How to Protect Your Skin after Transplant

  Download Speaker Slides  

How to Protect Your Skin after Transplant

April 27, 2024

Presenter: Silvina Pugliese, MD,  Clinical Associate Professor of Dermatology, Stanford Cancer Institute

Presentation is 41 minutes long with 16 minutes of Q & A

Summary: Bone marrow/stem cell transplant survivors can experience a number of skin problems after transplant. Monitoring yourself for skin abnormalities and seeking prompt treatment from a dermatologist can help relieve symptoms and prevent serious problems.

Key Points:

• Skin problems that often arise after a bone marrow/stem cell transplant include dry or itchy skin, dry lips, bruising, acne and changes to hair and nails. Patients may also have an increased risk for, wounds, skin infections, rashes and skin cancers.
• Transplant survivors have an increased risk for skin cancer. Taking steps to avoid sun exposure and seeing a dermatologist regularly can help prevent and treat skin cancer at an early stage.
• Lifestyle changes, such as using the appropriate amount of sunscreen, wearing sun protective clothing when outdoors, and preventing skin exposure to irritants and sources of infection can help reduce the risk of serious skin problems after transplant.

Highlights:

(01:53): Dry skin can be caused by genetic factors, medications, and environmental factors. Exposing skin to warm, rather than hot water, avoiding harsh soaps, and moisturizing skin regularly can help control dry skin.

(04:20): Dry lips can be caused by licking your lips, allergies, chronic sun exposure and graft-versus-host disease (GVHD). Therapies include petroleum jelly on the lips, avoiding mint- and cinnamon-flavored toothpaste and mouthwashes, using lip balm while in the sun and, in some cases, topical medications.

(06:54): Itching skin can be caused by allergies, eczema, psoriasis, medications, and certain medical conditions such as thyroid disease, kidney issues, or liver abnormalities..  

(09:35): Skin bruising can be caused by advanced age, sun exposure, medications and some blood conditions.

(11:16): Acne can be a problem for adults as well as teenagers and has many causes, including diet. It is usually treated with topical medications, including antibiotics.

(15:31): Skin wounds are often seen in areas with poor circulation such as legs and feet. Graft-versus-host disease can predispose patients the certain skin wounds.

(17:46): Some common skin infections after transplant  include impetigo, ringworm, nail fungus and shingles and warts.

(24:08): Drug rashes can resemble infections and need to be promptly treated, as some can be serious or even life-threatening.

(26:10):Two types of hair loss (alopecia) can occur after transplant. Several therapies are available to treat hair loss.

(31:36): Bone marrow/stem cell transplant survivors have an increased risk for skin cancer. Sun protection is essential to minimize the risks of skin cancer.

Transcript of Presentation

(00:00): [Marsha Seligman]:   Speaker Introduction. Welcome to the workshop, How to Protect Your Skin After Transplant. My name is Marsha, and I will be your moderator for the workshop.

(00:08): It is my pleasure to introduce today's speaker, Dr. Silvina Pugliese. Dr. Pugliese is Clinical Associate Professor of Dermatology and Attending Physician at Stanford Hospitals and Clinics and the Stanford Cancer Institute. She specializes in the management of skin complications associated with chemotherapy, radiation therapy and bone marrow transplantation (BMT) with an emphasis on graft-versus-host disease (GVHD) and survivorship. Please join me in welcoming Dr. Pugliese.

(00:44): [Dr. Silvina Pugliese]:   Learning objectives. Good morning, everybody. Thank you so much, Marsha, for that kind introduction. My name is Silvina Pugliese, and I'm really thrilled to have been invited here today. I'm going to talk about all the different ways that we can protect our skin after transplant and some specific diagnoses to look out for.

(01:02): Without further ado, I'll start with my learning objectives. First, I will review some common skin conditions that can arise post-transplant. Some of the things I'll discuss today are dry skin and lips, itchy skin, skin bruising and acne. I'll talk about how to recognize skin wounds and also skin infections, emphasizing bacterial, fungal and viral skin infections.

(01:27): I'll go over drug rashes, including some of the common things we can see with drug rashes and also emphasizing some findings that we can see in life-threatening drug rashes. I'll review hair and nail changes post-transplant, and finally, speak on how to recognize skin cancer and making sure everyone understands the role of sun protection including sunscreen and skin cancer prevention.

(01:53): Dry skin is common after transplant and can be caused by genetic factors, medications, environmental factors and personal habits like showering with hot water. Dry skin is something that is incredibly common. There are a number of different causes for dry skin. There's certainly a genetic component and there could be some skin conditions that are linked with dry skin. These are common things like eczema, for example.

(02:09): Some patients just have more sensitive skin that can be dry. Certain medications can dry out your skin and that's a big question we talk about that we ask patients about, as well as beauty products. : There are certain topical medications like topical retinols that can cause drying of the skin, different face washes and things of the sort that can dry the skin out as well.

(02:36): There are some environmental factors, for example, if you live in a very dry climate, or if you run your heat really high indoors, that can contribute to dry skin.

(02:49): And there are some habits that feel good, like taking long hot showers. That can dry out our skin as well.

(02:57): Exposing skin to warm, rather than hot water, avoiding harsh soaps, and moisturizing skin can help control dry skin. To treat dry skin, some of the things we recommend are modifying our habits. For example, when you're showering, taking a bath or washing your hands, use lukewarm water, not hot water. When you are showering or taking a bath, try to keep it short, five minutes or so.

(03:15): If you're doing what we call any wet work, washing dishes, laundry, things like that where you're submerging your hands in water, it can be helpful to wear gloves. Some gloves are waterproof, and the inside is lined with cotton, so it also feels nice on your skin and that can be helpful to avoid the irritant quality of the water on your skin.

(03:37): We ask that you avoid harsh soaps on your skin, also things that have heavy fragrances in them.

(03:43): And of course, dermatologists love moisturizers. We think that cream-based moisturizers work better than lotions. They're a bit more occlusive. They absorb better into the skin and they're usually the ones that come in the jars that you see in the store, as opposed to the pump bottles that you can get. If your skin is really dry, it can help to use moisturizers with some white cotton gloves, we call them white cotton spa gloves, over your skin that helps to improve the absorption of the moisturizer into your hands.

(04:20): Dry lips can be caused by licking your lips, allergies, chronic sun exposure and graft-versus-host disease (GVHD). Dry lips are common and have a number of causes. Along the same vein as dry skin are dry lips. This is very bothersome and there can be a number of causes for dry lips. One very common cause that we see is licking your lips. If you have dry lips, as you know, it can be really hard not to lick them. However, this can cause worsening of the dry lips and even cause a rash around your mouth.

(04:39): We see contact allergies that show up as a rash over the lips, which can be very dry. In some cases, the growth of bacteria on the lips can cause dryness. The growth of yeast on the lips can cause dryness. So, your doctor might take some swabs to try to figure out if that's what is going on.

(05:02): Chronic sun exposure can lead to changes on the lower lip primarily that can mimic dryness of the lips. Very importantly, the lower lip is exposed to more sun usually than the upper lip and it's a place that we sometimes don't think about protecting from the sun.

(05:18): One of the manifestations of graft-versus-host disease can be dry lips. Generally, dry lips in isolation, I am not going to be too worried about, but if we have lip changes plus some inside-the-mouth changes and also skin changes, we might think a little bit more about that diagnosis.

(05:36): Therapies for dry lips include petroleum jelly on the lips, avoiding mint and cinnamon flavored toothpaste and mouthwashes, using lip balm while in the sun and, in some cases, topical antibiotics, antifungals or topical steroids.  For dry lips, we're seeing a couple of treatments and prevention, and some of these are modifiable habits. Avoid licking your lips if possible We do like to use petroleum jelly on the lips. It's very moisturizing and doesn't have any allergens in it unless you happen to be allergic to petroleum jelly, which is rare but possible.

(05:57): Some people actually can be very sensitive to the mint and cinnamon flavors that are present in certain toothpastes, actually most of them, and mouthwashes as well. So, if you find that you're having persistent dry lips, one option is to change from those products to see if you have made improvements.

(06:14): Because we know that sun can play a role, it can be helpful to use a lip balm. Generally, and we'll talk more later, but our recommendation is going to be a sun protection factor, SPF, of at least 30. And of course, we have to balance the use of this with the risk of being allergic to an ingredient. So, it is a little bit of a nuanced trial sometimes.

(06:38): Because there are so many different causes for dry lips, your doctor might prescribe medications like topical antibiotics, topical antifungals or topical steroids. When I say topical, they're all going to be cleanings, lotions, etc.

(06:54): One of the side effects of dry skin is itchy skin. Actually, itchy skin is one of the main complaints patients can have. Anyone who's had itchy skin knows that it can be incredibly uncomfortable and can really cause a lot of issues with concentration, focusing on daily tasks and of course, sleeping.

(07:15): I talked about dry skin being one of the main factors. We can also have itchy skin if we have any allergies, and these could be allergies independent of skin allergies, like environmental allergies. Certain skin conditions like eczema and psoriasis can all cause itchy skin. Medications can cause itch without any kind of rash.

(07:40): Certain medical conditions such as thyroid disease, any kidney issues, having some liver abnormalities or liver disease could all cause itchy skin. And there are some conditions that affect primarily the nerves, and one manifestation of that is itchy skin.

(08:02): In treating itchy skin, by now you know that dermatologists love both moisturizers and sunscreens, so we do always start with dry skin care. We want to make sure the skin barrier is as healthy as possible to help reduce the risk of the skin becoming dry or itchy.

(08:18): Some over-the-counter options for itchy skin are a camphor-menthol or a pramoxine lotion. These are all topical anti-itch medications. For some patients, if we're thinking that there might be an allergic component or if the itch is so severe that it's getting in the way of daily activities and sleeping, we might use combination oral antihistamines or we might use different medications that help with itch. Medication you might have heard of like gabapentin or pregabalin.

(08:51): Because there are so many underlying causes to itchy skin, you want to make sure it's not related to anything else internal. Your doctor may order some labs to look for an underlying cause. And then additional treatments are definitely available. It often depends on whether we identify a particular cause and how severe the itch is, and also, of course, interactions with medications and things of the sort.

(09:19): Another skin issue that comes up very often in my post-transplant patient is skin bruising. Skin bruising not only can sometimes be tender and painful, but a lot of my patients just don't like having the bruises on their arms, which makes a lot of sense.

(09:35): Skin bruising can worsen from age, sun exposure, medications and some blood conditions. There are some really common general factors that can affect skin bruising. Age, our skin just gets thinner with age. Sun exposure, the more sun exposure we have throughout our life, the thinner our skin becomes later on. There are certainly some medications, steroids can thin out the skin. Both oral and topical can sometimes lead to skin bruising specifically. And in the case of blood thinners, it makes it more likely to have skin bruising appear on the skin. There are also some platelet conditions, some blood clotting conditions that can contribute to skin bruising.

(10:15): I do get asked a lot how to reduce bruising. There are not tons of easy treatments for the reduction of bruising. Of course, we want to prevent skin bruising as much as possible because sometimes we can't prevent some of those things we talked about like age and prior sun exposure. What we really focus on is, "What can we do now?"

(10:35): Several strategies can reduce the chances of skin bruising. Certainly, moisturizing the skin, keeping the skin barrier as healthy as possible can be really helpful. Avoiding injury to the skin and wearing long sleeves when able can all be helpful. There's some evidence that topical arnica creams, which are generally over the counter, can help with the bruising. Some patients do try topical retinoids. We use those a lot for things like acne. We use them for anti-aging and some folks also try them for a reduction in bruising on the skin. It can be very drying, so that's sometimes a limiting factor in their use.

(11:16): Acne can be a problem for adults as well as teenagers and has many causes. One of the things I see all the time is acne and a common myth I think is that only teenagers have acne. My practice is primarily adult and I see acne as one of the top concerns that patients have. The reason is that acne can be caused by many things.

(11:33): Skin type certainly plays a role. Patients with oily skin are more likely to develop acne. Certain medications can actually flare acne or cause acne in someone that never had it or had very mild acne in the past. Some things we commonly see are topical steroids. For example, if someone has a rash on their face, and they put on a topical steroid to help with the itch and the rash, and then that causes acne, or if an oral steroid is prescribed, that can cause acne on the face, on the body.

(12:03): Sometimes certain chemotherapies, or targeted therapies can cause acne as well. We know that there's certainly a bacterial cause — some bacteria on the skin that can be involved in the formation of acne. Sometimes there is yeast that we call fungal acne if that's on our skin, and that can also cause acne. Little Demodex mites that actually live on all of our skin can sometimes be more pronounced in patients that have things like rosacea for example or with certain immunosuppressive regimens. So, we also do see acne related to Demodex.

(12:41): An external factor that we see is the use of beauty products. Certain beauty products, some of them are thicker creams, oil-based serums, things of the sort, can clog up the pores and cause acne as well.

(12:59): Acne treatment may involve a number of topical medications including antibiotics. Well, it's fairly nuanced. There are a lot of different acne products. The first thing I say is that you really don't need a 15 to 20-step type of facial regimen. In general, having some cleanser that has glycolic acid, salicylic acid, benzoyl peroxide, those are some of our mainstays of acne treatment. We do like topical retinoids a lot. I know I've mentioned this a few times already, but they can really help with the initial formation of the first whitehead/blackhead on the skin.

(13:32): We know that topical antibiotics can be really helpful. These are medications you might've heard of like clindamycin. Sometimes we use oral antibiotics as well for a limited period of time. This is really just the tip of the iceberg and acne treatment. There are a lot of other treatment options and I think that certainly, if you're struggling with acne, especially acne that's causing scarring, a lot of discoloration, things like that, it'll be great to see your doctor, see a dermatologist and start a treatment regimen that works best for your skin type.

(14:03): Some foods and dietary issues can cause or worsen acne. Now I do want to talk a little bit about diet and acne. This is a question I get asked a lot, "Are there certain foods that trigger acne or worsen acne?" There's a little bit of information out there on this. It is certainly a very popular topic. Some of the foods that can worsen acne in many patients, I don't say all, because some patients can eat this diet and do not have any acne, but some patients are sensitive to foods that have what we call a high glycemic index. White carbs, foods that are more processed and sweets can all worsen acne in certain patients, (high sugar content). Skim milk has been shown to be implicated in certain studies, and then there was some information on chocolate as well.

(14:53): But again, this is not true for everybody. I have some patients that eat only these foods and don't have any acne, so it really is very variable. But if you feel like when you eat these foods, your acne flares, I think it's very reasonable to try avoidance and see if you get improvement. And the things that we note can help acne are probiotics and also actual omega-3 fatty acids. So, there is a role for some of these probiotics and supplements in prevention of acne or in treating acne. And some of this in terms of diet is also true when we talk about rosacea.

(15:31): Skin wounds often occur in parts of the body that have poor circulation, such as the hands and feet. Skin wounds are more common in some areas of the body than others. Switching gears completely from acne to skin wounds, two totally different diagnoses that we can see on the skin. Some areas in the body are more likely to form wounds, areas that have worse circulation; in the feet and the legs, for example, most people are going to have worse circulation than in the chest. Swelling of the legs is closely tied to issues of circulation, and sometimes can be really tied to medications as well. Some medications, specifically those that suppress the immune system, for example, can get in the way of wound healing.

(16:10): Patients who have graft-versus-host disease of the skin can be at greater risk for wounds, in particular with certain variants. You have heard a little bit this morning about chronic graft-versus-host disease. Some forms of that on the skin that cause a tightening of the skin, make the skin more fragile, can predispose to certain skin wounds. Some skin conditions can also predispose to skin wounds. I'm thinking about things like eczema where the skin barrier is impaired, but also more serious skin conditions or rashes where you get these open sores on the skin or even sometimes ulcers.

(16:48): Nutritional deficiencies can also play a role. Going through the process of having a bone marrow transplant in the hospital and getting medications that affect the gut, and maybe having GVHD affecting the gut, all of that can lead to ingesting less food and also absorbing fewer nutrients. We do want to be on the lookout for that and the appropriate patient checks, certain labs looking for nutritional deficiencies.

(17:15): One of my main jobs as a dermatologist is screening for skin cancer. I always want to keep a close eye on wounds that are not healing as expected. And remember, the wounds are going to take longer to heal than we would expect if some of these variables are in play, but wounds that don't heal the way that they should, we should check them for skin cancer, generally with the skin biopsy. And we'll talk a little bit more about skin cancer in a few minutes.

(17:46): Some common skin infections include impetigo, ringworm, and nail fungus. There are really common skin infections that we can see and I'm going to talk about some of the most common ones that we see in clinics. Instead of going through this list, I'll just hop right into chatting about them. The first one is a very superficial bacterial infection that we call impetigo. This is contagious and one of the characteristic skin findings that we see is this yellow or what we call honey-colored crust. We just love to compare skin rashes to food in dermatology, so honey-colored crust on the skin. Diagnosis is fairly straightforward. We generally will do a wound culture. We take a little Q-tip specimen, we rub it against the skin, and we send it to the lab to see whether any bacteria are growing there. And, this can be treated with topical antibiotics, and in certain cases, we'll use oral antibiotics.

(18:46): Another really common rash and one that maybe you've had or heard about is ringworm. Ringworm is a fungal infection affecting the surface of the skin. It tends to be very round. That's the ring of the ringworm and it has a bright red border usually. We can also easily diagnose this in clinic. We take a little scraping of the skin. We don't cut the skin. We just take a little bit of scale. We look at it with a microscope and we can see whether there are any fungal forms within that specimen. For this, treatment will be either topical antifungals or sometimes we'll need to use oral antifungals.

(19:26): Very closely related to ringworm is nail fungus. Sometimes when we have fungus affecting the feet, it can be like scale of the feet. We can notice some changes in between the toes. It's not uncommon to then also have the nail affected. Fungal infections of the nail are probably one of the harder fungal infections to treat because they're really stubborn and the creams tend to not penetrate as well into the nail as they do into the skin. But essentially, you should know that this can affect toenails and fingernails and that, for diagnosing the fungus, we actually take a nail clipping. We cut the nail the way you would just trim your nails and then we send that off to the lab to identify whether fungus is present and which type is present.

(20:15): Viral skin infections include herpes simplex and shingles which can be treated with oral antiviral medications. Moving on to our most common viral infections, herpes simplex, incredibly common, and can actually be anywhere. We think about it a lot in terms of the lips or genital skin, but we also see it in the buttocks, and we can actually see it really anywhere on the body. They're going to be these painful and clustered blisters. They love to be in a little group. And again, the diagnosis here can be easily made with a little swab that looks for the virus on the skin. Again, we're not doing a biopsy, we're just taking a little Q-tip and we're rubbing against skin and sending off to the lab for diagnosis. The treatment for this is generally going to be oral antiviral medication.

(20:57): Shingles is also a viral infection. It's the varicella virus that causes chickenpox. What happens with shingles is that this virus, after you've had chickenpox or a chickenpox vaccine, will lay dormant and quiescent and then generally during times of stress and that could be a life stressor, or it could be also a medical stressor like being immunosuppressed for example. What'll happen is that you'll get these clustered blisters, but they're in a line. It's a little bit different than what we saw with herpes simplex. These tend to be in a very painful line on the skin, small little blisters. This diagnosis is also treated with oral antiviral medication.

(21:40): The human papillomarivus or HPV can cause warts and is sometimes linked to skin cancer.   Continuing on with our viral theme to a completely different virus that we call human papillomavirus, HPV, which you might've heard a lot about. HPV is a virus that causes warts. It's incredibly common. There are all different strains of HPV. Specific strains are associated with warts in certain areas. Like one type will be warts on the hands and the feet and we might have certain types that are associated more with genital warts. We also have high-risk HPV variants that are sometime linked to skin cancer. And that can definitely be scary, but just know that most warts are not cancerous, but we definitely want to evaluate warts that are acting weird.

(22:22): Immunosuppressed patients are more susceptible to warts. What you need to know is that patients who are on immunosuppression can develop many warts and that's because in general the immune surveillance obviously that keeps these warts in check is a little bit lower than usual on immunosuppression, so more of these warts are allowed to grow on the skin.

(22:38): For treatment, we do a number of different things. We can do liquid nitrogen. That's like a squeezing treatment if you've ever had that done before. That's done in the office. We can prescribe different topical medications. We can do different injections into the skin of different things. Sometimes we'll inject candida, or we'll inject cidofovir, which is an antiviral. There is a lot that can be done for warts. Some will do laser procedures. So just something to keep in mind that the warts can be a little bit more challenging to treat in patients post-transplant who are immunosuppressed because they might have more of them.

(23:16): Transplant patients are at increased risk of more serious and less common bacterial, fungal and viral infections. Now, all of those skin infections, of course we want to diagnose them, and we want to treat them promptly. We want to look for any atypical signs that could be more serious, but I also just want to emphasize that because of the chemotherapy, and medications sometimes used after transplant to suppress the immune system, patients post-transplant can be at increased risk of more serious and less common skin infections. These can be caused by bacteria, fungi and also viruses.

(23:44): Not that you need to diagnose it on your own, but just be aware if you have any skin bumps, rashes, anything that just feels different on your skin, especially if you have symptoms like fever or you feel unwell or there's anything else that's untoward, we’re always happy to help diagnose these conditions and our goal is to get the promptest treatment possible.

(24:08): Drug rashes can resemble infections and need to be promptly treated. Drug rashes, similar to infections, we want to identify and treat very readily, and we also want to be aware of some of the symptoms that would be a sign of a more serious drug rash. A very common type of drug rash is called morbilliform, which actually just means measled-like. Hopefully, you haven't seen measles or had measles, but measles can look like pink-red bumps that all melt together and become this pink-red rash all over the body. It's very itchy, and it tends to start one to two weeks after a new medication. The only caveat being that if you've had the medication before, you could get this rash much sooner than usual.

(24:55): We can treat this with different topical and oral medications. In some cases, we stop the medication. If it’s a medication that's needed and so important that we can’t stop it, we’ll treat through the rash, because it's not a life-threatening rash, just a quality of life threatening, very itchy, with redness all over the body.

(25:12): Some drug rashes can be serious or even life threatening and should be promptly reported and treated. Now what I want you to know is that there can be some more serious drug rashes and some drug rashes can even be life threatening. So, if you have any symptoms like hives, (red welts on the skin) and you're also having some swelling of the lips, of the tongue and trouble breathing, feeling like your throat's closing, that's going to be an emergency. Go to the emergency room.

(25:36): If you're noticing something strange like you have a rash on the body that looks like what we just saw, but you have also swelling of the face or redness of the face, you have fever, we also want to make sure that's looked at very quickly. Painful skin is a big red flag in dermatology. Painful skin with blisters, skin peeling off, sores in the mouth and genitals must be evaluated very quickly. There can be some really serious drug rashes associated with those findings.

(26:10): Alopecia or hair loss involves many types of nonscarring hair loss. Now I'm going to move on to hair loss, which obviously could be its own talk in and of itself. Hair loss is such a common concern for patients coming into dermatology. The term we use for hair loss is alopecia. There are two main types of hair loss that we think about., two main categories. Scarring hair loss, meaning that the hair follicle scarred down, the hair is not going to grow back, and then nonscarring hair loss.

(26:37): Types of nonscarring hair loss, this is a bucket, and there are a lot of different types within nonscarring hair loss. There's the classic chemotherapy-related, what we call anagen effluvium, all the hair shedding or most of the hair shedding. There is something called telogen effluvium. This is a stress-related kind of hair loss. This is the kind of hair loss that we see now after, for example, COVID infection or a hospitalization or what you might see post-pregnancy where a few months after some sort of stressful trigger, many of the hairs on the scalp will shed. It's not complete hair shedding, but it's definitely a lot more hairs than usual.

(27:17): Alopecia areata occurs when the immune system attacks the hair follicle. We have a different variant of nonscarring hair loss called alopecia areata. That's that picture that you're seeing with just the round area of hair loss. This is the immune system attacking the hair follicle. We also have our classic androgenetic alopecia or male and male or female-pattern hair loss. This is how we lose hair generally as we age, sometimes due to certain medications.

(27:44): The difference between nonscarring and scarring hair loss is that usually a scarring type of hair loss will have some kind of symptom. A patient might have a rash, they might notice some scale, they might have some redness of the skin, they might have an itchy scalp and you sometimes see a bit of a shiny scalp if you look at it, areas where you're not seeing the hair follicles there anymore. There are a lot of reasons for this, there are a lot of different conditions, but this is what we might see with prior radiation to the scalp or for patients who have graft-versus-host disease.

(28:17): For hair loss interventions, it is very variable, again depending on the diagnosis. In most cases, we'll check some labs. We know that thyroid conditions, low vitamin D and low iron can all cause hair loss. We sometimes will obtain a biopsy or a sample of the scalp. This is most helpful when we're thinking about scarring hair loss and trying to distinguish between different types of scarring hair loss.

(28:43): There are many medications for hair loss including Rogaine. There are a lot of medications we can use. Topical minoxidil, or a brand-named Rogaine, is a very common medication we use for hair loss, but sometimes we use different oral medications or recommend different supplements, of course, depending on what we find during the initial visit.

(29:03): There are a lot of supplements for hair loss out there. There's a huge market. It's very lucrative. Nobody wants to lose their hair. It's a place where unfortunately I think there can be a lot of products that just aren't that good that are being sold for a lot of money.

(29:18): Biotin for hair loss can interfere with certain lab tests. Biotin is the most popular hair loss supplement, and in recent years, it has not been shown to help hair regrowth in the vast majority of patients, but it's still present in many over-the-counter supplements. I usually would just caution against it because it can interfere with certain lab tests, one of the main ones being a thyroid test, a TSH, thyroid stimulating hormone. I tend to not really recommend supplements unless there's a true deficiency.

(29:44): We talked a little bit about nutritional deficiency with wounds. We can sometimes see deficiency with hair loss. If someone has risk factors, I might check some labs specifically and then supplement for those vitamins or minerals. But in general, I don't recommend as a blanket recommendation that everybody start a hair loss supplement.

(09:35): Skin bruising can worsen from age, sun exposure, medications and some blood conditions. Causes of weak, brittle nails. The other part of the body that we see as dermatologists, we talked a little about skin, about the hair and also nails. Nails are within the purview of dermatology. There's a whole field of nail dermatology. I'm not really going to do its service by giving one slide on this topic, but I do want to talk about the most common thing that I see, which is weakening of the nails or brittle nails. Many times, it's caused externally. Hot water again, dry skin, having a dry cuticle, U-shaped area at the end of your nail, picking at the nail. Sometimes different irritants like cleaning agents. Again, medications and certain medical conditions can all weaken the nail.

(30:52): For treatment of weakened, brittle nails, we'll pull out our dry skincare recommendations that we talked about earlier. We try to avoid irritants. That's really also where the gloves that we talked about for wet work come in. We're doing Vaseline or a cream-based moisturizer with white cotton spa glove. So that can be helpful for the nails as well. And this is one place where we do use biotin. Biotin at 2,500 micrograms per day can help to strengthen the nail. Make sure that if you're having any labs checked, you let your doctor know you're on biotin, so they can tell you to stop it before getting your labs drawn. Sometimes we use certain nail hardeners and there are some over-the-counter ones. There are also some prescription ones.

(31:36): Patients who undergo bone marrow or stem cell transplants are at increased risk for skin cancer. With the remaining time that I have today, I'd like to discuss two big topics. One of them is skin cancer and the second is what we can do to prevent skin cancer. We know that patients who have undergone bone marrow transplants are at increased risk for skin cancer. The incidence or how often this occurs varies by study. I pulled out just two numbers here, but the 20-year cumulative incidence in one study was noted to be six and a half for basal cell skin cancer and 3.4% for squamous cell skin cancer. And another study had shown a two to four times increased risk compared to non-transplant patients.

(32:21): There are some risk factors that we see across the board for all patients even without transplant. We know that UV exposure is a known carcinogen. It's been very closely linked to skin cancer. There are different ways of getting sun. Some people tend to get intermittent sunburns when summertime comes around, for example, when they're on vacation. People like me who live in California have a little bit more chronic exposure in the sense that when the weather is nice all the time, you're getting more of that direct UV exposure. Certainly, patients who have lighter skin are at increased risk for skin cancer.

(33:00): Some medications, scars, chronic wounds, genetics, and smoking can all increase the risk o skin cancer. Certain medications can make you more photosensitive or increase your risk of skin cancer. Medications like azathioprine, medications like voriconazole, these can all increase skin cancers. Having a history of radiation can also increase your risk of skin cancer.

(33:16): Scars and chronic wounds, there are certain types of skin cancers that can occur in those two areas. Linking back to sun exposure, working outdoors. Genetics also plays a role. There are definitely some genetic predispositions to developing skin cancer. Smoking, when we think about skin cancers that affect the mouth and lips.

(33:40): Several transplant specific factors increase the risk for basal cell skin cancer in patients treated for leukemia, lymphoma, or malignant marrow disease. Some transplant-specific risk factors for developing skin cancer are the same or just slightly different for basal cell and squamous cell cancer. We'll go over these skin cancers in just a few seconds, but basal cell skin cancer has been shown to be more likely in patients with the primary diagnosis of leukemia, lymphoma or a malignant marrow disease. Younger age at time of transplant also increases the risk and having chronic graft-versus-host disease and also seems to increase the risk of basal cell skin cancer. You see here, the use of azathioprine can also be linked to basal cell cancer, and being on medications that suppress the immune system for more than two years.

(34:22): Squamous cell skin cancer has its own set of transplant-related risk factors. For squamous cell cancer, we're also seeing some common things that we just talked about, but diagnosis of leukemia, severe aplastic anemia, younger age at transplant, and total body radiation all make the list as does chronic graft-versus host disease.

(34:40): What do these skin cancers look like? Basal cell skin cancer is going to be a pink, red, shiny bump. It can be scaly, and on darker skin, it can be purple or blue. Squamous cell cancer can be pink, red, purple. It can be scaly. It can look like a sore or a wound that does not heal. It can also be a scar, but a scar that has some new symptom associated with it, and it can also be very painful. We're always going to ask about how these things feel, and pain is a big red flag.

(35:13): Melanoma is the most common skin cancer. It's generally going to be an irregular brown or black growth. It can be pink sometimes, or red. And one thing I always talk about is the ugly duckling sign. We're always going to be looking out for that mole, that spot on the skin that looks different from other spots in the skin that you have. That's going to be a big red flag for us as well.

(35:36): Skin cancer can affect all skin types but may be riskier for people with skin of color. I do want to emphasize that skin cancer can affect all skin types. We do know, unfortunately, that skin cancers can be diagnosed later and have more aggressive features at time of diagnosis in patients with skin of color. And we know that for patients with skin of color, UV exposure seems to play a lesser role, a smaller role.

(35:57): We see squamous cell cancer presenting, it's 8.5 times more likely to present in areas that are not exposed to the sun in skin of color patients, and melanomas as well. That is why we hear a lot about melanomas occurring on the palms and the soles in patients of skin of color. Specific risk factors in skin of color patients are radiation, immunosuppression, prior burns, chronic scars and also chronic ulcers.

(36:24): The treatment for skin cancer really depends on the skin cancer and subtype. It is a conversation to have with your dermatologist, but depending on the type, it can be treated many ways, from just a topical chemotherapy cream to a more advanced surgery. These are outpatient surgeries in general, and Mohs micrographic surgery is the most specialized type of surgery that we have for treatment of skin cancer. It is less common but still occurs that we can have advanced skin cancers that need radiation and systemic treatment as well like chemotherapy or immunotherapy.

(37:01): Regular screening for skin cancer is highly recommended. There’s no guideline or general recommendation for how often to have your skin screened post-transplant. We tend to recommend at least annual screenings. And of course, if you have more risk factors or you have a spot of concern, I advocate to be seen sooner, because we don't want any skin cancers going undiagnosed and untreated.

(37:25): Skin checks are pretty straightforward. For a skin check, you'll come into the dermatology clinic. You'll remove your clothing. You'll put a gown on. We'll check from your head to your toes. And then we use a little device instrument called a dermatoscope to zoom in and magnify certain features. And if we need to, we'll obtain a skin biopsy.

(37:46): Sun protection is essential to minimize the risks of skin cancer. And finally, I just want to emphasize the one modifiable factor that we have that we can do to protect skin cancer is sun protection. And I want to emphasize that it's more than just sunscreen. It's just things like seeking shade, avoiding the peak sun hours, wearing a hat and wearing UPF clothing, which has the built-in sun protection in it.

(38:06): It takes a lot of sunscreen to be truly effective. When we look at sunscreens, what the sun protection factor is telling us is how much longer you could be outdoors in the sun before turning red than if you did not have it on. But unfortunately, the big caveat here is that you have to put on enough sunscreen to reach that level of protection and that's about 1.5 ounces. That is a lot of sunscreen, and you have to reapply because sunscreen does not last more than two hours. So, it's really important to just keep those things in mind when we think about SPF.

(38:36): There are two main families of sunscreens. There are physical blockers and there are chemical blockers. The main distinction is that physical blockers sit on your skin, and they scatter UV rays, whereas chemical blockers are absorbed into the skin, which has some pros and cons.

(38:51): Because the physical blockers tend to sit on your skin more than absorb, they can leave more of a white residue. And the chemical blockers absorb well into the skin, but I think sometimes there can be some concerns, about coral reefs and bleaching of the coral reefs, but I do have some patients that don't really want to put a lot of chemicals on their skin and have it absorbed.

(39:12): Choose a sunscreen with at least SPF 30 protection. My recommendation with choosing a sunscreen is that the best sunscreen is the one that you'll wear. Look for something broad spectrum with UVA and UVB and look for at least SPF 30, choosing a little bit higher, thinking about just how imperfect we are as humans with application.

(39:28): Sunscreen has multiple benefits. Remember that sunscreen can prevent skin cancer and prevent aging, help against being sensitive with certain medications that make you more sensitive to the sun. It can help to prevent that from happening and also curtail flares of graft-versus-host disease related to sun exposure.

(39:46): And I do always get asked, "Is sunscreen safe?" It can sometimes cause minor skin irritation. Allergies to sunscreen are rare but can occur. And what I always say is, if you have concerns about the ingredients in sunscreen, the great option that we have is we have UPF clothing to protect most of your body and we can always have you use one of those physical blockers. But at the end of the day, we do know that UV exposure causes skin cancer. We want to make sure that you're not most of the time unprotected outdoors.

(40:14): Finally, for my patients who are concerned about vitamin D deficiency, I do tend to recommend vitamin D via diet and supplements. Here are some dietary sources that can be helpful as well. And we do partner really closely with primary care and oncology to make sure that our sun protection recommendations are not getting in the way of adequate vitamin D protection.

(40:38): In the interest of time, I'll leave the take-home points here for you to read, but I hope I've given you a good review of some of the most common skin concerns that happen post-transplant, that you have a better understanding of some of the infections, drug rashes, effects on hair and nails, and importantly, skin cancer post-transplant and sun avoidance, sun protection. Thank you so much for your time and the opportunity to be here today. I'm happy to take any questions.

Question and Answer Session

(41:04): [Marsha Seligman]:   Thank you, Dr. Pugliese, for this excellent presentation. We'll now begin our question and answer session. If you have any questions for Dr. Pugliese, please use the chat box on the left side of the screen to submit your questions. We will answer as many questions as possible. The first person would like to know, "How can immunoglobulin infusions impact skin condition?"

(41:32): [Dr. Silvina Pugliese]:   Thank you for that question. I think that it depends on the skin condition involved. We do use immunoglobulin and then for treatment of some skin conditions and then we sometimes see some reaction to it. So, it would depend on the type of skin condition that's being treated.

(41:54): [Marsha Seligman]:   Okay, the next question is, "My skin is more fragile after an unrelated donor transplant with bruising and skin tears. Does the skin ever return to its original condition or healthy state?"

(42:10): [Dr. Silvina Pugliese]:   Thank you for asking. That's an excellent question. In general, our skin will not go back to the way that it was, and this is just with age, sun exposure and then also of course in the case of transplant. We can do some things to improve the fragility of skin. The most important thing here would be moisturizing the skin to protect that skin barrier externally, trying to avoid, even though I know the injury that causes the tears is so minor, trying to do some things like wearing long sleeves can be helpful is trying to avoid those tears. But the most important thing I would say would be a lot of moisturizing, and then of course, you can talk to your doctor about whether there might be a role for using different medications like topical arnica to help with the skin losing itself.

(43:02): [Marsha Seligman]:   Okay, "How do you know the difference between chemotherapy-induced skin conditions as opposed to GVHD of the skin?"

(43:12): [Dr. Silvina Pugliese]:   This is such a good question, and it can actually be a whole lecture, so I'm happy that you asked this. I'll tell you that it can be challenging, and I think the most challenging time is the direct post-transplant period where patients have usually received chemotherapy prior to the transplant and then are engrafting, and that's when we start worrying about graft-versus-host disease. And all of that happens in such a short timeframe that it really can be very difficult in the beginning to parse out the differences. This is something that actually people have looked at because it again is a big challenge.

(43:37): When you're seeing a patient in the hospital like we do post-transplant, one of the main concerns beyond engrafting is graft-versus-host disease. It can be really serious to tell somebody, "I think you have graft-versus-host disease of the skin." So, we try to use some clinical features first. What does that mean? Many of the chemotherapy regimens, and of course, it just depends on what the preparatory regimen is, but we know that many chemotherapy regimens that are used during that time can cause a classic rash that we call toxic erythema of chemotherapy. This tends to affect the armpits, the folds of the body, armpits, groin folds, under the belly, and is less likely to cause a rash in other areas of the body.

(44:43): Now that's not perfect, but if we're seeing primarily that pattern, sores in mouth, and we're not seeing more of that widespread pink rash that we see for acute graft-versus-host disease, we can feel a little more confident that it might be chemotherapy and not GVHD. Unfortunately, both GVHD and toxic erythema of chemotherapy can affect the palms and the soles, so that's a place where we don't really have that much information. I also want to note that there are other rashes that pop up during this time that are not GVHD, which just complicates the picture. One of the things we do a lot here is that we follow patients really closely in the hospital.

(45:26): We want to make sure that if someone develops a rash, we see what it's doing every day and eventually, toxicity of chemotherapy should improve, which are more, I'll say, mild treatment modalities. But yes, I think it can be really challenging and it's a place where skin biopsy doesn't help all that much, so that can also make things difficult.

(45:50): [Marsha Seligman]:   Okay, we have a couple people asking specifically about rosacea and so I'm going to combine the two questions. First person would like to know if you have any advice for treating worsening rosacea, either vascular and/or inflammatory, that developed post-transplant, and another person is asking, "Can a probiotic supplement help with the rosacea?"

(46:15): [Dr. Silvina Pugliese]:   Perfect. Well, I'll start with the second one. Probiotics supplements have been shown to be helpful for rosacea, similar to acne. So yes, it can. For the first question, talking about treatments for rosacea, so great question, because you also hit on there being many different types of rosacea. There's the flushing type of rosacea where we have mostly pink or redness of the skin of the face that first comes and goes and then later on can be more fixed on the skin. So, you're always feeling red and flushed. Sometimes we can have a burning sensation that goes along with that.

(46:51): Then we have our more acne-like rosacea. We actually get acne bumps. The treatment — and we have different variants of rosacea, but in the interest of time, I won't go into those, the two most common. The treatments are different. For the acne-like rosacea, we do many similar things that we do for acne. We use topical antibiotics, a common one being metronidazole. We use different topical medications like azelaic acid. We use medications against Demodex, which we know is implicated or plays a role in rosacea. That is ivermectin. We often use a cream, ivermectin cream or we sometimes use an oral ivermectin for treatment.

(47:31): In cases that are really challenging to treat with those and other topical medications, we will do oral medications. One thing we do quite often is an oral antibiotic. There's one called doxycycline that we tend to use not infrequently because it is very good for rosacea, and some patients have really severe rosacea that doesn't respond to anything. Again, more like the acne-like rosacea, we'll do isotretinoin or Accutane. We can do that as a low-dose medication. So those are some treatments, not a full comprehensive list, but some treatments for that more acne-like rosacea.

(48:06): For the pink type of rosacea, the more blood vessel one, there are some topical medications that can help with redness. They are prescriptions. The two that I'm thinking about are oxymetazoline, which is Rhofade, and there is one called Mirvaso, that's the brand name. These medications you put onto the skin, and they temporarily help the redness, but the redness will come back. So, there's an immediate rebound effect in a few hours. I think one really great treatment for the redness and rosacea is actually laser treatment. I don't do any cosmetics, but my lovely colleagues here will often help out with my patients that have that more flushing vascular type of rosacea because the topicals can sometimes have a little bit of a limited role in how much they help.

(48:58): [Marsha Seligman]:   "What is the most common problem you encounter with CAR T-cell recipients?"

(49:06): [Dr. Silvina Pugliese]:   Great question. We see some of the things that we talked about. Dry skin is really common, and we see different types of rashes in chimeric antigen receptor (CAR) T-cell recipients. So often, our first goal is checking the entire body, seeing what the patient's main concern is in terms of dryness or rash. And if it's a rash, we try to better identify what type of rash it is so that we can treat it appropriately.

(49:33): [Marsha Seligman]:   "How do you check for nutritional deficiencies?"

(49:38): [Dr. Silvina Pugliese]:   That's a really good question. So first, it's identifying the right patient. It's not a test that we tend to do across the board, but if someone does have — If we have cause for concern, someone that has lost a lot of weight, isn't eating as much, has limited types of foods that they're taking in, or has a lot of diarrhea that leads to problems with absorption, or if there are medications that get in the way of absorption that sometimes certain chemotherapy does, then we'll check. But the check itself is very easy. It's just in general laboratory work, a blood draw. We would just order certain labs: vitamin B, different B vitamins, vitamin C. We'll look for iron and vitamin D. Once we get all the results back, we'll discuss them with the patient, and if there are any deficiencies, then we'll talk about how to supplement them with over-the-counter supplementation.

(50:38): [Marsha Seligman]:   Okay. The next question says, "What about immunity-related fungal dark spots on the face that look like age spots?"

(50:49): [Dr. Silvina Pugliese]:   That's a good question. Immunity-related fungal age spots, I'm not sure what exactly is the diagnosis. There's something that we call tinea versicolor that is a yeast-related rash that we can see sometimes and that can have a bit of a dark scaly appearance. And it can be really common on the chest and the back, but we certainly can get it in other areas as well. And that is something that we'll treat with topical antifungal shampoos or creams and sometimes oral medications. And if that's the diagnosis of the treatment for it, but I'm not sure if there might be another thing that I'm not getting diagnosis for.

(51:35): [Marsha Seligman]:   Okay. Someone would like to know what your preferred oral antibiotics for a BMT patient with acne if you have a preferred oral antibiotic suggestion?

(51:48): [Dr. Silvina Pugliese]:   That's a great question. I think it depends. It's certainly very dermatologist-specific, the antibiotics that we might be more likely to use. Unless there's any reason not to, like an allergy, or if a patient has another medication that might interact, I usually will use doxycycline as my main one. There are a couple of reasons for that. There are some side effects that you do need to know about. It can cause stomach upset. That can be a really serious side effect. It's more common to happen if you take it on empty stomach, so I do recommend taking it with food. There can be some lower absorption taking it with dairy products, but you certainly don't want to take on an empty stomach because you'll get really nauseous.

(52:36): Now the second thing is that it can make you very sensitive to the sun and that is often problematic in California because the weather is quite nice. You have to make sure, be really realistic about the sun exposure of the patient that you're prescribing it for. And it can cause some reflux sometimes, acid reflux. It's important not to lay down after taking it. And then if someone already obviously has acid reflux or ulcers or anything like that, you really don't want to use it. But even though that sounds like a really extensive side effect list compared to some of the other antibiotics that we use, it's actually one of the shorter ones.

(53:12): I tend to go for that first, but I do want to emphasize that antibiotics are not a long-term fix. We do use them longer, we might use them longer for infection. You might be on antibiotics for a week or two weeks, right? For acne, we'll sometimes do one-to-three-month courses of antibiotics. So, it's not short, but we certainly don't want to do it for many months, year plus, just because how the antibiotic can affect the gut and all the other side effects that can occur. But my personal, I guess, and only favorite, but the one antibiotic I tend to use the most is doxycycline.

(53:52): [Marsha Seligman]:   Okay. Someone is concerned that since they've had their transplant, they've been more affected by insect bites, and they said that they get swelling and sometimes the skin forms quite large blisters. Have you ever heard of this, and do you have any suggestions?

(54:09): [Dr. Silvina Pugliese]:   Great question. Some patients without transplant can be really sensitive to insect bites and we sometimes can have it happen post-transplant as well. The prevention methods are, of course, trying to wear long-sleeve clothing, protecting yourself from insects when able to and using insect repellent in some cases can also be helpful. There are a lot of different types, and of course, there's a whole discussion about more natural ones and more chemical ones and whatnot. So that's the main prevention piece. When you do get an insect bite, usually what we want to do is just stop the itch, because when we start scratching it, we just get more rash, and we can get scarring and things like that.

(54:51): What I usually would recommend for that is a topical steroid medication. You could certainly start with over-the-counter hydrocortisone. It's a little bit weak sometimes, so you might want to get something a little bit stronger from your doctor, just using that, if you put it on, you just have to use it for fewer days than you might need to use the hydrocortisone. For patients that are really itchy, because these bug bites can be really itchy, we'll use antihistamine.

(55:19): [Marsha Seligman]:   Okay, the next person asks, "Post transplant, I have chronic skin GVHD. My skin is almost exquisitely sensitive to heat, hot water certainly, but even if I very briefly stand in the sun with sunscreen, it feels like my skin is literally burning as soon as the ray of sun hits it. It gets very hot and painful almost immediately. What is the mechanism for this?"

(55:44): [Dr. Silvina Pugliese]:   Thank you. That's a really good question. There can be a number of things causing that. And of course, we want to take into account chronic graft-versus-host disease. But I'll say, we don't want to always assume three things related to one thing. We want to keep that in mind, but make sure we're not missing anything else. One would, of course, be medications. Whether the person asking the question is on any medications that can make them sensitive to the sun, that could be one reason that really severe response is happening.

(56:16): A second thing is whether there could be a separate skin condition. We often will see graft-versus-host disease of the skin and then something else. For that reason, we do want to make sure that we're not thinking about other conditions that can affect the skin. There are certain skin conditions that are triggered by sun exposure. It would be helpful to talk to a doctor about it and see whether they're concerned about that or whether they think it could be a medication or whether it could just be graft-versus-host disease.

(56:48): [Marsha Seligman]:   Okay. This is going to have to be our last question since we are running out of time. Someone would like to know if sun exposure has been identified as a trigger for GVHD flares, but can just plain heat also be a trigger?

(57:03): [Dr. Silvina Pugliese]:   That's a really good question. We know for sure that sun exposure, UV exposure can flare GVHD. I am not personally aware about just heat as a trigger. That does not mean it doesn't exist, but just not something that I'm knowledgeable on, but thank you for asking that.

(57:23): [Marsha Seligman]:   Closing. On behalf of BMT InfoNet and our partners, I'd like to thank Dr. Pugliese for a very helpful presentation. And thank you, the audience, for your excellent questions. Please contact BMT InfoNet if we can help you in any way.