Bernice Kwong, MD, clinical professor of dermatology, Stanford University, expands on her session about graft-versus-host disease diagnosis and management presented at the 2022 American Academy of Dermatology Annual Meeting, emphasizing the importance of the relationship between patients and doctors.
Bernice Kwong, MD, clinical professor of dermatology, Stanford University, expands on her session about graft-versus-host disease (GVHD) diagnosis and management presented at the 2022 American Academy of Dermatology (AAD) Annual Meeting, emphasizing the importance of the relationship between patients and doctors.
What was the main focus of your discussion regarding diagnosis and management of cutaneous GVHD?
As dermatologists managing patients who might have graft-versus-host disease, one of the most important things that we try to look at is the wide differential diagnosis for skin conditions that can happen in a patient who's had an allogeneic stem cell transplant. That includes graft-versus-host disease, but because of these patients' immunocompromised state and all the medications that they have—and just so many things going on in their complex medical history—one thing that we just notice so often that is helpful technology is that the patients have more than 1 disease at a time.
So, they will often have graft-versus-host disease, but the reason the skin might not be improving is that, in addition to that, they might have a skin infection; in addition to that, they might have a drug eruption; in addition to that, they might have a nutritional deficiency contributing to some dermatitis. Taking a step back and recognizing that they probably have GVHD, but what else might they have that we have expertise in as dermatologists, and let's think about considering working up and managing those concurrently. Perhaps that can allow us to get the patients better.
That was kind of the focus of that talk there, just really to emphasize that more than 1 thing can be happening at the same time. And recognition of that—which we can do because we can see the skin, we can think about it, we can do skin biopsies to help us—is so important for these patients because they're so sick and there's lots of things going on at the same time. The acknowledgement that 2 things can be true, or maybe 3 or 4, at one time, is really helpful in approaching their management.
What can both dermatologists and patients do to diagnose GVHD earlier and therefore initiate treatment earlier?
Counseling patients to recognize that there is a skin rash and alert or voice that to a clinician is probably one of the best steps. It's empowering our patients to know that they can call us for help or call upon dermatologists. And maybe not that first. Maybe they're going to call on their bone marrow transplant [BMT] doctor first for help. [We are] letting patients know to just be vocal—"I have a rash, what is this?”—and then, as dermatologists, forging partnerships with our wonderful colleagues in oncology, such as our BMT doctor partners, in order to foster that ease of being able to ask for help when it happens.
Kind of like the answer to the previous question: The skin rash after transplant doesn't always equal GVHD, and recognition of that knowledge of that is important so that we get to be inserted in at the right time, earlier, if possible, if things are just not getting better. Or sometimes something looks like GVHD to a patient who is not a trained dermatologist, nor is an oncologist. We are able to recognize if this is a tinea infection or if this is a drug eruption sooner, and so establishing that partnership with patients and oncology colleagues to call upon us and us to be available to help kind of tease things out early is what I think is the best thing that we can do in helping these patients.