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Notes: It is well recognized that patients who have undergone renal transplantation are at an increased risk of developing cutaneous malignancy. The incidence of this problem rises as survival time increases, and multiple dysplastic lesions may develop, especially on sun-exposed sites. Conventional treatment by excision, curettage, cryotherapy or topical cytotoxic agents is often unsatisfactory because of the number and extent of lesions present. In non-immunosuppressed patients, treatment with etretinate has been shown to be helpful in treating both basal cell carcinomas and solar keratoses. There are, however, no previous studies of its safety or efficacy in renal transplant patients who have developed dysplastic lesions, and the immuno-adjuvant effect of retinoids is a potential limitation to this type of treatment. We have therefore undertaken a study in which patients with functioning renal allografts who had developed multiple dysplastic lesions were treated with etretinate, 1 mg/kg/day for a period of 6 months. Six patients (five males, one female), who had been immunosuppressed for between 166 and 240 months (mean 210 months), were entered into the study. All patients had histological evidence of severe epidermal dysplasia, and four patients had previously developed invasive squamous cell carcinomas. In addition, all patients had numerous viral warts, some of which showed evidence of dysplastic change. No deterioration of renal function was detected in any of the patients during treatment, as measured by serial plasma creatinine estimations. Circulating lymphocyte numbers were unaffected by treatment and there was no consistent change in the relative numbers of T helper or suppressor cells. Intradermal challenge with multiple antigens was undertaken at o and 6 months, and all patients remained completely anergic. Serum cholesterol and triglyceride levels were monitored throughout the study, and only one patient had a rise in lipid values which did not respond to dietary manipulation. Four patients had almost complete clearing of hyperkeratotic lesions, one patient had a partial response, and one patient developed two further squamous cell carcinomas during treatment. Side-effects were no more severe than those normally encountered with retinoid therapy. Etretinate appears to be a safe and useful treatment in this group of patients. Fears concerning its immuno-modulating effects proved groundless, and its effects on a heavily suppressed immune system appear to be negligible.

Notes: The prevalence of dysplastic cutaneous lesions was determined in a group of 68 renal transplant patients whose immunosuppressive therapy included cyclosporine but not azathioprine. The mean age of the patients was 41 years (range 17-67), and the mean transplant time was 44 months (range 24-75). Dysplastic cutaneous lesions were found in 14 out of 68 patients, a prevalence of 20.6%. Although the lesions arose on sun-exposed sites, there was no apparent correlation with previous sun-exposure. The cumulative prevalence of dysplastic cutaneous lesions in 64 patients who had received cyclosporine for between 24 and 72 months was compared with 33 renal transplant patients who had been treated with azathioprine over a similar period of time. The overall prevalence of cutaneous dysplasia was 22% in the cyclosporine group and 9% in the azathioprine group. The cumulative prevalence of cutaneous dysplasia in the cyclosporine group was greater at all time points studied. In contrast to previous reports, we have found no evidence that the risk of cutaneous malignancy in patients treated with cyclosporine is less than that found in patients maintained on azathioprine.

Notes: The prevalence of cutaneous fungal infection was studied in 72 patients who had undergone renal transplantation and compared with a group of age and sex matched controls. Samples were obtained from toe nails, toe webs, and the upper back; clinically suspicious lesions from other areas were also examined. A total of 576 sites were sampled (288 in each group). Pathogenic fungi were identified from 44 sites (15%) in the renal transplant (RT) group compared with 26 sites (9%) in the control group, (P 〈 0.05). However, site-specific differences were less marked; no difference was found between the RT group and controls when the results from the toe nails and toe webs were analysed separately. Trichophyton mentagrophytes was the most common species isolated from both groups.Colonization of the back with Pityrosporum yeasts was significantly more common in the RT group, but few patients in either group had tinea versicolor.‘Mixed infections, with more than one species of fungus isolated in an individual, were only found in the RT group.We also examined the relationship between the presence of fungal infection and the presence or absence of cutaneous malignancy in the renal transplant group. No increase in the prevalence of fungal colonization was found in those patients who had developed cutaneous malignancy compared with those who had not.