ANSWER 68
The description of the lesion has the characteristic features of a carcinoma of the skin.
The risk factors are his age, the many years exposure to sunlight as farmer, and the chronic
immunosuppression. There is an increased risk of several different types of malignancy in
patients on chronic immunosuppression, and skin cancer is now well recognized as a fre-
quent complication of chronic immunosuppression unless preventative measures are used.
With improving survival rates for transplant patients in general, there is a potential increase
in the incidence and prevalence of skin malignancy. Patients on long-term immunosuppres-
sion for whatever reason should be strongly advised to avoid direct exposure to sunlight as
much as possible, and certainly not to sunbathe, and to use high-factor barrier creams. They
should cover their skin in the lighter months (April to September inclusive in the northern
hemisphere) – no shorts, sleeveless tops or shirts, and a hat to protect the scalp and forehead.
This is particularly irksome but even more important for children and young adults who
have a potentially longer period of exposure to sunlight ahead of them. The damage caused
to skin by sunlight is cumulative and irreversible, and when transplanted at the age of 50
years this patient had already had over 30 years’ occupational exposure to ultraviolet radi-
ation. His immunosuppression needs to continue and should be kept at as low a dose as is
compatible with preventing rejection of his transplant.
The diagnosis of the lesion was made by biopsy, which showed a squamous cell cancer. This
was treated by wide excision and skin grafting. An essential part of the follow-up is regular
review, at least 6-monthly, of the skin to detect any recurrence, any new lesions or malig-
nant transformation of the solar hyperkeratoses.
- Ultraviolet radiation is a cumulative risk factor for skin cancer.
- Preventative measures to reduce exposure to sunlight are an important part of the man-
agement of patients on long-term immunosuppression.