Cath Lab Digest

A llogeneic (nonidentical) hematopoietic stem cell transplant (HSCT) is a potentially curative treatment option for certain hematologic malignancies. The procedure requires the patient to receive a conditioning regimen consisting of moderate to high doses of chemotherapy and/or radiation therapy. This therapy destroys the patient’s stem cells and suppresses his/her immune system. Donor stem cells, infused into the patient, travel to the bone marrow and begin to produce new blood cells, essentially building a new (transplanted) donor immune system. A graft-versus-leukemia (GVL) or graft-versus-disease (GVD) response can have a desired direct antitumor effect in some allogeneic recipients.¹ Unfortunately, severe clinical complications are often encountered.

The primary, persistent limitation to the success of HSCT is graft-versus-host disease (GVHD), which affects 40% to 80% of allogeneic transplant recipients depending on the degree of major histocompatibility mismatch between recipient and donor.¹ This common, potentially fatal inflammatory autoimmune process results from the attack of the recipient’s tissues by donor T-cells and natural killer (NK) cells.^{1, 2} Graft-versus-host disease that occurs in the first 100 days post transplant is referred to as acute GVHD (aGVHD), initially observed as early as 7 days but more often appearing around 21 days post stem cell transplant (see Figure 1). Graft-versus-host disease that occurs after 100 days post transplant is referred to as chronic.² Clinical staging and grading of GVHD can be made by evaluating the performance level of the patient and assessing the skin, liver, and gastrointestinal tract, the most commonly affected target organs.

Skin is typically the first site of aGVHD, clinically presenting as a nonspecific maculopapular rash that can be pruritic or painful. It may present on the palms and soles, and if untreated can quickly spread to form a confluent erythema (erythroderma) on the cheeks, neck, and trunk, further progressing to bullae and skin sloughing (desquamation).^1,3

The traditionally accepted clinical stages for skin findings are as follows:

Stage 1 — maculopapular rash <25% of body surface

Stage 2 — maculopapular rash 25% to 50% of body surface

Stage 3 — rash on >50% of skin (per revised grading system)

Stage 4 — bullous formation.¹

The “rule of nines” for burn patients is used to determine the extent of the rash.¹

Case Study

This case study illustrates the agony patients with grade 4 skin involvement of aGVHD experience and how tandem effective medical and nursing management can achieve patient comfort. The contribution of appropriate dressing selection to the management of the severe pain universally observed in and reported by patients with grade 4 aGVHD of the skin is emphasized with the hope that other oncology practitioners might find it a helpful adjunct in relieving pain, managing fluid loss, preventing infection, and promoting wound healing.