Post-transplant sunscreen use is poor

Journal of Drugs in Dermatology, May, 2007 by Kendra G. Bergstrom

Post-Transplant Sunscreen Use Is Poor

Commentary on:

Sunscreen use before and after transplantation and assessment of risk factors associated with skin cancer development in renal transplant recipients. Moloney FJ, et al. Arch Dermatol. 2005;141:978-982.

Summary

This study surveyed 270 renal transplant patients at the national transplant center in Dublin, Ireland about their use of sunscreens before and after transplantation. Researchers assessed skin cancer risk in terms of skin phototype, outdoor occupations and hobbies, skin phototype, and years on immunosuppressive therapy using a survey format. The majority of patients were men (182 men and 88 women) ranging in age from 13 to 84 years (mean of 46 years). These patients were an average of 6.8 years post-transplant on a standard immunosuppressive regimen including prednisone, cyclosporine, and azathioprine.

Prior to transplantation almost 70% of patients never applied sunscreen. After transplantation only 25% of patients never applied sunscreen. People who never applied sunscreens were more likely to be men over age 50 with a history of skin cancer and outdoor occupations or hobbies.

In the cohort, 100 nonmelanoma skin cancers appeared in 56 patients. The majority were squamous cell carcinomas (SCCs), appearing on sun-exposed areas of the face, neck, forearms, and dorsal hands. The median time from transplant to first basal cell carcinoma was 3.5 years and to first SCC was 4 years.

Comment

As post-transplant patients live longer on immunosuppressants, management of their health may shift from acute disease management to mitigating some of the side effects of their long-term immunosuppressive regimens. Dermatologists have long understood that organ transplant participants are at an increased risk of skin cancer, particularly squamous cell carcinoma. This risk is mitigated by other factors including sun exposure, (1) HPV infection, (2) skin phototype, (3) and the length of time using immunosuppressive agents. (3)

This study evaluated predictors for skin cancer among a post-transplant population. The strength of the study lies in the broad cross-section of transplant patients from all over Ireland; the limitations are significant for survey format and recall bias. Ironically, the patients at highest risk for skin cancer in terms of increased age, history of skin cancer, outdoor occupations or hobbies, or history of blistering sunburns were least likely to protect themselves with sunscreen. On a more positive note, younger patients were more likely to use sunscreen. The longer survival of renal transplant patients is a very positive trend. However, it brings with it risks of long-term immunosuppression. For dermatologists in particular, immunosuppression increases the risks of ultraviolet-induced squamous and basal cell carcinomas and these risks will continue to increase with time. Education for patients is an important aspect of risk reduction but it is important to acknowledge its limitations. For this reason, increased surveillance of this at-risk population is critical.

References

1. Ramsay HM, Fryer AA, Hawley CM, Smith AG, Harden PN. Non-melanoma skin cancer risk in the Queensland renal transplant population. Br J Dermatol. 2002;147:950-956.

2. Harwood CA, Proby CM, McGregor JM, Sheaff MT, Leigh IM, Cerio R. Clinicopathologic features of skin cancer in organ transplant recipients: a retrospective case-control series. J Am Acad Dermatol. 2006;54:290-300.

3. Euvrard S, Kanitakis J, Decullier E, et al. Subsequent skin cancers in kidney and heart transplant recipients after the first squamous cell carcinoma. Transplantation. 2006;81:1093-1100.