title: Reduction of immunosuppression for transplant-associated skin cancer: rationale and evidence of efficacy.
abstract: BACKGROUND
  Solid organ transplant recipients may develop numerous or life-threatening skin cancers. In addition to aggressive standard treatment of skin cancer, reduction of immunosuppression has been considered an adjuvant therapeutic strategy, albeit without direct proof of efficacy.
  
  
  OBJECTIVE
  To review the rationale for and evidence supporting the efficacy of reduction of immunosuppression for severe skin cancer in transplant recipients.
  
  
  METHODS
  Review of the literature regarding direct and indirect evidence on reduction of immunosuppression for transplant-associated skin cancer.
  
  
  RESULTS
  Although there are no randomized controlled trials of reduction of immunosuppression as a therapeutic intervention for transplant patients with skin cancer, multiple lines of evidence suggest that this strategy may be an effective adjuvant therapy. A randomized trial has demonstrated a lower incidence of skin cancer in transplant recipients after reduction of immunosuppression, albeit in a cohort not previously affected by skin cancer. Case series of reduction or cessation of immunosuppression demonstrate a lower incidence of skin cancer or improved outcomes of preexisting skin cancer. Lower overall immunosuppression is associated with a lower incidence of skin cancer. Multiple cancers affecting the skin have been shown to regress with reduction of immunosuppression.
  
  
  CONCLUSIONS
  Reduction of immunosuppression may be an effective adjuvant therapeutic strategy when confronting severe transplant-associated skin cancer. The risks of reduction of immunosuppression must be better defined, and randomized trials of this strategy are necessary.
authors.affiliation: Division of Dermatologic Surgery, Department of Dermatology, Mayo Clinic and Mayo School of Medicine, Rochester, Minnesota 55905, USA. otley.clark@mayo.edu
authors.forename: Clark C
authors.initials: CC
authors.lastname: Otley
authors.forename: Sherry L H
authors.initials: SL
authors.lastname: Maragh
mesh_terms: D001379:Azathioprine / Q000008:administration & dosage / Q000627:therapeutic use; D016572:Cyclosporine / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D008297:Male; D016377:Organ Transplantation; D011239:Prednisolone / Q000008:administration & dosage / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D012878:Skin Neoplasms / Q000517:prevention & control*
chemical_list: D007166:Immunosuppressive Agents; D016572:Cyclosporine; D011239:Prednisolone; D001379:Azathioprine