Inflammatory Skin Diseases in Solid Organ Transplant Recipients

Conclusions

• Inflammatory dermatoses are common in solid organ transplant recipients, affecting up to about one quarter of patients, and are likely under-recognized compared with skin cancer and infection.
• The pattern of disease in transplant recipients is shaped by multiple mechanisms, including immune skewing from immunosuppressive drugs, barrier and microbiome disruption, resurfacing of pre-existing disease, and cancer-therapy–associated inflammation.
• Some dermatoses, such as bullous pemphigoid, prurigo nodularis, and lupus, appear to be more frequent in transplant recipients than in controls, while atopic dermatitis and psoriasis may be similar to or lower than background rates overall.
• Rosacea and seborrheic dermatitis can be driven by microbiome-related factors such as Demodex and Malassezia, and these conditions may respond well to targeted therapy like ivermectin.
• Immune checkpoint inhibitors can trigger multiple skin eruptions in transplant recipients, but they are being used more often because the balance of cancer benefit versus graft risk can be acceptable in selected patients.
• In a reported case, dupilumab successfully treated checkpoint-inhibitor–associated bullous pemphigoid while sparing steroids and preserving graft function and ongoing cancer therapy.
• Psoriasis often improves immediately after transplantation but can flare again when immunosuppression is reduced during maintenance therapy.
• For psoriasis in transplant recipients, topical therapy remains first-line for mild disease, acitretin and/or phototherapy are favored for more severe disease, and biologics are options for refractory cases.
• Published experience with newer psoriasis biologics in transplant recipients is limited but has not shown major safety signals, and these agents may have lower infection and cancer risk than older TNF inhibitors.
• TNF inhibitors have the largest safety dataset in transplant recipients, with overall infection risk that is substantial but generally comparable to immunocompetent patients on TNF inhibitors, and graft rejection appears uncommon.
• Atopic dermatitis can occur de novo or recur after transplant, with higher risk in younger patients, certain transplant types, women, those with atopic history, EBV infection, and eosinophilia.
• Dupilumab has the strongest evidence among systemic therapies for atopic dermatitis in transplant recipients and has not been associated with reported rejection in the published cases.
• JAK inhibitors may be effective but should be used cautiously in transplant recipients because of concerns about thrombosis, infection, malignancy, and liver test abnormalities.
• Overall management of inflammatory skin disease in transplant recipients requires individualized balancing of inflammation control, infection and malignancy risk, and graft survival, with biologics used selectively when needed.