Solid organ transplant recipients began receiving immunosuppressive drug regimens in the late 1950s and almost immediately began to manifest various dermatologic conditions. More than 90% of patients have dermatologic problems after transplantation. The three most common in the early days of transplantation were herpes simplex, warts, and acne but dermatologic problems ranged from annoying minor infections with dermatophytes to life-threatening disseminated fungal infections. Adverse effects were associated with specific medications: gingival hyperplasia, hirsutism, and gynecomastia from cyclosporine; Cushing's syndrome, acne, striae, skin fragility, and ecchymoses from corticosteroids; alopecia from tacrolimus; edema, folliculitis, hidradenitis suppurativa, aphthous ulcers, vasculitis, and nail abnormalities from sirolimus; and bacterial, fungal, and mycobacterial infections from general immunosuppression.

The initial response from the dermatologic community was to treat transplant patients like “regular” dermatology patients because their problems were in the realm of general dermatology. But these patients had problems of a different magnitude. From a therapeutic standpoint, one of the most difficult problems for dermatologists was the large number of recalcitrant warts that were common in these patients. A mixture of warts and cancers on the hands were referred to as the “transplant hand” and sometimes required resurfacing the backs of the hands. The incidence of these warts, often associated with human papillomavirus infection, rose from 15 to 50% in the first 12 months to 50 to 90% after 5 years.

As patients began to live longer and received allografts at older ages, the number of skin cancers increased substantially.