Immunosuppressive agents in solid organ transplantation: Cutaneous adverse effects and dermatologic considerations

Solid organ transplant recipients are living longer due to advances in immunosuppressive therapy, but chronic immunosuppression carries a high burden of cutaneous adverse effects. This clinical review provides a practical, agent-specific overview of cutaneous toxicities associated with commonly used immunosuppressants in solid organ transplant recipients, including induction agents, calcineurin inhibitors, antimetabolites, mammalian target of rapamycin inhibitors, corticosteroids, and co-stimulation blockers. Cutaneous adverse effects range from early hypersensitivity reactions, alopecia, and aphthous ulcers to delayed complications such as photosensitivity, impaired wound healing, and skin cancers. Azathioprine and cyclosporine are associated with increased risk of cutaneous squamous cell carcinoma, while mammalian target of rapamycin inhibitors may offer protective benefits. Dermatologists play a central role in screening, prevention, and management of these toxicities. Risk stratification tools such as the skin and ultraviolet neoplasia transplant risk assessment calculator can guide timing of dermatologic referral and surveillance. Close collaboration with transplant teams is essential to adjust immunosuppressive regimens safely and minimize dermatologic morbidity while preserving graft function. This review aims to equip dermatologists with an updated framework for recognizing, managing, and preventing cutaneous adverse effects in this growing patient population.