Study Underscores Need for Multidisciplinary Management of Skin Rashes in Patients Completing HCT

A new study found a high frequency of skin rashes among patients who underwent allogeneic hematopoietic cell transplantation (HCT). According to study authors, the results justify the multidisciplinary management of these high-risk patients, who can require early assessments from dermatological and hematological experts.

Findings were published in Journal of the European Academy of Dermatology and Venereology.

The atypical clinical presentation and biology biased by immunosuppression and graft present challenges for managing patients who experience cutaneous eruptions following HCT, the study authors explained. Because of this, the diagnosis has to be based on multiple grounds.

HCT is a therapeutic option for patients with malignant and nonmalignant hematological diseases. Malignant diseases include acute leukemia or multiple myeloma. However, the HCT itself and prophylactic immunosuppressive treatment can play different roles in different conditions.

“Whereas skin reactions following allogeneic HCT are common and may considerably impact the morbidity and the mortality of these patients, few studies have focused on their clinical presentation, epidemiology, and management,” the researchers explained.

To better assess the frequency of skin rashes in these patients and describe their diagnostic and therapeutic approach, the investigators followed individuals in the first year after transplantation. All individuals were patients at a single university center in France.

Any adult who underwent allogeneic HCT between January 2018 to December 2019 (n = 196) was included in the study. Sixty percent of patients were male, and all patients had a mean (SD) age of 52.3 (13.0) years. Ten patients also had a history of skin disease.

In addition, “allogeneic HCT was performed for 117 acute leukemias (59.7%), 29 myelodysplastic syndromes (14.8%), 25 lymphomas (12.8%), 18 myeloproliferative syndromes (9.2%), 4 bone marrow aplasias (2%), and 2 myelomas (1%),” the authors wrote. Stem cells were typically derived from peripheral blood (n = 120; 61.2%).

Data showed these results:

• 89 patients (45.4%) presented with a skin rash during the first year after transplantation, and among them 78.7% had acute graft-versus-host-disease (GVHD); 6.7%, chemotherapy toxicity; 4.5%, chronic GVHD; 2.2%, infectious origin; and 1.1%, drug hypersensitivity
• The outcome was mainly favorable, as 74.2% of patients experienced resolution
• During follow-up, symptoms worsened in 4 patients (4.5%) and changed in 7 patients (7.9%)
• A skin biopsy was performed in 9% of cases
• Viral polymerase chain reactions were positive in 7.1% of tested patients

Results also showed that among those with rashes, final diagnoses were made by hematologists alone in 73% of cases. Dermatologists’ expertise was required in 27% of cases.

After 12 months, 21 patients with a rash had died, even though 56 had achieved complete remission. For patients without a rash, 62 complete remissions occurred and 28 deaths. However, no deaths were linked with the skin eruption.

The institution where the study took place is the only one in the north of France performing HCT according to international guidelines, the authors highlighted.

The study’s retrospective design marks a limitation. Due to the low number of drug reactions, researchers also were unable to draw conclusions regarding clinical data that could be useful to tell drug reactions from acute GVHD disease.

Overall, “our study highlights the high frequency of skin eruptions within the first year after allogeneic HCT,” they concluded.

“A multidisciplinary approach is needed, concerning hematologists and dermatologists for an appropriate diagnosis and management, especially considering the complexity of these patients and the potential severity of the skin eruption,” authors wrote.

Reference

Dambricourt V, Bassompierre A, Le Calve C, et al. High frequency of cutaneous eruptions within the first year after allogeneic hematopoietic stem cell transplantation. J Eur Acad Dermatol Venereol. Published online May 24, 2023. doi:10.1002/jvc2.125