GRAFT VS. HOST DISEASE

By Gary M. White, MD

Graft vs. Host Disease showing a sclerotic lesion on the foot Chronic GVHD with a sclerotic lesion.


Graft vs. Host Disease (GVHD) is a rare condition occurring after stem cell (or bone marrow) transplant in which immune cells from a genetically different donor attack cells of the host. This type of transplant is called allogeneic (whereas transplant of one's own cells is called autologous). The new, transplanted cells regard the recipient's body as foreign. When this happens, the cells attack the recipient's body. Onset is most common about 3 months after transplantation.

See also linear (Blaschko), and Solid Organ Transplant GHVD.

Potential Manifestations of GvHD

GvHD may mimic other skin conditions including PR, PRP, eczema craquele [JAAD 2015;72;690].

Acute GvHD

Acute GvHD occurs within the first 3 months after transplantation. Chronic GvHD is defined as any reaction thereafter. Acute GvHD usually has its onset between 7 and 21 days after grafting. Pain or itching of the skin may occur initially. Then, a diffuse maculopapular erythematous eruption develops. Perifollicular papules are typical as are acral lesions. Other patterns are possible, e.g. scarlitiniform or Stevens Johnson like with initial erythema followed by sloughing of the skin.

Viral infections and reactivation of various viruses (e.g. CMV, EBV, VZV) is common in acute GvHD [JAAD 2015;72;696].

Chronic GvHD

Chronic GvHD begins 4 months or later and is characterized by lichenoid or sclerodermatous lesions. Hypo or hyper pigmentation and later poikiloderma, sclerosis, alopecia and ulceration may occur. Typical changes include thickening or induration of the skin with resulting irregularity of the surface or morphea-like changes. The epidermis, dermis, subcutaneous tissue or fascia may be involved by the thickening.

Rarely, the lesions may present in a linear fashion (e.g. along the lines of Blaschko [JAAD 1998;37;1004], or localized to a previous viral exanthem.

Treatment

Referral to a specialist is in order. In the past, treatment of acute GvHD has commonly involved high-dose corticosteroids (1-3 mg/kg/day), tacrolimus and mycophenolate mofetil. Cyclosporin, cyclophosphamide or other immunosuppressive agents have also be given. Treatment of chronic GvHD often involves extracorporeal photophoresis, tacrolimus, mycophenolate mofetil, rituximab and cyclosporin.

NB UVB phototherapy can be effective for the patients with sclerotic chronic cutaneous GvHD [JAMA Derm 2015;151;635].

Additional Pictures

Fibrotic, indurated lesions.
Graft vs. Host Disease showing a sclerotic lesion on the leg Graft vs. Host Disease showing a sclerotic lesion on the leg

Color change post GVHD
Graft vs. Host Disease showing dyspigmentation

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