Evidence-based, Skin-directed Treatments for Cutaneous Chronic Graft-versus-host Disease

Abstract

Chronic graft-versus host disease (cGVHD) occurs in 30% to 70% of patients undergoing allogeneic hematopoietic cell transplantation (HCT). Cutaneous cGVHD affects 75% of cGVHD patients, causing discomfort, limiting the range of movement, and increasing the risk of wound infections. Furthermore, systemic immunosuppression is often needed to treat cGVHD and long-term use can lead to adverse events. Optimal use of skin-directed therapies is integral to the management of cutaneous cGVHD and may decrease the amount of systemic immunosuppression required. This study reviewed English-language articles published from 1990 to 2017 that evaluated the effect of skin-directed treatments for cutaneous cGVHD. A total of 201 papers were identified, 164 articles were screened, 46 were read, and 18 publications were utilized in the review. Skindirected treatments for cGVHD included topical steroids, topical calcineurin inhibitors, psoralen with ultraviolet A (PUVA) irradiation, ultraviolet A1 (UVA1) irradiation, and ultraviolet B (UVB) irradiation. We report the number of complete remissions, partial remissions, and systemic immunosuppression reduction in each study, as available. Twenty-two out of 30 (73.3%) patients experienced overall improvement with topical calcineurin inhibitors. At least 26 out of 76 patients (34.2%) receiving PUVA experienced complete remission, and 30 out of 76 patients (39.5%) experienced partial remission. In UVA1 studies, 44 out of 52 (84.6%) patients experienced overall improvement. In UVB studies, nine out of 14 patients (64.3%) experienced complete remission and four out of 14 patients (28.6%) experienced partial remission. As more HCTs are performed, more individuals will develop cGVHD. Awareness and optimal use of skin-directed therapies for cutaneous cGVHD may help improve patient outcomes and quality of life.

Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan

“…This approach allows for minimisation of treatment-related side effects, and, in case of high risk of relapse or infection, it may spare systemic immunosuppression saving the protective GvL effect. The latter aspect is supported by consensus opinion predominantly, and controlled data are scarce in this regard (140)(141)(142).…”

The clinical landscape of chronic graft‐versus‐host disease management in 2021

“…Lower-potency topical steroid cream or ointments should be used on the face and other thin sensitive areas such as the axillae and groin due to risk of skin atrophy or development of striae. [99][100][101] Patients and clinicians should also address and treat other associated symptoms such as itching, wound/ulcers, and encourage avoidance of significant sun exposure. 101,102 Topical-oral First-line therapies for oral cGVHD include high-potency topical corticosteroid rinses.…”

“…For skin‐directed topical therapy, topical steroids serve as the main backbone for this approach as long as the cGVHD involvement is limited to the skin and involving body surface area (BSA) < 50%. Lower‐potency topical steroid cream or ointments should be used on the face and other thin sensitive areas such as the axillae and groin due to risk of skin atrophy or development of striae 99–101 . Patients and clinicians should also address and treat other associated symptoms such as itching, wound/ulcers, and encourage avoidance of significant sun exposure 101,102 …”

Skin and wound care for individuals with graft versus host disease: a scoping review protocol

“…1 2 4 There is evidence available to guide skin-directed treatments such as topical or systemic medications and specialist therapies such as phototherapy and extracorporeal photopheresis. [4][5][6] However, a significant evidence gap regarding day to day supportive skin care (including cleansing and moisturising, keeping skin healthy and intact, providing comfort and supporting wellbeing), 7 and wound management procedures (including dressing and product selection, treatment regimens, pain, itch and other symptom management), remains.…”

“…Clinical decision making regarding supportive skin care and wound management for this cohort is complex, often requiring multidimensional interventions. Due to immunosuppressive therapies, the risk of infection is an ongoing threat for these patients, 5 6 and must be a primary consideration in skin and wound management plans. In addition, prevention and management of xeroses, pain, skin injury and further deterioration of skin barrier function are critical factors in skin and wound management for these patients.…”