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Introduction

Skin care is very important for everyone, but particularly for renal patients who have received transplants. Because of the drug regime, which is vital to the success of your transplant and its long-term survival, the specialised immunological cells in your skin are gradually being impaired over a number of years. This means that certain infections can develop in the skin which the immune system would generally inhibit, and cells that are undergoing change to cancer cells in response to sun exposure may not be recognised and destroyed. It cannot be stressed too highly that the sun is dangerous to all of us. Due to the loss of the ozone layer and ‘the greenhouse effect’ we are all being bombarded with more and more ultra-violet light. All the general warnings about skin cancer must be taken seriously by everybody, but especially by transplant patients.

What is dangerous about the sun?

The damaging force in sun-light is ultra-violet (UV) light. This is divided into 3 spectra - UVC, UVB and UVA. Around the earth there are 2 layers, the stratosphere and the ozone layer, through which the different strengths of UV light can penetrate.
Although the UVC spectrum is VERY carcinogenic (cancer-forming), the ozone layer prevents UVC getting through the atmosphere.

UVB

UVB will get through the ozone layer, and although a certain amount is filtered out the remainder will penetrate down to sea-level. It is the UVB spectrum that causes sun-burn, and as the ozone layer is being depleted more UVB is getting through making everyone more sensitive to the sun. UVB is very carcinogenic, and it is this that is the main cause of skin cancers. As depletion of the ozone layer continues, there is more potential for developing skin cancers, and people with a transplant are therefore even more prone to this.

UVA

UVA penetrates through the ozone layer to below sea-level. It used to be thought that UVA could be safely used in sun-beds or for some therapeutic treatments, because of its long wave-length, but evidence now shows that UVA can also be dangerous. People being treated with UVA therapy are now developing skin cancers, and the medical profession is having to be more cautious in its use of this treatment.

How do my drugs affect my skin?

You will be aware that the special drugs you are taking to keep your kidney working and prevent rejection are immuno-suppressant. Over the long term these are absorbed into the skin, reducing the immune response.
Meanwhile, the sun penetrates through the epidermis (the outer layer) of your skin and continually bombards the cells that are growing, causing changes in them. Throughout your life this damage is repaired to a certain extent by the white cells circulating in the blood-stream and destroying the abnormal cells. However, when there is a breakdown in that system then skin cancers can arise. Being immunosuppressed, your white blood-cells are restrained and fewer abnormal cells destroyed. This means that lower levels of sun exposure than usual are capable of causing skin cancers.

This is why it is very important that all patients who are on such drugs should avoid exposing themselves to the sun.

Skin infections

Despite the above warnings, not all skin problems are potentially cancerous. Due to the drug regime transplant patients are very prone to skin infections, a common one being a fungal infection which causes pale or dark patches or rather liverish-looking spots. This is very easily treated, but is a good indicator of reduced immunity.

Warts

Another skin ailment frequently seen in transplant patients is common warts. Warts are caused by a whole range of viruses and in the transplant patient take a long while to disappear, due to the reduced immune system. Some warts are very infectious and can be spread anywhere over the body just by scratching one. Again, though, they are easily treatable and provided full and early attention is paid to them they are not dangerous.
However, warts caused by papilloma viruses can be carcinogenic, and if left for long enough and perhaps exposed to sunlight, will develop into skin cancers. Again, early treatment is worthwhile and much less traumatic than at a later stage.

Changes in the skin

Any changes in the skin need to be carefully monitored. Solar keratoses, or sun-spots, are premalignant conditions which must be treated. They are usually found on exposed sites such as the backs of hands, and faces or scalps.
Sun-spots can remain dormant for 10 to 20 years, but eventually they are activated by the sun: in winter they may actually seem to get better, but as soon as you go out in the summer they swell up and become more active. Once they are larger than 1-centimetre across they become more dangerous because there is then more risk of developing real cancerous change.
These changes are much more common in transplant patients, being evident at an earlier age than in a normal population, because your reduced immunity accelerates the effect.
If left untreated for a long time a keratosis will eventually develop into an invasive squamous cell carcinoma, which could then spread round the body and eventually kill you. As with most skin conditions, however, these can be treated at an early stage with little discomfort.

Tumours

The most common form of tumour seen in Britain is a basal cell carcinoma (or rodent ulcer). They are commonest in old people, but are now being seen generally in much younger age groups. in themselves they are not dangerous: they are locally invasive and will grow bigger at the site, but they do not spread round the body like a skin cancer. Fortunately, there does not seem to be an increased

Moles

The most easily-recognisable skin complaint, and potentially one of the most dangerous, is moles. Again, due to your immune-suppressants, transplant patients are at more risk of moles developing into a malignant state.

The pigment cells in moles come from tissue around the spinal cord during development, and eventually migrate into the skin. This can take many years, and new moles can still develop when you are in your 40’s without any daole cells first infiltrate and colonize right at the bottom of the growing part of the skin, and are flat and usually uniform in shape (round or oval) and colour. One mole may be darker than another, but the colour is uniform throughout that single mole. This is most important.

As the mole matures, the cells grow, fall deeper into the skin and accumulate, bulging the skin out slightly with the mole becoming lumpy. As a mole grows even further, cells fall totally into the deeper part of the skin producing a large mass of cells completely away from the overlying epidermis (outer layer).

The only cells that have any malignant potential are those within the epidermis, so as a mole matures and grows and becomes lumpy it loses all its cancerous potential and is no longer dangerous.

Care has to be taken, though, if you have a flat or slightly raised mole. When a mole changes and the cells become malignant it grows along the surface of the skin, usually in an irregular way. From a regular mole that is round or oval a little arm, or a couple of arms, develops and its shape becomes irregular. These cancerous cells also change their ability to produce pigment. Within the mole you may have variations in colour, one bit brown, one bit pale. These are the most important changes to look for. If you catch a mole at that stage and have it removed then you are cured.

One very common change is the white halo around a mole. It is an auto-immune response, is totally benign and will never give any trouble. It is one way that the body has of getting rid of moles. Eventually the mole will disappear and just leave a small white patch. Some moles are blue in colour which denotes that it is much deeper in the skin, but these are totally benign lesions. Lots of people have them, particularly on the face.

Other skin ailments

Of course, not every brown mark is a mole. A spreading patch of dark in the skin that comes on well after birth, usually in the teens, and can eventually spread down the arm is totally benign and nothing to worry about.

Ageing warts are very common everywhere on the body, particularly on the back and the chest. They look like little pastilles that have been pressed onto the skin. Very often bits fall off. They cause a lot of problems, but are totally benign and nothing to worry about.

Visit the British Association of Dermatology website at : www.bad.org.uk

Prevention is better than cure

As with all illnesses, prevention is better than cure.

Check your skin regularly, and if you see anything at all suspicious ask to be referred to a dermatologist (Your renal clinic may already do this automatically).

When you go out, especially during the months of March to October, you should always wear a high factor sunblock SPF 50, all through the year.

Even keeping in the shade you are still prone to damage from the sun, so be sensible as to how you dress - you can wear cool clothing but you must not uncover completely. Wear a hat or some other head-covering, particularly men who have little hair on top.

If you drive, wear gloves in the summer to reduce the effect of the sun through the screen on to the back of your hands.

Never sun-bathe, however tempting this might be. A“healthy” tan is not at all healthy, and you are only storing up serious problems for yourself later on by trying to get brown.

Consult your GP if you are suspicious about anything on your skin, the GP will refer you to the Dermatologist.

Above all, enjoy the sun but BE SENSIBLE!

The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.

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