Published on
Differential Diagnosis
- Drug eruption
- Viral exanthem
- Acute graft-versus-host disease
- Radiation dermatitis
- Erythema multiforme
- Toxic epidermal necrolysis
Diagnosis
The correct diagnosis is acute cutaneous graft-versus-host disease (GVHD), an immune-mediated condition resulting from donor lymphocytes attacking host tissues after a hematopoietic cell transplant (HCT).
The combined stages of skin, liver, and gastrointestinal disease are used to determine the overall severity (grade) of acute GVHD. A staging system is used to describe the extent of cutaneous involvement:
- Stage 1 – Less than 25 % body surface area (BSA) involvement
- Stage 2 – 25 to 50 % BSA involvement
- Stage 3 – Greater than 50 % BSA involvement
- Stage 4 – Erythroderma with bullae or skin sloughing
In the absence of extracutaneous manifestations, making a definitive diagnosis of acute GVHD may be challenging; the rash can be difficult to distinguish clinically from other skin eruptions that occur in post-HCT patients. Biopsy may provide information that can be used in conjunction with other clinical findings to support a diagnosis of acute GVHD. A 4 mm punch biopsy sent for hematoxylin and eosin staining is generally sufficient to evaluate for acute cutaneous GVHD.
What To Look For
- Symptoms begin with erythematous, blanchable macules on the ears, lateral neck, cheek, upper back, palms, or soles. Some lesions may follow a follicular distribution.
- Lesions progress to a generalized, morbilliform (measles-like) appearance. Smooth or hyperkeratotic papules and postinflammatory hyperpigmentation may occur.
- Lesions may be pruritic or accompanied by a burning sensation, sometimes these symptoms precede the onset of visible lesions.
- Erythema, ulcers, lichenoid lesions, xerostomia, and pain involving the oral cavity may be present.
Pearls for Urgent Care Management
- Topical corticosteroids may provide improvement in patients with limited skin disease. High-potency corticosteroid solutions or gels and topical anesthetic agents are also used for oral symptoms.
- Patients with xerostomia should be encouraged to maintain good oral hygiene and may benefit from salivary stimulants such as sugarless gum or candy.
- Encourage prompt follow up with patient’s transplant providers for ongoing evaluation and management of cutaneous GVHD. Phototherapy and systemic therapies are the mainstays of treatment for patients with sclerotic lesions.