title: Conversion from tacrolimus/mycophenolic acid to tacrolimus/leflunomide to treat cutaneous warts in a series of four pediatric renal allograft recipients.
abstract: BACKGROUND
  The challenge of immunosuppression in pediatric renal transplantation is to balance preventing rejection while avoiding infectious complications. A dermatological complication of immunosuppression is viral warts, which cause significant disfigurement and increase the risk of skin malignancy.
  
  
  METHODS
  We present three pediatric and adolescent renal allograft recipients with multiple, recalcitrant verrucae vulgares lesions and one patient with molluscum contagiosum who were switched from mycophenolate mofetil to leflunomide. Teriflunomide metabolite levels were carefully maintained between 50,000 and 100,000 ng/mL to balance its immunosuppressive and antiviral properties. No adverse events requiring discontinuation of leflunomide were encountered.
  
  
  RESULTS
  Switching from mycophenolate mofetil to leflunomide successfully cleared verrucae vulgares and molluscum lesions in all four renal transplant patients.
  
  
  CONCLUSIONS
  The ability to minimize and even resolve warts can improve quality of life by reducing risk of skin malignancies and emotional distress in solid organ transplant patients. Leflunomide is a potential therapeutic option for posttransplantation patients with skin warts because it serves both as an adjunct to the immunosuppressive regimen and an antiviral agent.
authors.affiliation: Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA. lieuko@gmail.com
authors.forename: Lieuko
authors.initials: L
authors.lastname: Nguyen
authors.forename: Robert B
authors.initials: RB
authors.lastname: McClellan
authors.forename: Abanti
authors.initials: A
authors.lastname: Chaudhuri
authors.forename: Steven R
authors.initials: SR
authors.lastname: Alexander
authors.forename: Sharon F
authors.initials: SF
authors.lastname: Chen
authors.forename: Waldo
authors.initials: W
authors.lastname: Concepcion
authors.forename: Paul
authors.initials: P
authors.lastname: Grimm
mesh_terms: D000293:Adolescent; D000998:Antiviral Agents / Q000008:administration & dosage*; D002648:Child; D057915:Drug Substitution; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000009:adverse effects*; D007555:Isoxazoles / Q000008:administration & dosage*; D016030:Kidney Transplantation / Q000009:adverse effects*; D000077339:Leflunomide; D008297:Male; D008976:Molluscum Contagiosum / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D009173:Mycophenolic Acid / Q000009:adverse effects / Q000031:analogs & derivatives*; D017193:Skin Diseases, Viral / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D016559:Tacrolimus / Q000009:adverse effects; D016896:Treatment Outcome; D014860:Warts / Q000188:drug therapy* / Q000276:immunology / Q000821:virology
chemical_list: D000998:Antiviral Agents; D007166:Immunosuppressive Agents; D007555:Isoxazoles; D000077339:Leflunomide; D009173:Mycophenolic Acid; D016559:Tacrolimus