More than skin deep? Emerging therapies for chronic cutaneous GVHD

The options for treating skin disease after haemopoietic progenitor cell transplant (HPCT) have broadened considerably over the last decade to include much more than topical steroids and emollients. This article reviews current and emerging therapies for chronic cutaneous GVHD, a well-recognised complication of HPCT. Alongside skin-directed therapies, there is now a wide range of systemic agents with differing targets for which an evidence base is emerging. Of particular interest, we summarise the role of electrocorporeal photopheresis, a therapy increasingly used in the United Kingdom to treat severe sclerodermoid manifestations of GVHD. We include a discussion of the expanding knowledge of the pathogenesis of cutaneous GVHD, which is informing our understanding and development of second line therapies (for example, the role of B cells and the utility of rituximab). Additionally, we draw attention to challenges encountered in the evaluation of chronic GVHD treatments and highlight recommendations for further research that may enable haematologists and dermatologists to provide better care for these patients. Finally, we present a clinical algorithm to aid the approach to treating limited and extensive disease and steroid refractory or persistent disease where steroid sparing may be necessary.