Guarding against nonmelanoma skin cancer in solid organ transplant recipients
Periodic skin examination and ongoing counseling are central in your posttransplantation care of these patients at high risk of skin malignancy.
PRACTICE RECOMMENDATIONS
› Conduct a full-body skin examination at least once annually for solid organ transplant recipients. C
› Encourage daily use of broad-spectrum SPF ≥ 30 sunscreen and sun-protective clothing (long sleeves, pants, wide-brimmed hats) for these patients. A
› Consider chemoprophylactic agents for patients at especially high risk of nonmelanoma skin cancer. A
› Treat nonmelanoma skin cancer in a solid organ transplant recipient aggressively because of their increased risk of recurrence, local invasion, and metastasis. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Diclofenac is a nonsteroidal anti-inflammatory drug that reversibly inhibits the enzymes cyclooxygenase-1 and cyclooxygenase-2, resulting in a decrease in the formation of inflammatory prostaglandins, which have been observed in chronically sun-damaged skin, AKs, and cSCC.34,45 Diclofenac 3% gel, applied topically twice daily for 60 to 90 days has been approved by the FDA for treatment of AKs, in conjunction with sun avoidance.34 Topical diclofenac has been demonstrated to be efficacious in treating AKs in the SOTR population46,47; however, multiple meta-analyses using data from immunocompetent patients have demonstrated that topical diclofenac is inferior to other treatment options, particularly 5-FU, at achieving complete clearance of AKs.43,48,49 Diclofenac might be a useful option when patient adherence is expected to be difficult because of adverse effects of therapy: Multiple studies have suggested that diclofenac might be more tolerable than other options.43,48,50
Systemic chemoprophylaxis
Systemic therapies that have been used for chemoprophylaxis against cutaneous malignancy include nicotinamide, oral retinoids, capecitabine, and HPV vaccination. (See TABLE 2.27-40)
Nicotinamide, the amide form of vitamin B3, protects against cutaneous malignancy by aiding repair of DNA damaged by ionizing radiation, such as UV light.27 Efficacy has been demonstrated in reducing development of new AKs and cSCC in immunocompetent patients with a history of more than 2 keratinocyte carcinomas within a 5-year span.27,35 Nicotinamide is especially relevant to the SOTR population because it reduces the level of cutaneous immunity suppression induced by UV radiation without altering patients’ baseline immunity.27,36
There are insufficient long-term follow-up data in the literature to assess the sustainability of the antitumor effects of nicotinamide; studies specific to the SOTR population have been underpowered for assessing its impact on formation of cSCC.27,35Patients taking nicotinamide should be informed of the risk of liver failure at dosages > 3 g/d (antitumor efficacy has been demonstrated at 500 mg twice daily) and advised to avoid purchasing over-the-counter nicotinic acid or niacin as a substitute for nicotinamide, because of the increased incidence of flushing associated with their use.27
Oral retinoids. Systemic retinoids—in particular, acitretin—are efficacious in reducing the risk of cSCC in SOTRs.27,37,38 The primary drawback to cSCC prophylaxis with oral retinoids is a rebound effect, in which treatment discontinuation leads to a rapid return to baseline cSCC formation.27
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