Late effects: Skin health

Very few people realise that the skin is the largest organ in the body. The skin is the body’s first line of defence against outside invaders. It also keeps the body temperature normal and stores water, fat and vitamin D. Such an important organ requires care and monitoring. Treatment for blood disorders sometimes causes damage to the skin.

Who is at risk?

The following people are at risk of damaging their skin:

Patients who received radiation to any part of the body, including total body irradiation (TBI)
Patients with chronic graft versus host disease (GVHD) following stem cell transplantation from a person other than yourself (allogeneic)

What problems can occur?

Telangiectasias

These small blood vessels on the surface of the skin are commonly referred to as spider veins and can occur in the field of radiation. They are caused by changes to the lining of blood vessels resulting from radiation. These do not typically cause any health problems and require no specific care.

Fibrosis

Fibrosis is caused by scarring of the lining of blood vessels, resulting in a woody skin texture. The skin may not be as flexible in the fibrotic area and may be more easily injured. Care of fibrotic skin should include routine moisturising and avoidance of trauma. Because the blood supply is not as good in fibrotic skin, healing may be slow after cuts and scrapes, so avoiding these when at all possible is important.

Scleroderma

People who have chronic GVHD following stem cell transplantation sometimes develop scleroderma. In this condition, the donor white blood cells do not recognise the patient’s skin cells as their own, and begin to attack them. This causes the skin to become stiff and inflexible. This may happen anywhere on the body, but if it happens to the skin around joints, it can make the joints less mobile. The therapy for scleroderma is treatment of the underlying GVHD. It is also important to avoid injury to this skin, since healing time will be prolonged.

Vitiligo

Vitiligo is loss of pigment on patches of the skin. This can occur after stem cell transplantation and may be due to GVHD or other autoimmune reactions. In this situation, the white blood cells do not recognise certain normal skin cells (melanocytes) and so they attack and destroy them. Melanocytes are the cells in the body that control skin colour. Without melanocytes, the skin has a milky white appearance.

Vitiligo usually occurs only in patches. The therapy for vitiligo is treatment of the underlying GVHD or autoimmune process. Even if this therapy is successful, the colour may not return to the skin because the damage to the melanocytes may be permanent. While all skin should be protected from sun, skin that has lost its pigment is very vulnerable, and sunscreen should always be applied to these areas before going outdoors.

Hyperpigmentation

Hyperpigmentation is a darkening of the skin that may occur after radiation or some types of chemotherapy. The chemotherapy agents most commonly associated with hyperpigmentation include bleomycin, busulfan, cyclophosphamide, hydroxyurea and methotrexate. The dark discolouration can occur on the skin or nails. There is no specific treatment for hyperpigmentation associated with chemotherapy, but it usually continues to fade over time without any treatment.

Skin cancers

People who have received radiation are at risk for developing skin cancers. Other risk factors include light skin colour, chronic sun exposure, severe sunburn, atypical moles and a family history of skin cancer. The good news about skin cancer is that if it is diagnosed early, it is usually very treatable.

Find out more about skin cancers for stem cell transplant patients.

What monitoring is needed?

If you have any risk factors, you should check your skin each month for changes. If you notice any new or unusual spots or changes or discover a spot that changes shape, colour or size, see your doctor immediately.

Have a thorough skin examination by a doctor at least once a year.

What can I do to keep my skin healthy?

The most important thing to remember in caring for your skin is to protect it from the sun. Here are some things you can do:

Wear protective clothing including a hat and sunscreen at all times when your skin is exposed to the sun, even on cloudy or hazy days. Use a sunscreen with an SPF (sun protection factor) of 15 or higher
Sand, snow, concrete, water and high altitudes all increase the risk of sun damage - take extra caution to protect your skin in these environments
Do not attempt to tan your skin - avoid tanning booths
Avoid outdoor activities from 10am to 2pm when the sun’s rays are most intense (11am to 3pm during daylight savings time). Plan outdoor activities in the early morning or late afternoon hours
Reapply sunscreen frequently or use a water resistant sunscreen when swimming or perspiring heavily