Body Surface Area Predicts Death in Erythema-Type Chronic Graft-vs-Host Disease

Erythema is a clinical prognostic marker for mortality, and body surface area should be measured and reported for patients with chronic graft-vs-host disease.

Common and occurring early during chronic graft-vs-host disease (cGVHD), erythema-type cGVHD, if persistent, can predict mortality. Estimated body surface area (BSA) involvement of erythema is a better predictor of mortality than the 2005 National Institutes of Health (NIH) Skin Score. These are among the study findings published in Journal of the American Medical Association Dermatology.

Researchers conducted a longitudinal, multicenter study that comprised patients aged 2 years and older with a clinical diagnosis of cGVHD who received systemic immunosuppression treatment from 2007 through 2012. Follow-up lasted until 2018. The primary outcome was nonrelapse mortality (NRM) and overall survival (OS) comparisons between NIH Skin Score and BSA prognostic models over time and adjusted for patient sex, age, race, conditioning intensity, and donor sex.

Of the 469 participants with cGVHD at enrollment, there were 267 with skin involvement and at least 1 year of follow-up (mean age, 51±12 years; 39% women). Additionally, 89 participants (19%) developed skin involvement. Patients underwent NIH Skin Score grading and BSA estimation of cutaneous cGVHD at enrollment and subsequently every 3 to 6 months.

Participants with skin involvement and cGVHD vs participants without skin involvement were more likely to be men (61% vs 51%), White (94% vs 87%), and have a peripheral blood stem cell source (92% vs 85%). They had a shorter time from cGVHD diagnosis to baseline examination (1.1 months vs 1.9 months) with predominantly moderate or severe disease. Among the 267 patients at baseline with skin cGVHD, 162 had erythema-only subtype.

Findings suggest that erythema-type cGVHD is common, occurs early during cGVHD, and can prognosticate mortality when persistent.

There was earlier onset and greater responsiveness to treatment of erythema-type disease vs sclerosis-type disease. A total of 77 of the 112 cases of sclerotic disease occurred without prior erythema. Incident sclerosis was more responsive to treatment than prevalent sclerosis. After adjusting for participant sex, age, race, conditioning intensity, and donor sex, researchers observed an association at first follow-up visit between BSA involvement of erythema and NRM (hazard ratio [HR], 1.33 per 10% BSA increase; 95% CI, 1.19-1.48; P <.001) and between erythema-type cGVHD and OS (HR, 1.28 per 10% BSA increase; 95% CI, 1.14-1.44; P <.001). There was no significant association between mortality and sclerosis-type cGVHD.

The model with erythema BSA collected at baseline and first follow-up visits retained 73% of the total prognostic information for OS, and 75% for NRM. There was no statistical difference between prognostic models (likelihood ratio test χ2, 5.9; P =.05).

The model with NIH Skin Score collected at baseline and first follow-up visits lost significant prognostic information (likelihood ratio test χ2, 14.7; P <.001), retaining 58% of the prognostic information for OS compared with 38% for NRM.

Limitations of the study include the preponderance of White participants, which limits the generalizability of the results, limited availability of granular information from the Chronic GVHD Consortium limits prognostication by subtype of erythema, and the lack of a single outcome capturing cGVHD survival.

“Findings suggest that erythema-type cGVHD is common, occurs early during cGVHD, and can prognosticate mortality when persistent,” the researchers conclude.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Dermatology Advisor


Baumrin E, Baker LX, Byrne M, et al. Prognostic value of cutaneous disease severity estimates on survival outcomes in patients with chronic graft-vs-host disease. JAMA Dermatol. Published online March 8, 2023. doi:10.1001/jamadermatol.2022.6624