Long-term dermatological surveillance valuable after liver transplant

Though skin cancer incidence is low, liver transplant recipients may still benefit from long-term dermatological surveillance to help monitor malignancies and infections, according to a recent Singapore study.

“The incidence of skin cancer after liver transplant is low in this Asian cohort, concurring with epidemiologic data worldwide,” the researchers said. “In our cohort, inflammatory skin conditions were most common after liver transplant, followed by cutaneous infection and benign cutaneous tumours.”

A retrospective cohort study was conducted using medical records of liver transplant patients with follow-up at the gastroenterology and dermatology departments of the Singapore General Hospital from 2006 to 2021. Subsequently, databases of PubMed, Medline, and Cochrane were accessed to review studies that documented the frequency of dermatologic conditions in liver transplant recipients.

A total of 99 liver transplant patients (mean age at transplantation 57.7±7.2 years, 68 percent men) were enrolled. Over a mean follow-up duration of 7.4±4.1 years, 79 percent (n=78) of the patients developed dermatologic diagnoses, of which inflammatory skin conditions were the most common (53 percent). [JAAD Int 2021;4:70-78]

Other skin diagnoses included benign lesions, such as cysts and seborrheic keratoses, and infections, including warts, folliculitis, herpes simplex virus, and fungal infections.

Notably, only 10 cases of malignant or pre-malignant conditions were detected, only four of which were eventually deemed malignant. One patient developed basal cell carcinoma, while three were diagnosed with Bowen disease. The remaining six had actinic keratosis, with 80 percent of detected lesions found in sun-exposed areas. All malignant/pre-malignant cases were treated with surgery or cryotherapy.

The accompanying literature review included nine eligible studies, corresponding to 10,193 liver transplant patients, followed for 3–9 years after the procedure. As in the retrospective analysis, skin malignancies were rare in the literature review, with a pooled incidence of 2.8 percent, with a reported range of 0.8 percent to 48 percent.

Such malignancies were more commonly detected 3 years after the transplantation, with a mean duration of 5.1 years after the procedure. In studies with 3 years of follow-up, the cumulative incidence of cutaneous malignancies was 1.1 percent, which jumped to 10.8 percent when looking at studies with at least 5 years of follow-up.

Opportunistic infections were also relatively common, with tinea infections and viral warts showing cumulative incidence rates of 48 percent and 8.7 percent, respectively.

“Although the skin cancer burden in liver transplant recipients is low in Singapore (a predominantly Asian cohort), control of viral wart infections remains a key area of need. Moving forward, a long-term dermatology follow-up should be routine for all liver transplant recipients, in view of the wide spectrum of skin conditions faced by liver transplant recipients,” which can be best managed by dermatologists, the researchers said.

“Future studies on larger cohorts will also be needed to better document the epidemiology of the cutaneous disease in Asia,” they added.