Protecting Your Skin after Transplant 

Transcript of Presentation:

(00:00): Marsha Seligman: Introduction.  Welcome to the workshop, “Protecting Your Skin After Transplant”. My name is Marsha and I will be your moderator for this workshop.

(00:06): It is my pleasure to introduce today's speaker, Dr. Rachel Rosenstein. Dr. Rosenstein is an assistant professor of medicine in the dermatology division at Hackensack Meridian School of Medicine. She's an onco-dermatologist who focuses on the skin concerns of oncology patients, particularly Graft-versus-host Disease (GVHD) patients. Her research focuses on understanding the steps that lead to chronic GVHD, validating biomarkers of skin disease, and identifying new treatment targets. Please join me in welcoming Dr. Rosenstein.

(00:43) Dr. Rachel Rosenstein: Overview of Talk.  Thank you everyone for the invitation and for coming to listen to this talk today. I'm very happy to be here to speak to you about protecting your skin after transplant.

(00:58): So, some learning objectives for the talk today. Following the presentation, you should be able to understand malignant and nonmalignant skin problems that can develop after a hematopoietic cell transplant in the short and long term; who's at risk for developing nonmalignant skin problems after transplant; who's at risk for developing malignant skin problems after HCT; recommended skin care and sun protection after transplant; and tests that transplant recipients should have for early detection of malignant and nonmalignant skin problems.

(01:37): Skin problems are common after transplantation and although many of these same problems can develop in patients who haven't had transplants, they often occur more frequently in transplant patients and transplant patients can benefit from regular skin exams, and I'll get into the details of this further as we proceed.

(02:00): Dry skin can happen to transplant patients with or without graft-versus-host-disease (GVHD). So, let's first talk about dry skin. Dry skin is common in the general population, particularly in the wintertime. It can also be associated with graft-versus-host disease and it can also be seen in transplant patients without graft-versus-host disease.

(02:17): One of the key treatments for dry skin is to use a moisturizer twice daily. So what moisturizer to use? Well, there are many different types of moisturizers. Some are ointments, which are more occlusive and are less likely to cause burning or stinging, but some patients may not be happy with the greasiness of an ointment, they may find it unacceptable or just don't enjoy using it and then wouldn't use it.

(02:45): Another option would be the creams. Those have faster absorption than ointments. They're less occlusive, but they're still thick and they can be great moisturizers. Another option would be lotions. They have higher water content, they're thinner, they sometimes can have alcohol in them, which can sometimes burn.

(03:06): So, for people with dry skin, we typically recommend using a cream or an ointment and not a lotion twice daily. In warmer weather, when the skin's less dry, a lotion may be acceptable, but when treating dry skin, we usually don't recommend that.

(03:20): In general, any of these topicals can also be applied under occlusion, which is when you put the topical on and then you cover it with something else, such as cotton gloves for the hands or socks for the feet. If the arms or the legs are very dry, the moisturizer can be wrapped with Saran wrap to really lock in the moisture.

(03:41): For people with sensitive skin, it's good to avoid allergy-provoking ingredients in moisturizers. So this can be any type of fragrance, perfume, herbal extracts, or even lanolin, which is an ingredient in Aquaphor. Although most people don't have reactions to lanolin, it's just something to keep in mind.  

In general, I'll recommend that people with sensitive skin use fragrance-free or free and clear moisturizers, which differ from unscented moisturizers as unscented moisturizers might have another additive added to remove a scent. So, look for fragrance-free or free and clear if you have sensitive skin.

(04:27): So, what are some tips for basic skincare? It's good to use a mild, gentle cleanser. Dermatologists often recommend Dove moisturizing soap, and you don't need to use soap on all areas of the body; just focus on the soiled or sweat gland-containing areas.

(04:44): In general, it's a good idea to avoid bubble baths, scented salts, or oils for some of the same reasons that I discussed on the prior slide. We typically recommend taking a lukewarm bath or shower, not using hot water as this can lead to drying of your skin further, and not to shower more than once daily, and to shower for only a short period of time, like 10 to 15 minutes. Afterwards, when you get out of the shower, just pat dry gently. You don't have to rub roughly; this is typically the best time to put a topical on. So if you're planning to use a moisturizer, it's good to apply that within three minutes of exiting the bath to kind of lock in the moisture that you already have on your skin.

(05:30): If you've been prescribed a topical steroid for a rash, it's good to apply it first. So apply it immediately after the bath within the first few minutes and then follow that with the moisturizer. Although it's very hard to execute, try not to scratch itchy skin. Scratching can worsen the itching and lead to thickening of the skin that provokes further itch sensations.

(05:58): Infection a common reason why patients develop a skin rash after transplant. There are many different reasons that someone can develop a rash after transplant. One large category of rashes includes infections and there are many different etiologies of infections.

(06:13): First, we're going to start with bacterial infections. Bacterial infections can occur because there are bacteria that make contact with our skin. We can also have bacterial infections of the skin from bacteria that are in our blood causing a blood infection.

(06:31): Typically, we can diagnose these types of infections by the clinical appearance, but sometimes further tests are necessary. You can see in the upper right corner a patient with impetigo with these honey colored crusts around the mouth. Next to that you can see a deeper bacterial infection called cellulitis, and in the bottom corner you can see an infection around the hair follicle called folliculitis and folliculitis is quite common post-transplant for multiple different reasons.

(07:03): Here we're seeing this due to a bacteria and in the last photo, this is a bacterial infection of the skin from a source in the blood. So if the clinical picture and the exam findings don't clearly lead to a diagnosis, we may do a culture and we also may do a culture to try to find out what the particular bacteria that's causing this rash is. And those results are usually available in a few days. Sometimes they're helpful in choosing antibiotics to treat the condition. Sometimes we need to know the results because there could be resistance to the antibiotic that we might've already chosen.

(07:46): For deeper rashes that cause a deeper infection, sometimes we'll do a biopsy if the diagnosis is not clear clinically or if we want to get tissue to culture to try to identify what the bacteria are that's causing this deeper infection. Treatment is often with topical antibiotics or other antimicrobial agents. Sometimes we use oral antibiotics, and for more serious infections, we might need to use intravenous antibiotics.

(08:18): Viral infections from the herpes family of viruses can also occur after transplant. Moving on to a viral infections. There are many types of viruses that can cause problems post-transplant. Sometimes these are respiratory viruses or other viruses that lead to fevers and sometimes you can have a rash as a manifestation of those viruses.

(08:37): Here I'm referring to viral infections that are particularly of the skin and that's often with the herpes virus family of viruses. So this includes herpes simplex virus, or HSV or varicella-zoster virus, which also causes chickenpox and shingles.

(08:55): You can see in the upper right this grouping of blisters on a background of redness, and this is characteristic of a herpes virus infection. And below that, similarly you can see these blisters on a background of redness, but they're only occurring in a certain line on the skin called a dermatome and this is typical of shingles. It can be in many different areas, but usually in a somewhat linear fashion.

(09:22): Oftentimes people have already been infected with these viruses previously and then the virus reactivates and manifests with this rash. But sometimes they can be transmitted by skin-to-skin contact post-transplant and rarely in the airborne setting.

(09:40): Typically, we'll scrape the bottom of the blister to try to culture the virus or send it for a molecular test to identify what type of virus it is. Often, a patient will be treated with an antiviral medication such as an oral or, if the rash is very extensive, intravenous antiviral medication.

(10:06): Viruses can also lead to the development of benign skin lesions. Two of those are here. One of them is molluscum contagiosum, which is from a virus that is actually very common among kids. Adults are less likely to show disease manifestations from it as they've often developed immunity to it. But in the post-transplant setting, sometimes molluscum can develop.

(10:33): These are typically transmitted by skin-to-skin contact and can even be transmitted by wet towels that have been used by someone who has the virus. Typically, they can be treated with cryotherapy, which is freezing of the spots. They can also be treated with curettage, which is kind of scraping off of the spots. And there are a variety of topicals that can be used. This isn't typically a dangerous condition, but it can be a nuisance when new spots keep developing.

(11:03): Another viral-induced benign skin lesion that can be a problem post-transplant are warts, also called verruca vulgaris. Now these are very common as well in kids and in people who have not had transplants, but they can be particularly problematic in patients post-transplant in that they can get large, or patients can develop multiple lesions. This is due to the human papillomavirus, and there are many different types of human papillomavirus. Our skin is in contact with many different types, but our immune system can often defend against them.

(11:38): There are types of human papillomavirus that can be associated with skin cancer, cervical cancer, or oral cancer, but the type of human papillomavirus, or HPV, that causes warts is typically low risk for skin cancer.

(11:55): Typically, the warts come out due to viral reactivation, and there are multiple different ways that they can be treated. One is with a decrease in immunosuppression. They can also be treated with cryotherapy or freezing, and oftentimes we'll have patients come into the office, we'll pare them down with a blade and then freeze them.

(12:15): Once the sites heal from the treatment, a patient may apply topicals to the area at home, as the virus can then lead to regrowth of the wart. Unfortunately, this process often involves multiple treatments in the office. Sometimes, it can be treated with injections that try to make the body's immune system attack the virus in these spots, or other topicals that try to sensitize the immune system to the virus.

(12:45): Fungal infections can also be an issue post-transplant; they can often present as dermatophyte infections like ringworm. Here you can see, on the upper right, an example of this infection. They can also be very superficial, like tinea versicolor, and you can see that in the image next to that with the light brown spots that have subtle scale overlying them. They can also be somewhat pink sometimes.

(13:14): People can also develop yeast infections from candida, as shown by the bright red rash below. It is also known to have satellite lesions or smaller spots next to the larger patches. Candida can also manifest in the mouth with the development of white debris.

(13:31): Rarer opportunistic fungal infections can also cause deeper rashes. Diagnosis can often be achieved by clinical observation, but sometimes a scraping is done, and we can look for a fungus under the microscope. We can also send the specimen to the lab for a culture to try to identify the organism and its susceptibility to antifungal medications.

(13:57): In rare situations when it's a deep fungal infection, we sometimes do a biopsy to identify the fungus, and sometimes, this biopsy can also be used to culture it to try to identify the fungus and what medications we need to use to treat it.

(14:12): For superficial fungal infections, we'll typically use topical antifungal cream or shampoo. If the rash is very extensive, we'll sometimes give an oral antifungal. In very rare situations, for rare fungal infections, we'll sometimes do surgery or debridement.

(14:32):  Transplant patients may also experience drug rashes in response to medications. So moving away from infections, there are a variety of other types of rashes that are more inflammatory in etiology. One large category is the set of drug rashes. Now drug rashes are sometimes described as morbilliform drug rashes or maculopapular rashes, and this is typically referring to redness on the skin that can be flat or bumpy, it can be quite extensive and it can be associated with severe itch.

(15:01):  Sometimes it can be treated with topicals, but sometimes oral medications are needed, and typically these morbilliform drug rashes occur many days to a few weeks after starting a new medication. In the post-transplant period, they can look similar to a generic viral infection or a graft-versus-host disease rash. So sometimes the diagnosis can be tricky. Sometimes a biopsy is done, sometimes it's not, as it may not be helpful, but identifying new medications before the onset of the rash will be very important.

(15:33): Sometimes these rashes can lead to facial swelling and be more severe, associated with fever or involvement of the liver, the kidneys, or the heart. So, looking out for worsening of rashes and systemic symptoms is also important when this occurs.

(15:51): There's another type of drug rash that is uncommon but very severe, a blistering drug rash, called Stevens-Johnson syndrome or toxic epidermal necrolysis. These are very severe rashes, and it's very important to stop the medication causing this and support the patient with wound care, with fluids and electrolytes to make it through the drug rash. And there are a variety of treatments used still under investigation.

(16:19): In the post-transplant period, a lot of new medications are started, so keeping a drug diary can be helpful. Certain drugs are associated more often with certain rashes and the timing before the development of these rashes varies. So knowing when new drugs have been started can be helpful if this is to occur.

(16:40): Hair loss is a common problem post-transplant. Oftentimes, people are dealing with

non-scarring hair loss, and this may be a result of chemotherapy and radiation, as well as of stressors like the stress of the transplant itself.

(16:58): There are many types of reversible hair loss, and typically the hair loss due to chemotherapy and radiation starts two to four weeks after starting these medications. The loss due to the transplant itself may be a few months after transplant. Usually this is reversible, but there are settings where people develop persistent hair loss due to the chemotherapy. In general, in this situation, you want to minimize trauma to the scalp and protect from the sun when there's less hair to protect the scalp.

(17:30):  Pattern hair loss can develop, which is female pattern hair loss and male pattern hair loss, and this can be uncovered by the temporary hair loss that one can see post-transplant. There are many possible treatments for this type of hair loss including oral and topical minoxidil and oral and topical 5-alpha reductase inhibitors.

(17:48): And the goals of the treatment are typically to support the hair growth post-transplant when this is the reversible hair loss, improve the appearance of the hairs that are there, make them appear thicker and prevent further loss.

(18:06): It's also possible to develop scarring, hair loss post-transplant, and this can be due to graft-versus-host disease or an infection and the goal would be to treat early after the diagnosis is made to prevent further scarring, as it's difficult to lead to hair regrowth after the hair follicles have scarred.

(18:28): Nail changes also can occur post-transplant and they present in 17 to 63% of chronic graft-versus-host disease patients. It's thought that the development of nail changes does not correlate with the overall severity of graft-versus-host disease, but it can happen more frequently in patients with a longer duration of graft-versus-host disease.

(18:49): You can see on this slide various examples of the different types of nail changes that can occur, some of which are due to the stress of the transplant. The growth of the nail can stop and then the nails will regrow, but there will be a ridge in the nail.

(19:05): There can also be longitudinal ridging of the nails. Sometimes the nails can be kind of disordered and thick and there might be a concern for infection. So we can sometimes do a clipping to look for a fungal infection either by pathology or by culture.

(19:22): Sometimes bacteria can get under the nail and it may appear green and that can be due to a bacterial infection.

(19:30): When these nail changes are persistent, we want to rule out nutritional deficiency so your dermatologist can order blood work looking to evaluate for various vitamins and minerals, and a good policy is to avoid irritants of the nails, and that's oftentimes water. So, wear gloves while doing the dishes and limit contact with water when possible. Also using moisturizers and strengtheners of the nail, even moisturizing with Aquaphor can be helpful.

(20:02): Many different types of skin lesions can develop after transplant. Some can be precancerous.

First, we're going to be discussing actinic or solar keratoses, and these are considered to be potentially precancerous. There's a low risk of developing skin cancer from one of them, but it is possible, and you'll see a variety of numbers listed in the literature. They're believed to be atypical keratinocytes, which are the skin cells, and are most often induced by sun damage.

(20:34): In the picture above, you can see the rough scaly spots that are often pink, which are typically associated with actinic keratoses. And in the lower photo you can see in the center that a squamous cell carcinoma, a skin cancer, has developed in a background of these actinic keratosis. Most often they'll occur in areas that get a lot of sun, for example, the face, neck, tops of the hands, forearms, scalp, and this can even involve the lips and it has a different name when it involves the lips.

(21:08): Skin lesions can be treated by several methods. When a patient has scattered isolated lesions, they're typically treated individually, often with cryotherapy or freezing, but when there are many of them, they're often not treated individually, and we use a method called field therapy to treat them.

(21:27): Oftentimes, we'll use various topicals. Very commonly people will use something called 5-fluorouracil or Efudex and you can see in the photo to the right a patient that has applied 5-fluorouracil over the forehead and nose and a different patient who has applied it to the chest, and you can see a really strong reaction on the chest with redness. And this happens because the treatment identifies the precancerous changes in cells. So not only are the gritty pink spots treated, but the surrounding skin.

(22:00): There are other less common ways to do this field therapy including chemical peels and photodynamic therapy. Not all practitioners have these available in their offices, but it is something that you might be offered by some people. The goal is to control the skin damage, but unfortunately, all of these types of treatment have a high rate of recurrence, so it's possible that repeat treatments will be needed in the future.

(22:25): Transplant patients are at increased risk of skin cancer. Moving on to malignant skin problems. Allogeneic hematopoietic cell transplant recipients are at an increased risk for skin cancer. One study done in Northern Europe had noted that 2.6% of allogeneic transplant patients had skin cancers compared to 0.9% of the age-matched sex-matched population. These are typically non-melanoma skin cancers including squamous cell carcinoma and basal cell carcinoma, but also melanomas and more rare non-melanoma skin cancers are possible.

(23:00): Basal cell carcinoma is the most common skin cancer. It's usually localized, it very rarely metastasizes, but it can be more aggressive depending on specific features of the particular tumor or the patient's immunosuppressive status.

(23:19): Here you can see multiple different types of basal cell carcinomas. You'll often hear them described as being pink or having a pearly shiny appearance. Sometimes they can be red scaly bumps. They might be a spot that you note bleeds easily and they may appear to be scar-like. You can see in one of these photos that it can be quite dark or pigmented as well.

(23:45): They're typically slow growing, but they can become large if they're left in place and it's possible that they'll ulcerate or open up and be crusty and they could bleed. They could also continue to grow where they are if untreated and become locally destructive.

(24:03): Basal cell carcinoma can be treated with several methods. First, we'll do a skin biopsy to achieve the diagnosis, and this is helpful because there are different types of basal cell cancers. Some of them are superficial, there's also the nodular type and then there are more infiltrative types that are more difficult to treat and may go deeper in the skin and the treatment choices depend on the pathologic features of the basal cell carcinoma, the location of the tumor and its size.

(24:31): Oftentimes, they're treated with surgery, and I'll go into the details of that. Sometimes they're treated with destructive methods such as electrodesiccation and curettage, which are common. This is a technique where there is scraping of the spot and then burning of it and sometimes multiple rounds of this. And this aims to destroy the skin cancer where it is, but it's not cut out, and it's not sent to the lab to evaluate the margins. There's a slightly lower cure rate with this, but for some types of skin cancer, it can be indicated.

(25:05): Other options include cryotherapy or freezing 5-fluorouracil like we discussed for the precancerous spots or radiation.

(25:14): Oftentimes surgery is done and this would include an excision where the skin cancer is cut out with a margin of normal skin and then the tissue is sent to the laboratory to be evaluated under the microscope to ensure that the margins are clear and it's a good way to cure the site.

(25:33): For basal cell cancers that are on the face or that are larger or higher risk or the scalp, neck, tops of the hands, shins, Mohs micrographic surgery may be indicated. In Mohs micrographic surgery a specialist, a Mohs surgeon, will remove the skin cancer and try to take out as little as possible and then look at the pathology under the microscope in the immediate period and evaluate the margins of the specimen and see right then if it appears to be clear or not. If it's clear, the site can be closed or wound care recommendations can be made. But if it's not clear, the Mohs surgeon goes back and takes another section and continues the cycle of taking further sections and looking under the microscope until the lesion is cleared.

(26:27): Squamous cell carcinoma presents differently but can often be treated with the same methods as basal cell carcinoma.  Moving on to squamous cell carcinoma, these typically appear as scaly pink bumps. They may cause pain, they can ulcerate or open up, they may bleed, they may crust. Sometimes they can present  as dome shaped crater-like bumps, and this is a particular type of squamous cell carcinoma that's quickly growing but can be pretty well-behaved. In general, squamous cell carcinomas have a greater potential to recur, invade, or metastasize compared to basal cell carcinomas.

(27:00): Here you can see some more extensive squamous cell carcinomas that you could envision being difficult to clear. On the right, it looks like there's a grouping of squamous cell cancers together.

(27:09): The treatment of squamous cell carcinoma is similar to basal cell carcinoma. First, a skin biopsy is done to diagnose the squamous cell carcinoma and identify features under the microscope that might say if there's a better or worse prognosis for it, and treatment, again, depends on the location and the size of the cancer. And the same types of methods are used to treat squamous cell carcinoma, but they're typically treated a little bit more aggressively than basal cell carcinoma and sometimes may require further imaging or evaluation of the lymph nodes.

(27:48): Melanoma presents with features that are described by ABCDEs of melanoma. Next we're going to talk about melanoma. And you may have heard about the ABCDE's of melanoma. These are features you can use to examine the skin looking for melanoma.

(28:00): So A stands for asymmetry. If you were to fold the lesion over, it wouldn't fold on top of itself. B stands for border. You would look for irregular borders or scalloped borders. C stands for color. Multiple different colors or irregular colors. You can see in this picture there's black, there's dark brown, there's light brown, there's a whitish blue appearance, there's even pink. Diameter is D. Typically melanomas are larger, but there can be small melanomas as well. And E stands for evolution or changing.

(28:36): Melanomas are typically thought of as dark brown or black, but they can sometimes be pink. Here we see one that's pink and brown.

(28:46): Treatment of melanoma starts first with the full diagnosis that's achieved by doing a skin biopsy, and this helps us look at the depth of the melanoma which tells us how it should be further treated. There are different margins that are taken depending on the depth of the melanoma, and sometimes it's treated by a dermatologist and sometimes by a surgical oncologist. They're most often excised and a patient may require imaging or a lymph node biopsy and may require additional systemic therapy depending on the results of the prior tests.

(29:19): There are several risk factors for skin cancer after transplant including sun exposure, the primary cancer, its treatment, and GVHD, as well others. What are the risk factors for development of non-melanoma skin cancers like basal cell or squamous cell carcinoma? Sun exposure is a big risk factor. Having a primary diagnosis of leukemia, lymphoma, malignant marrow disease or severe aplastic anemia can be a risk factor for the development of basal cell or squamous cell carcinoma, having lighter skin color, having a younger age, at transplantation, having received total body irradiation, having chronic graft-versus-host disease and having a history of use of immunosuppressive medications for greater than 24 months.

(29:56): Melanoma shares some of these risk factors as well as personal or family history and other risks. Some of these factors can also play a role in melanoma development, but we also think about patients that have a personal or family history of melanoma as being at higher risk, people that have many moles to start, patients who have had T-cell depleted transplant, female recipients and patients who have had total body radiation. Studies done in solid organ transplant recipients have identified other features that suggest the timing of these patients in regard to when they get their skin cancer screening and these haven't directly been addressed in hematopoietic cell transplant patients but could be considered when thinking about your own risk for skin cancer, including history of previous skin cancer or precancerous lesions. If you've spent more than an hour outside daily, being greater than 50 years old, living in a hot climate for greater than 30 years, having many sunburns and having decreased pigment in the skin.

(30:54): Skin cancer can be detected through self-exams and routine cancer screenings. So what can you do to look out for skin cancers? The Skin Cancer Foundation recommends self-exams. You can use the ABCDs of melanoma as we discussed. Look for new growing lesions or open sores. Look for spots that itch, hurt crust, scab, bleed. To do these self-exams, you'll want to be in bright light, use a full-length mirror to see areas of the body that are difficult to see, and you can use a hand mirror to further reflect against the full-length mirror to see these areas better. You can also use a blow-dryer to look at someone's scalp, and asking for help from family can also be helpful, as it's sometimes difficult to see everywhere on yourself.

(31:40): Also go to a local dermatologist for skin cancer screening. Although patients that have not had a transplant, there are not clear recommendations as to when or how often they should see a dermatologist. A lot of people do go once a year in post-transplant. I think that's a good recommendation to go at least once a year.

(31:59): If you've had a history of prior skin cancer, the recommendation is typically to go every six months. And if you've had a recent melanoma, it would be even more frequently every three months and then every four months and then every six months after a few years have gone by.

(32:17): To prepare for the skin check, you would want to think about any lesions that are of concern to you, come in without nail polish and makeup so the nails can be observed and the face can be observed more fully and wear hair loose so the dermatologist can look at the scalp. You'll also want to remove jewelry or watches so all of the skin can be observed.

(32:41): Sun exposure is a common cause of skin cancer so using sunscreens is crucially important. So let's talk about sun exposure. Ultraviolet radiation is a cause of skin cancer and it's thought that in the United States, at least one in five people will be diagnosed with skin cancer. Some post-transplant medications can also sensitize to the sun. This can lead to more sun damage, and it can also lead to rashes. In some people, sun exposure can trigger graft-versus-host disease.

(33:04): So it's important to think about the sun exposure you're getting post-transplant and it's important to do sun protection. The sun protection can help prevent skin cancer and it can also help prevent the development of benign skin lesions that may occur more frequently in sun-exposed skin. There are some rashes that can occur due to sun exposure as well. And also, sun protection is very important to help with the aging process and help prevent further aging of skin.

(33:37): One of the best ways to do sun protection is to use sunscreen, which limits UV wavelengths that interact with molecules in the skin. They're considered over-the-counter drugs regulated by the FDA, and sunscreen is labeled with a sun protection factor, which measures the amount of UV radiation exposure it takes to cause sunburn when using sunscreen compared to how much UV exposure it takes to cause sunburn without sunscreen. So an SPF of 20 would lead to the ability to tolerate 20 times the amount of sun exposure with sunscreen compared to what you could tolerate without sunscreen.

(34:14): Sunscreens may also be labeled with the term broad spectrum, which means that they protect against UVA and UVB light and they also may be labeled as water-resistant.

(34:26): Here you can see a graph that shows the SPF value on the X-axis and the redness radiation filtered on the Y-axis, and you can see that an SPF of 30 filters 96.7% of radiation and an SPF of 50 filters 98%. But as the number goes up, it doesn't really change very much.

(34:51): Sunscreen forms a coating on the surface of the skin that filters out radiation and sunscreens come in different forms. They may have active ingredients that are considered to be chemical sunscreens. They also may have active ingredients that are considered to be physical sunscreens. If you see a list of many different active ingredients on the back of a sunscreen, it likely has multiple different chemicals and there are two typical physical sunscreens that you may identify, those are titanium dioxide and zinc oxide.

(35:21): Sunscreens act by absorbing light or scattering light energy. There can also be the addition of iron oxide to sunscreen and this can help tint sunscreen and this is helpful for the physical blockers that may appear very white, but it also can protect against UV invisible light and can help prevent redness and darkening of the skin that may occur due to visible light.

(35:48): So some patients will say their sunscreen didn't work. So why doesn't sunscreen always work? People don't often apply sunscreen at the same thickness as has been studied in the clinical studies. So most users will often apply 20 to 50% of the suggested amount of sunscreen.

(36:07): To cover the skin of an adult, it's recommended to use two to three tablespoons of sunscreen or one to one and a half ounces like in the shot glass in the image for the face. It's usually recommended to use one to two teaspoons of sunscreen for the face. So what are strategies to improve outcomes? You could apply the sunscreen twice in a row and you could use a product with a higher SPF.

(36:31): Other ways to protect against sun exposure include avoiding direct sun exposure between 10:00 AM and 4:00 PM, seeking shade to shelter from direct sun, and wearing protective clothing. There is sun protective clothing that has a rating with a UPF similar to the SPF, and this can be really helpful. Wearing a hat, make sure it's a wide-brimmed hat to protect your face, your ears, and your neck, and also wearing sunglasses. Apply sunscreen to all exposed skin when outdoors. Use sunscreen that is labeled with a broad spectrum and we usually recommend an SPF of 30 or higher and use the appropriate amount of sunscreen as we discussed on all exposed skin.

(37:16): Other guidelines include to apply sunscreen 15 minutes before sun exposure, use water-resistant sunscreen and it's recommended to use it not only if swimming or perspiring, but it's more important if you are. Reapply sunscreen every two hours particularly if swimming or perspiring. And sometimes when using spray sunscreens, you just have to be careful that you know how much you're putting on. So make sure to use a liberal amount of spray sunscreens.

(37:46): So there are sunscreen controversies that people discuss, but sunscreen's been utilized for decades, has a great safety record, the concerns typically come from animal and lab studies and haven't been seen in human studies and the setting that these other studies in animals have been done is difficult to compare to the real-life use in humans. So overall, the risk-benefit analysis favors sunscreens.

(38:14): The actual side effects that you can think about include irritation and allergic reactions, and some people do have sensitivities to particular sunscreen ingredients. Oftentimes, people react when they do react to inactive ingredients that may be in the sunscreen. Typically, if you are sensitive to sunscreens, you'd be less likely to be sensitive to those with only the physical blockers like zinc oxide or titanium dioxide, unless it's one of the inactive ingredients. And if this is a problem for you, you can discuss with a dermatologist or an allergist, and they can consider testing to identify what particular ingredients are problematic for you.

(38:58): So do we need sun exposure to generate vitamin D? Sun does play a role in the generation of vitamin D, but it's been found that vitamin D levels in sunscreen users are lower than non-users but are still within the normal range and it's possible to get vitamin D from food like fish oils, fortified milk and milk products or from supplements. So it's typically recommended to use sunscreen and make sure your vitamin D levels are checked and you can get vitamin D from other sources if necessary.

(39:29): Indoor tanning should be avoided because it significantly increases the risk of skin cancer. Lastly, I just want to touch on indoor tanning. Indoor tanning is thought to contribute to 400,000 skin cancers each year. It leads to a 75% increased risk of melanoma from one indoor tanning session before the age of 35. Any use of tanning devices is associated with a two-and-a-half times higher risk of squamous cell carcinoma and a half times higher risk of basal cell carcinoma.

(39:53): Women with basal cells have an average twice as many visits to tanning beds, and women younger than 30 are 6 times more likely to get melanoma if using indoor tanning beds. So definitely recommend not to do indoor tanning.

(40:08): So to summarize, transplant patients are at risk for malignant and non-malignant skin problems. There are good dry skin care techniques that can help alleviate itch, rash and are just a good policy for people in general. Sun protection is important. Skin cancer screening should be done regularly. A variety of rashes can merit dermatologist evaluation.

Question and Answer Session

(40:34): Marsha Seligman Thank you, Dr. Rosenstein for this wonderful presentation.

Our first question, "I've had several skin yeast infections in the genitalia, my transplant was four years ago. What preventative measures can I take?"

(41:07): Dr. Rachel Rosenstein: So I think part of this depends on the sex of the patient and where in particular the rashes are. I can comment on infections in the skin folds.

(41:23): Very often patients may have more sweating in that area and that area can predispose to fungal infections. So minimizing moisture in the area, minimizing sweating can be helpful for patients who have the problem in the skin fold.

(41:42): Sometimes, using an antifungal powder as maintenance can be helpful just as a routine to prevent the development of fungal infections. However, if the infections occur, you'll need topical antifungal creams or, in rare situations, oral medications. I don't want to comment on vulvar fungal infections or, sorry, vaginal fungal infections in particular. I would leave that to a gynecologist.

(42:14): Marsha Seligman: The next person first wants to thank you for your presentation and would like to know do you recommend the use of gloves for sun protection. They said their hands usually get the most sun exposure because they end up washing off the sunscreen before going outside. Are the hands a common place for skin cancer?

(42:33): Dr. Rachel Rosenstein: That's a great point. Hands are a common place for skin cancer. They do make sun-protective gloves. A lot of people will wear them driving and I wanted to make the point and I forgot to, when you're in the car, you can still get UV exposure through the windows. So time in the car, it's still important to wear sunscreen.

(42:53): Wearing gloves in the car would be great. Wearing gloves for sun protection on the beach would be great and washing off sunscreen is definitely a concern. So reapplying is really somewhere where you can also have help, but reapplying is very important not only for the hands, but I like the idea of using gloves for the hands.

(43:14): I also wanted to mention, and I forgot to mention during the presentation that even on cloudy days, even in the wintertime, it's still good to wear sunscreen and it's great to make it part of your daily routine. Before you leave your bedroom in the morning, put on sunscreen so you have that base even if you're not planning to be out much walking from building to building if you have appointments or you're going shopping or you're in the car, it's just good to get into that habit.

(43:41): Marsha Seligman: Okay, the next person has a question also about sunscreen and they'd like to know if they should use sunscreen underneath sun-protective clothing.

(43:52): Dr. Rachel Rosenstein: That's a good question. A lot of sun-protective clothing has a high UPS and in my personal experience, I haven't found that I've gotten much sun exposure through that. I would say if you have noticed that you're still getting tan or burn under the UPF you could use sunscreen, but oftentimes it can be sufficient.

(44:14): But I think we also have to just be aware that it doesn't cover everything. So making sure parts of the neck that are not covered by the clothing are covered with sunscreen and the tops of the ears, the hands, just making sure all the areas that could be exposed are covered either with clothing or sunscreen is important.

(44:36): Marsha Seligman: Okay. I know you talked about the nails in your presentation, but someone would like to know if you could describe signs of nail changes to watch for. They want to know are rigid nails a cause for concern either pre- or post-menopause age?

(44:54): Dr. Rachel Rosenstein: So there are a lot of different changes that can occur in the nails post-transplant and also as time goes on, bridging is very common to occur in people who haven't had a transplant as well and can be associated with dryness and with aging, and I'd say ridging is one of the most common nail signs that people have. Moisturizing the nails can be helpful, moisturizing the skin around the nails can be helpful and I wouldn't say that it's a point of particular concern for GVHD or for other problems, but if it's something that bothers you, there are ways that you can try to address it.

(45:36): Marsha Seligman: "My sweat glands are not working following bone marrow transplant; will this ever go away?" The problem is obviously more difficult in the summer.

(45:50): Dr. Rachel Rosenstein: And that is something that I've heard particularly in patients with sclerotic skin involvement. Sometimes the fibrosis might lead to destruction of the sweat glands and I think it depends on why this is happening, if it will improve or not. But yes, the summertime must be very difficult and not having the ability to sweat to aid in temperature regulation can make things very difficult. I'm sorry that you're dealing with that. I think it all depends on how long it's been going on and how the factors leading to the decreased sweating are affecting improvement.

(46:40): Marsha Seligman: Okay. The next question comes from a caregiver. They'd like to know what they should bring with them to have on hand after their spouse's CAR T-cell therapy.

(46:54): Dr. Rachel Rosenstein: I think when people are dealing with these major treatments, setting them up for success with the skin would involve good dry skincare, gentle moisturizing creams and using them twice a day even if there's no problem with the skin.  

Obviously one should listen to the local healthcare team and run anything by them, but moisturizing the skin with a gentle cream twice a day would be helpful, protecting from the sun when out of the hospital and even if there's no skin problem, just setting the skin up for success by using the good dry skincare tips like not taking a lot of hot showers, not spending a lot of time in the shower, not using harsh soaps would be a way to kind of have a good background to recognize if anything concerning showed up in the future.

(47:53): Marsha Seligman: The next question is, "I currently have a rash caused by yeast for nine months. I use Nystatin powder and fluconazole, but it is not working. I am diabetic post-transplant one year and two months. Is this related to Revlimid (lenalidomide)? It isn't clear yet, so they want to know what could be causing that?

(48:22): Dr. Rachel Rosenstein: I think it partly depends on what other medications you're on. If you are requiring a lot of immunosuppressive medications for graft-versus-host (GVHD) disease or for treatment of a recurrent cancer. Diabetes can contribute to the development of fungal infections.

It's hard to know if someone has done a culture, if they know for sure what particular strain is growing and if there's resistance in that strain. If you've received a lot of fluconazole and Nystatin, maybe those wouldn't be the choices for you. Maybe you would need something different. But it's possible that this all relates to the current therapy or prior therapy, but if your current providers are not clear that it does, seeing an immunologist might be helpful too.

(49:26): Marsha Seligman: Are spider veins on my face treatable after a stem cell transplant? Is this a side effect of the treatment or medications I am taking for immunosuppression?

(49:38): Dr. Rachel Rosenstein: So different vessels on the face can develop post-transplant, which can be related to conditions that develop post-transplant or medications. I do see rosacea develop in patients post-transplant somewhat commonly, which can be associated with telangiectasias or little vessels on the face.  

The use of steroids, both systemically and topically, can also be associated with the development of these red vessels. So it all depends on your underlying health now, and if you have other rashes or GVHD on the face.

But if things are overall going well, and if your doctors agree, there are lasers that can be used to treat vessels on the face and they can be effective, but they can be associated with bruising and you would want to check with your team to see if they would be okay with that or not.

There are also topicals that can be used for redness on the face. They're not always effective, but they might be something to start with to see if that's helpful enough. And those would be topicals that are sometimes used for rosacea.

(50:52): Marsha Seligman: "Do you have any advice about how to care for steroid-thin skin that bruises and easily scars? Any tips to toughen up or thicken the skin?"

(51:03): Dr. Rachel Rosenstein: So that's a very common problem post-transplant and oftentimes people will be most bothered by it on the forearms. So we call this solar purpura, where it's thinning of sun-damaged skin, and this can be worsened by having had exposure to steroids, both topically and systemically.

Some of my post-transplant patients find that moisturizing with a nice cream twice a day can make a significant impact. I've had people come back and say how much better they're doing after moisturizing twice a day. Also, protecting from the sun can be helpful because some of this can be related to sun damage in this area. Protecting from the sun also gives the body an ability to repair.

A lot of dermatologists and others are trying to put compounds together and are marketing them on their own. I don't know that large studies have been done to validate their efficacy, but I know they're out there. I can't really comment on their efficacy because I don't think they've been studied in a very rigorous manner yet. But people are developing compounds to try to help with the bruising in thin skin that can occur with steroid use or as time goes on.

(52:26): Marsha Seligman: "Do you recommend vitamin E oil for the skin?"  

(52:31): Dr. Rachel Rosenstein: I don't routinely recommend vitamin E oil. I like simple over-the-counter moisturizers that are not very expensive. If the question is related to scarring, I usually recommend silicone sheets. If someone has had a procedure or traumatic scars that have developed, you could start using them several weeks after the sites have healed, and sometimes, that can help with scarring.

(53:07): Marsha Seligman: "Is there any amount of sun that is okay on a daily basis?" And they did also ask about sunscreen, which you did hit on, but they'd like to know if they should use it daily.

(53:19): Dr. Rachel Rosenstein: I do recommend that sunscreen be used daily. As I said during the talk, most of us, and sometimes I myself, don't put enough sunscreen on. So I think we are getting more sun exposure than we anticipate.

So I don't say that there's any particular amount that is safe, but there are certainly safer situations and certainly less safe situations. And I think it has to do with where you're going to be, what time of day, and how long you're going to be in the sun. As a good routine, I recommend daily sunscreen and then reapplying it if you're really going to be out there for a long time.

(54:05): Marsha Seligman: Someone would like to know if it is safe to use acne products with retinols or retinoids.  

(54:14): Dr. Rachel Rosenstein: So retinoids are great for acne and sometimes acne can be a concern post-transplant and retinoids can be quite safe. Still, sometimes they can be difficult to tolerate, so they can be associated with redness, irritation, scaling, and different strengths of retinoids. So sometimes you'll have to start out using a lower strength and maybe work up to using a higher strength.

When people are using retinoids, I typically recommend using a very small amount, a pea-sized amount for the whole face at night and to start using it just a few times a week and slowly increase as tolerated to using it every three nights, every other night, and if you can, nightly. If you can't, stick with the frequency that you can tolerate, you can try to avoid the side effects like irritation, redness, and scaling.

One concern with retinoids is sensitivity to the sun, which is a bigger concern if you're using them. Wearing a hat and sunscreen is particularly important regardless, and moisturizing twice a day is important, too. If you're able to manage the possible local side effects of the retinoid, use sunscreen, protect from the sun, and moisturize, that can be safe and helpful for acne.

(55:48): Marsha Seligman: Closing. On behalf of BMT Infonet and our partners, I'd like to thank Dr. Rosenstein for this wonderful presentation. And thank you the audience for your excellent questions. Please contact BMT Infonet if we can help you in any way.