination. I think everyone should avoid products if they can with benzene. Unfortunately, benzene is in a lot of products. To my knowledge, white petrolatum is safe to use. Most of the benzene with sunscreens were in the spray sunscreens. I personally have never favored spray sunscreens. They're very unpredictable. You can inhale them. And I tend to tell people to avoid them, but benzenes in any level are probably not advisable.

(51:45): [Steve Bauer] Thanks. "What if you have acne and get aggravated acne with sunscreen?"

(51:53): [Dr. Sharon Hymes] Yeah. That's a very good question. On sunscreens on the labeling of sunscreens they'll also say non-comedogenic. Non-comedogenic means does not cause acne, doesn't apply to everybody, but it's a good sunscreen to choose. Some people cannot tolerate sunscreens at all, because of acne problems or because of irritation. And that again, encourages us to use physical sun protection. Wear a big broad hat, carry a sun umbrella. So, if you absolutely cannot use sunscreen, make sure that you're using photoprotection.

(52:40): [Steve Bauer] "What can be done for hair loss with GVHD? I've heard that triamcinolone and Rogaine can cause hair regrowth."

(52:54): [Dr. Sharon Hymes] So, it depends why you have the hair loss. So, graft-versus-host disease can cause a scarring hair loss, and it can cause a non-scarring hair loss, it can cause both. So, it's important to identify why you have the scarring. If it's from a non-scarring hair loss, triamcinolone is a topical steroid that can be used. And we use that, sometimes we use a stronger steroid. We actually sometimes go in with a needle with the steroid, because the topical steroids don't go down very deep. And I showed you the little cartoon of the skin, the hair follicles do. And we'll inject steroid into areas with graft-versus-host disease.

The other thing was Rogaine. It was Rogaine. Rogaine is topical minoxidil. Topical minoxidil is approved only for genetic pattern baldness. Sometimes we'll use it in an attempt to encourage the hair to grow in that area, but it's an off-label use of it.

(54:13): [Steve Bauer ] Thank you. "I am a 20-year survivor BMT, 2002 allergenic full match sibling donor. Had severe shingles, 2004, chronic GVHD, 2004, of eyes. Skin problematic recently. Zoster caused irritation, rashes. What is the treatment? I do not want the shingles vaccine."

(54:39): [Dr. Sharon Hymes] Well, first of all, congratulations to you. I know you've been through a lot, but it sounds like you're way past your transplant. So, the question is, are you getting zoster again? So, if you're ... there's two parts of this question. So, if you're getting zoster again, you need to be treated for zoster. And some patients remain on prophylactic treatment with antivirals indefinitely, because they're prone to herpes simplex or prone to herpes zoster.

So, at MD Anderson, we do give the shingles vaccine to patients. I'm not sure why you don't want it, but I'll assume that you're not going to take it. If you're getting zoster irritation, you need to make sure, number one, you don't have active zoster and I would go to your doctor to get treated for if you do. Some people get prolonged problems with rashes, where they have had zoster and they get prolonged pain where they've had zoster. And there are a lot of treatments available for that. And usually that's done at pain management centers, So, that might be some way to approach it.

(55:55): [Steve Bauer] Thank you. So, we are about out of time. So, I only have one last question. "Is Vaseline ointment or any white petroleum product safe?"

(56:05): [Dr. Sharon Hymes] Yes. To our current medical knowledge, they are safe. I know there are some people that don't want to use anything that's a petroleum product. And for those people, I also tell you to use things like Crisco on your skin for dry skin. We see some allergic reactions with coconut oil, but you can use coconut oil. You can use a more "natural" substance on your skin, if you prefer. There are some people that don't want to use these products, but to our current medical knowledge, they are safe.

(56:42): [Steve Bauer] Closing. On behalf of BMT InfoNet and our partners I'd like to thank you, Dr. Hymes for your very helpful remarks. And thank you, the audience for your excellent questions. Please let BMT InfoNet know if we can assist you in any way.