May 15, 2024Partners, Patients

Ready for a mind-blowing statistic? Just one inch of our skin contains almost 20 million cells! That’s hard to imagine, isn’t it? Multiply that to cover an entire body and we each have trillions of skin cells. When GVHD attacks these cells, uncomfortable symptoms like rashes, redness, tightness, blisters, and more can result.

In addition to skin changes, a person’s nails, hair/scalp, and glands may also be affected by this type of GVHD, too, because they’re all interconnected parts of what’s called our integumentary system…our body’s outermost layer that provides us with protection from the outside world.

This can result in nails that split or crack easily; impaired sweating, or an inability to handle heat because of damaged sweat glands; and changes to the hair, like thinning, hair loss, and changes to texture or color.

A Crash Course on Skin GVHD

Graft vs. Host Disease (GVHD) can occur following a blood or bone marrow transplant when the donor’s cells (the graft) begin attacking healthy cells in the transplant recipient (the host’s) body. Nearly any area of the body can be affected when this happens, and skin GHVD — also known as cutaneous GVHD — is the most common type of chronic GVHD.

When GVHD attacks skin cells, it causes a variety of uncomfortable symptoms. Things like:

  • Thin skin that breaks easily, or, on the opposite end of the spectrum, thick, hard skin
  • Rashes, scaly patches, sores, blisters and bumps
  • Changes in skin color or texture, including redness and irritation
  • Overly dry, itchy skin
  • Swelling or scarring
  • Skin tightness, or a “pulling” sensation
  • Burning sensations in hot or cold weather

You can see some photo examples of skin GVHD here.

When skin becomes thick, hard, and uncomfortably tight, it’s known as sclerotic skin GVHD. Deeper tissues may become sclerotic as well, which can make it a challenge to bend joints like your elbows, ankles, wrists, and shoulders. If the skin covering the abdomen becomes hard, it can also make breathing more difficult, or cause you to feel full soon after you begin eating. Sclerotic skin can also result in open sores, especially on the legs, because it slows down wound healing. It’s sometimes possible to “loosen” the sclerosis through gentle stretching, massage, and physical therapy, but these interventions shouldn’t make your pain worse — if they do, they might be causing more harm than good!

Treatments and Skin Care

Treatments for skin GVHD often include topical solutions — things you apply directly to your skin, like medicated and non-medicated creams and ointments — and systemic treatments that work inside the body, like corticosteroids, to suppress the immune system. Your doctor will work with you to determine what’s right for your unique situation.

A special type of light therapy called extracorporeal photopheresis (ECP) is also sometimes used. During ECP, photosensitizing chemicals are combined with a patient’s blood before being exposed to ultraviolet light, which reduces immune cells’ reactivity and calms the overactive immune response responsible for GVHD. ECP has few side effects, and is very well tolerated by most patients.

It’s incredibly important to keep your skin clean and moisturized when you have skin GVHD, too — not only to mitigate uncomfortable symptoms, but also to minimize the chances of getting an infection from bacteria entering your body through dry, cracked skin.

Memorial Sloan Kettering Cancer Center (MSKCC) has created an extremely helpful resource for people suffering from all types of GVHD, skin GVHD included. In it, they recommend the following to keep skin healthy:

  • Wash your hands frequently, even if they’re dry, to avoid infection. Use lukewarm water, not hot, and wash no longer than 20 seconds. When you dry your hands, leave them a little damp and apply a moisturizer right away. Always apply moisturizer after using hand sanitizer as well. When showering, follow the same protocol and use cool or lukewarm water to avoid over drying the skin, keep it short (under 20 minutes), use a moisturizing cleanser, and apply lotion on damp skin when you’re done. Avoid exfoliating products and antibacterial soaps, too.
  • When selecting a cleanser and moisturizer, choose a gentle, fragrance-free option from one of these brands:
    • Aquaphor®
    • Aveeno®
    • CeraVe®
    • Cetaphil®
    • Dove®
    • Eucerin®
    • Lubriderm®
    • Sarna®
    • Vanicream®

Udder Balm® or Udderly Smooth® are also favorites among patients — ointments and creams are always preferable to lotions, as they’re more moisturizing and less irritating. At bedtime, it’s a good idea to reapply your moisturizer, or rub a petroleum jelly (like Vasoline®) into your hands and feet before covering both with cotton gloves and socks. This helps the ointment penetrate your skin more effectively.

You can see the full MSKCC guide here.

Sun Safety with Skin GVHD

People with chronic skin GVHD may be more susceptible to skin cancer, so sunscreen is a must all year round. Even if the sun isn’t shining, wear your sunscreen — UV rays penetrate cloud cover more than you’d think is possible!

In addition to protecting against skin cancer, sunscreen guards against skin discoloration as well. Melissa Pugliano-Mauro, MD, a dermatologist with the University of Pittsburgh Medical Center (UPMC), says many of her patients with skin GVHD experience increased hyperpigmentation — or dark spots on the skin — particularly on their faces.

“Using sunscreen, especially with iron oxide and other physical blockers like titanium dioxide or zinc oxide, is important to block UV light as well as blue light from screens, which can cause darkening of skin on the face as well,” she advises. “Iron oxide can be found in tinted sunscreen as well as tinted moisturizers with sunscreen. The tint is key. I like brands like Elta MD, La-Roche Posay, and ISDIN.”

Choose a broad-spectrum sunscreen, SPF 30 or higher, and apply it after you’ve applied any medicated creams or ointments and moisturizer that you use, at least 20 minutes before going outside. Neutrogena® Sensitive Skin Sunscreen Broad Spectrum SPF 60+, Vanicream™ Sunscreen Broad Spectrum SPF 50+, and CeraVe® Hydrating Mineral Sunscreen Broad Spectrum SPF 50 are a few that are recommended in the MSKCC resource.

It’s also wise to wear clothing that hides your skin from the sun altogether, like long sleeve shirts, pants, and hats…bonus points if the clothing has an Ultraviolet Protection Factor (UVF) rating! Dr. Pugliano-Mauro recommends Coolibar, Solumbra, and Patagonia as companies with plenty of options. Staying out of the sun between 10 am and 4 pm is advisable, too, when UV rays are at their strongest.

Keeping Your Immune System Strong

Practicing healthy habits to maintain good overall health is important when it comes to dealing with the side effects that come along with GVHD — skin GVHD included.

While there isn’t a cure for GVHD (yet!), you can minimize symptoms and keep your immune system in fighting shape by integrating healthy behaviors into your daily routines.

  • Good nutrition goes hand-in-hand with good health, and should be prioritized by GVHD patients. In general, focus on eating a nutrient-dense, whole food diet that’s low in processed foods and added sugar. Working with a nutritionist to identify the types of foods that work best for your body is key, too — they will help you uncover food sensitivities (to things like gluten or dairy) or allergies that may be contributing to systemic inflammation, and help you build a customized eating plan.
  • Be sure to stay well hydrated by drinking plenty of filtered water. Minimize soda and sugary drinks.
  • Exercise is an important way to keep your body healthy, too — start slow, and work with your doctor to develop an exercise plan that’s right for you. It’s important to incorporate cardio (exercises like riding a bike, walking, playing tennis, swimming, etc.), resistance (weight training), and flexibility exercises (like stretching) into your routine.
  • Manage stress by finding activities that you enjoy to decompress. Breathing exercises and meditation are wonderful for this, too.
  • Prioritize your sleep — aim to get between 7 and 9 hours of sleep each night, and keep your sleep routine consistent, even on the weekends.

Tips for Using Makeup with Skin GVHD

If you’re someone who likes wearing makeup, skin GVHD can throw a wrench in your beauty routine. Products that were once a staple may now cause a skin reaction, or you’ve come to find out that they contain ingredients that are harmful to your health.

Choosing makeup options that are as “clean” as possible is important, which means that much like food, the shorter the ingredient list, the better. Aim for 10 ingredients or less, and consider using a database like EWG’s Skin Deep® that ranks skincare and beauty products with a health hazard score from 1-10 (10 being the most hazardous). The less ingredients are in a product, the easier it will be to determine what’s causing an issue as well, if you experience a reaction. When you first start adding things back in, try one at a time every few days to make sure you can tolerate it.

Memorial Sloan Kettering Cancer Center (MSKCC) also recommends the following:

  • Avoid products with parabens, plant-based (or botanical) ingredients — things like tea tree, eucalyptus, menthol, etc. — and talcum powder.
  • Choose products formulated for sensitive skin, ideally fragrance free.
  • Stay away from “organic” or “natural” products, as they may be unpreserved and harbor germs.

Covering rashes or skin discoloration caused by GVHD with concealer, foundation, or tinted moisturizer is fine, says MSKCC, as long as your skin isn’t broken. Dermablend is a brand Dr. Pugliano-Mauro often recommends to her patients, along with Elta MD, La-Roche Posay, and ISDIN, as mentioned above.

Lastly, make an effort to replace your favorite products on a regular basis — mascara every three months, eyeshadows once a year, and foundations, lipsticks, and blushes every 1 ½ to 2 years.

The Bottom Line on Skin GVHD

Living with skin GVHD can be a pain (literally and figuratively), but using the right skin care products and applying sun protection can go a long way to help counteract symptoms. In addition to topical treatments, your doctor may also recommend systemic treatments — like corticosteroids — to calm the overactive immune response responsible for skin GVHD. Lifestyle modifications can also help keep your immune system strong, so be sure to focus on eating a whole food, nutrient-dense diet, manage your stress, get plenty of sleep, and work with your doctor to create an exercise plan that’s right for you.


Read more in this series:
Eye or Ocular GVHD

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