GvHD of the skin occurs when the white cells from the new “donor” attack the skin. It occurs because the donor cells “see” the patient’s skin as “foreign” and “attack” it. GvHD may occur within the first 3 months after the transplant, (when it is called “acute”) or later (when it is called “chronic”). It is more likely when the match between the donor cells and the recipient is less good. Drugs are usually given to try and prevent it but sometimes they don’t fully work and indeed for some patients e.g. with leukemia having some GvHD helps to get rid of the cancer cells. Sometimes the acute GvHD starts as these preventive drugs are reduced in dose.

Acute GvHD usually affects the top layer of the skin (the epidermis), which is the same layer that is inflamed in eczema and therefore both acute GvHD and eczema may look similar: the skin becoming red and sometimes swollen. The skin is usually involved symmetrically: affecting both sides of the body at the same time. The skin feels sore and itchy.   In people with darker skin then the inflammation may cause darkening of the skin, which should normally be temporary. Rarely the acute GvHD is very severe so that the skin blisters and may peel extensively. The diagnosis of acute GvHD of the skin is made usually on the basis of the red appearance of the skin and timing (following a transplant) but it is often difficult to distinguish at first from other causes of a red skin such as viruses or rashes caused by the many drugs which tend to be needed after transplants. It is often necessary to take some skin to look at down the microscope to be sure (to do a skin biopsy) which is a quick and simple procedure usually done under local anaesthetic.

If transplant patients notice new redness and soreness of the skin especially if both sides of the body are involved (even if the redness is patchy) then it is important to seek medical advice.

Chronic GvHD also results from “attack” of the skin by the immune system, but possibly in a rather more complicated way than in acute GvHD. It is different in that the damage is much more in deeper parts of the skin. Some damage occurs at the junction between the epidermis and the dermis and some predominantly within the dermis. The dermis is the deeper layer of skin, which is made up of the tough proteins such as collagen, and structures such as blood vessels.

When the inflammation is at the junction of the epidermis and the dermis then the skin may look purple rather than red, and the rash may be streaky.

Fig 2. Skin GvHD


There may be similar changes in the mouth although there the tissues might look unusually white or be ulcerated. These changes tend to come on more gradually than acute GvHD, and may be more difficult to treat. It is caused by changes in the immune system which tend to continue and therefore are more difficult to control other than by longer term treatment. As for acute GvHD, damage may also occur to the hair follicle causing hair loss and patchy colour change in the skin can be seen with both paler and darker areas.

When the inflammation is occurring deep in the dermis then it may cause thickening of the skin and something rather like scar tissue so that the skin feels less elastic than usual.

Top tips

Keeping the skin moisturised, particularly if you have GvHD is very important.

Use a non perfumed moisturiser such as aqueous cream. Patients have advised that aveeno and bio-oil are useful (not on skin that has active cGvHD).

 Skin affected by GvHD can become thicker, delicate and have less elasticity sometimes causing restriction in movement. Stretching exercises can be useful to improve elasticity. A physiotherapy consultation may also be of benefit.

When in the sun use a high protecting sunscreen of at least SPF30 (5-10 minutes without sun cream will not burn the skin and allow for some vitamin D uptake, see the information on bones).

Cover arms and legs and wear a hat if you are in direct sunlight.

Note and inform clinical team of any dry skin, itching, rash, sores, ulcers, swelling and changes in skin colour or texture.

Note and inform clinical team of any new changes with moles, for example change of appearance (raised or bleeding).

Nails can become ridged and brittle and can split; good hand care and the use of moisturisers is recommended.

 For a small minority of patients hair can be thinner at the scalp.

If you are prescribed steroid cream be careful how much you apply as applying too much to the skin will damage the surface and cause stretch marks. A finger tip unit (FTU) is a useful way to measure how much cream is needed for areas of the body. A FTU is a line of cream from the finger tip to the 1st crease of the finger.

Area of skin Size is roughly FTU each dose (adults)
A hand and fingers 2 adult hands 1 FTU
Front of chest and abdomen 14 adult hands 7 FTU
Back and buttocks 14 adult hands 7 FTU
Face and neck 5 adult hands 2.5 FTU
An entire arm and hand 8 adult hands 4 FTU
An entire leg and foot 16 adult hands 8 FTU


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