Melanoma or molluscum? Skin disease due to fingolimod-associated immunosuppression

Melanoma or molluscum? Skin disease due to fingolimod-associated immunosuppression Majeeda Patel, Muhammad Hyder Junejo, Giulia Ruina, Portia Goldsmith and Catherine Harwood The Royal London Hospital, Department of Dermatology, London, UK Fingolimod was the first oral medication approved for treatment of multiple sclerosis (MS). It is a sphingosine-1-phosphate (S1P) receptor modulator and sequesters CD4/8 T cells and B lymphocytes in lymph nodes, preventing their infiltration of the central nervous system. Lymphopenia is an inevitable consequence of its use and is associated with possible risk of skin malignancy but, more commonly, extensive skin infections, as illustrated in our case. A 40-year-old woman with skin type 5 and a history of MS was referred urgently with suspected melanoma. A pigmented lesion on her abdomen had been present for 18 months and was enlarging. Fingolimod was started 3 years previously for relapsing and remitting MS. On examination, she had a 1 cm, pigmented and umbilicated nodule in the umbilicus and > 100 smaller but similar papules and nodules elsewhere, particularly the face and genital areas. She was HIV negative and her CD4 count was low (10 9 9 10 cells L; normal > 455) secondary to fingolimod. Molluscum contagiosum (MC) rather than melanoma was diagnosed clinically and confirmed on a skin biopsy performed to exclude atypical infections such as Cryptococcus. Some larger lesions were removed surgically, but there were significant concerns regarding dyspigmentation risk with more extensive surgery/cryotherapy. However, she failed to respond to hydrogen peroxide and imiquimod creams, and the extensive and cosmetically striking facial involvement had a significant impact on her quality of life. For this reason, funding was agreed for a trial of cidofovir cream (£1500 per 30 g) and her neurologists transitioned her to an alternative MS treatment, with ongoing evidence of improvement. Widespread skin infections are well described with fingolimod. Herpes infections may be particularly severe, disseminated and fatal. Cryptococcus and leishmaniasis are also described, but there are few reported cases of MC, possibly because MC may be subtle and not diagnosed until it becomes more extensive, as in this case. MC treatment is challenging and almost all clinical trials have excluded immunocompromised individuals, despite immunocompromise being common in adults presenting with MC. Cidofovir is the only specifically antiviral agent described and it depends less on an intact immune response than many treatments – the rationale for its use in this case. Although the risk of skin cancer, including melanoma, is reported to be increased with fingolimod, the strength of this association remains uncertain. Nevertheless, increasing use of fingolimod and other S1P receptor modulators will inevitably lead to a rise in their associated cutaneous side-effects, underscoring the importance of routine educational advice for patients and heightened awareness among clinicians using these newer immunosuppressive drugs. BI23 Use of biologics for psoriasis in solid organ transplant recipients: a case report and review of the literature Marta Costa Blasco, Sophie Diong and Siona Ni Raghallaigh Beaumont Hospital, Dublin, Ireland Biologics have played a crucial role in managing a multitude of inflammatory disorders. Significant advances have been seen since the first biologics were introduced, including the development of anti-tumour necrosis factor (TNF)-a and further progress on the understanding of the pathogenesis of psoriasis (Rønholt K, Iversen L. Old and new biological therapies for psoriasis. Int J Mol Sci 2017; 18: 2297). However, very little is known about the use of biologics in immunosuppressed patients such as solid organ transplant recipients. There are multiple dermatological manifestations related to solid organ transplants ranging from benign infections to malignancies. However, inflammatory skin conditions are rare given the immunosuppressive regimens required to prevent graft rejection (Madankumar R, Teperman LW, Stein JA. Use of etanercept for psoriasis in a liver transplant recipient. JAAD Case Rep 2015; 1: S36–7). We aimed to evaluate treatment using these agents in immunocompromised patients by reporting a case about a patient from our institution and conducting a review of the current literature available on this topic. Our case was that of a 29-year-old man with a background of psoriasis who underwent a renal transplant secondary to Alport syndrome. Prednisolone, mycophenolate mofetil (MMF) and tacrolimus were his maintenance treatment regimen. He presented with erythroderma secondary to psoriasis 1 year post-transplant and failed on treatment with acitretin and subsequently apremilast. It was decided to commence adalimumab to treat his symptoms, and MMF was discontinued, considering the increased risk of opportunistic infections on several immunosuppressive medications. A review of the literature was performed in MEDLINE, Cochrane and Embase, to identify published cases reporting the use of biologic treatments in solid organ transplant patients with psoriasis. We collected data on demographics, efficacy and reported complications. In total, nine articles were included. Etanercept was used in six patients (66 6%), followed by ixekizumab, brodalumab and ustekinumab. Our patient was treated with adalimumab with good response, which has not been previously documented in the literature. There is a lack of published data regarding treatment with biologics in this cohort of immunosuppressed patients and the use of these treatments should be done with caution. Further studies are required to assess efficacy and safety profiles. 114 Posters