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BACKGROUND

A wide variety of cutaneous disorders may affect immunocompromised pediatric patients. Children can be immunocompromised due to an underlying malignancy, immunodeficiency, or secondary to immunosuppressive therapy. Chronic immunosuppressive therapies may be administered for numerous reasons including solid organ transplantation and chronic conditions. In addition, immunosuppression may result from chemotherapeutic treatment regimens for malignancies or conditioning regimens in preparation for bone marrow or stem cell transplantation. The cutaneous disorders associated with immunosuppression range in severity. Even the most banal skin lesions in immunocompromised children can herald life-threatening conditions. Skin biopsies can thus be useful tools in immunosuppressed patients with skin lesions to aid in diagnosis.1 Skin lesions are most frequently a consequence of drug side effects or infection caused by immunosuppression.2,3 Skin disorders affecting immunocompromised patients may occur acutely during high levels of immunosuppression (such as in transplant patients during the early post-transplant period or during periods of acute rejection), while other skin eruptions may be secondary to exposure to various medications. Table 66-1 displays a range of cutaneous lesions seen in immunocompromised patients.

TABLE 66-1Skin Diseases in Immunocompromised Pediatric Patients

Graft-versus-host disease (GVHD), an important disorder with various cutaneous manifestations, is discussed in Chapter 134.

INFECTIOUS COMPLICATIONS

Infections with common and unusual organisms are a complication of immunosuppression. Extensive involvement caused by relatively minor but still problematic skin infections such as tinea corporis, pityriasis (tinea) versicolor, or viral warts is a consequence of long-term immunosuppression.2-4 The most worrisome complication of chronic immunosuppression is the increased risk of life-threatening skin infections that may be associated with significant morbidity The clinical presentation of cutaneous infections caused by a variety of different pathogens is often similar. Prompt evaluation and treatment of these life-threatening infections can reduce morbidity and mortality. Cutaneous lesions suspicious for an infectious process should be biopsied and sent for routine histology, special stains, and tissue culture, as superficial skin cultures are often not sufficient to establish a diagnosis.

BACTERIAL INFECTIONS

Bacterial infections such as impetigo, folliculitis, and cellulitis may arise in immunocompromised patients. Moreover, skin infection may herald or coincide with systemic infection with a variety of pathogens. Common pathogens such as Staphylococcus aureus and group A streptococci may be causative agents, but less common pathogens, including gram-negative organisms, may also cause skin disease. Ecthyma gangrenosum is a manifestation of Pseudomonal sepsis that can occur ...

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