The Skin Cancer Foundation Journal

MAY 2013

The 2012 edition of The Skin Cancer Foundation Journal features medically reviewed, reader-friendly articles such as tanning, the increasing incidence of skin cancer diagnoses among young women, & the prevalence of melanoma among white males over 50.

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Page 72 of 103

TABLE 1: RISk FACTORS FOR NONMELANOMA SkIN CANCER IN TRANSPLANT RECIPIENTS Pale skin exposure to ultraviolet radiation type and duration of immunosuppression Advancing age Male sex Human papillomavirus (HPv) infection Pale skin, a key risk factor for skin cancer in the general population, is a far greater Warts and benign keratotic lesions Precancerous lesions, such as actinic keratoses predisposing factor in transplant patients, especially after many years on immune suppressant drugs. genetic polymorphisms [genetic variations] Other important risk factors include the length of time the patient has been immunosuppressed;7,11,13-17 advancing age;7,9,11 male sex;7,9,11 human papillomavirus (HPV, or wart virus) infection, warts,18 and predisposing genetic variations (polymorphisms) such as the MC1R gene (the so-called red-headed gene) that lighten skin color and increase UV sensitivity, or those that reduce the body's ability to repair UV damage, for example by disrupting folate metabolism19 [table 1]. Just how much immunosuppressive drugs increase skin cancer risk depends on all of these factors, as well as the drugs themselves — azathioprine and calcineurin inhibitors such as tacrolimus, for example, may cause more cancers, while regimens revolving around mycophenolate mofetil or rapamycin may be lower risk, though data are insuffcient to say any of this conclusively.2,11,13-16 In any event, patients may remain on several of these drugs for decades, and those taking three or four are more likely to develop skin cancer than those taking just two.7,17 THE IMPACT OF VIRUSES Skin cancers associated with viruses that trigger tumor growth are seen at a far higher rate in immunosuppressed patients.20 There is increasing evidence implicating HPV in the development of squamous cell carcinomas, which can be especially aggressive in transplant patients.21-25 Similarly, the Merkel cell polyomavirus and human herpes virus (HHV) 8, respectively, contribute to development of the dangerous skin cancers Merkel cell carcinoma and Kaposi's sarcoma,26 which are likewise more common in the transplant population. PERSONAL PREVENTION Though UV exposure is such an important skin cancer risk factor for transplant patients, it can be readily reduced. Following a transplant, patients must be exceptionally diligent about using sun protection. First and foremost, they need to seek the shade and avoid sun exposure when the sun is most intense, between 10 AM and 4 PM in temperate zones. This is true even on cloudy days, since UV rays pass through clouds. If sun exposure is unavoidable, they should wear brightor dark-colored, tightly woven or knit opaque clothing. Ideally, this should include long-sleeved shirts, long pants, a broad-brimmed hat, and wide-lensed wraparound UVblocking sunglasses to cover as much skin as possible. For greater assurance, they can seek specially designed UV-protective clothes that display an ultraviolet protection 71

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