Cutaneous Side Effects of Immunosuppression and Viral Infections in Solid Organ Transplant Recipients

Conclusions

• Common maintenance immunosuppression in solid organ transplant recipients usually centers on tacrolimus or cyclosporine, an antimetabolite, and prednisone, with regimen customization based on tolerance and risk reduction goals.
• Corticosteroids commonly cause acne, cushingoid changes, and striae, especially at higher doses or with prolonged exposure.
• Cyclosporine is associated with hypertrichosis and gingival hyperplasia, while tacrolimus is notable for alopecia that can often improve with minoxidil.
• Calcineurin inhibitors can also contribute to sebaceous hyperplasia, which may respond to retinoids or destructive therapies.
• mTOR inhibitors are useful conversion agents, especially when trying to reduce calcineurin-inhibitor nephrotoxicity or skin cancer risk.
• Switching from calcineurin inhibitors to mTOR inhibitors can improve skin cancer-free survival in transplant recipients with prior skin cancer.
• The most common early mTOR-inhibitor toxicity is painful oral or perianal ulceration, which may require dose adjustment or discontinuation if severe.
• mTOR inhibitors commonly cause acneiform eruptions, particularly in younger men, and these can often be managed stepwise with topical therapy, doxycycline, or isotretinoin.
• Impaired wound healing is a practical concern with mTOR inhibitors, so they are often held around surgery in coordination with the transplant team.
• Belatacept is a newer co-stimulation blocker that can be used de novo or as a conversion strategy to avoid calcineurin-inhibitor toxicity.
• Belatacept conversion may reduce skin cancer burden, but de novo belatacept has not yet shown the same clear skin-cancer benefit.
• Belatacept has relatively few recognized skin toxicities, but chilblain lupus and psoriasis can occur.
• Viral skin disease is common in transplant recipients, especially HPV-related warts, along with HSV, VZV, and molluscum contagiosum.
• HPV vaccination is recommended for solid organ transplant recipients, but real-world uptake is poor and represents a major prevention gap.
• Recalcitrant HPV disease may improve with combined approaches such as vaccination and systemic retinoids like acitretin.
• Kaposi sarcoma often responds best to reduction of immunosuppression and addition of an mTOR inhibitor when feasible.
• Human polyomavirus-associated dermatoses should be recognized early because they may signal significant immunosuppression and sometimes systemic involvement.
• Overall, dermatologic management in transplant recipients depends on recognizing medication-specific toxicities and coordinating immunosuppression changes with the transplant team.