Real-world experience from the expert panel determined that the most critical transplant-related new patient referrals were for transplant recipients with active concerning growths. Other time-sensitive scheduling matters included pre- and post-transplant skin screening exams (Table 2). We defined three clinical settings that receive these new patient referrals: tertiary dermatology clinics with a high-risk transplant clinic (HRTC), tertiary dermatology clinics without a HRTC, and community dermatology clinics. The panel determined that both the timelines for scheduling new patients and the appropriate type of physician can vary based on the reason for referral and the clinical setting. While ideally all patients would have access to a tertiary dermatology center with a HRTC, the triage algorithm reflects recommendations but not guidelines given the limitation of this resource and potential barriers to patient access. The HRTC model, components of the pre-transplant screening visit, and a suggested approach to follow-up after the initial visit are outlined in subsequent sections of the results.

Based on the identified clinical need and resource availability challenges defined above:

1. We recommend that SOTRs with an active concerning growth (lesion that is rapidly growing, tender or painful, or easily bleeds) are seen by a dermatologist, preferably in a HRTC if available, within 1–2 weeks of receiving the referral. All referrals for concerning growths should include high-quality photographs of the growth, ideally one from close-up to demonstrate lesion morphology and one from further away to demonstrate relevant anatomic landmarks. These referrals may be triaged via teledermatology prior to an in-person visit, and lesions concerning for invasive squamous cell carcinoma or other aggressive cutaneous malignancies on teledermatology should be seen within 1–2 weeks.

HRTCs provide comprehensive dermatologic care for transplant patients in an ideal model that is highly dependent on resource availability and not feasible in every practice setting [7–9]. In general, transplant dermatologists offer screening exams, field treatments, oral chemoprevention, surgical and non-surgical treatments for skin cancer, access to multispecialty care for management of high-risk skin cancers, and coordination with the primary transplant team to manage systemic immunosuppression to mitigate skin cancer risk. Counseling for all patients includes patient-specific skin cancer risk assessment and prevention. Additionally, these clinics should have the capacity for urgent add-on visits for lesions concerning for invasive squamous cell carcinoma or other aggressive cutaneous malignancies ideally within 1–2 weeks. Although most dermatologists who provide this comprehensive transplant care are at dedicated HRTCs, community or academic dermatologists who specialize in transplant dermatology can also meet this ideal clinic model and serve as a valuable resource for transplant patients.

The pre-transplant screening visit should include a comprehensive review of the patient’s pertinent medical history, thorough physical exam, and appropriate counseling, either within a HRTC (if available) or general dermatology clinic depending on the patient’s history of skin cancer (Table 3). If the pre-transplant screening visit has not been conducted or is not feasible with the transplant team’s timeline, the components of this visit should be included with the first post-transplant visit. Regarding the medical history review, this should include the patient’s history of melanoma and non-melanoma skin cancer, reviewing relevant previous pathology records and confirming all skin cancers were appropriately treated, any history of risk factors for skin cancer (i.e., history of extensive UV exposure including tanning bed use, actinic keratoses and prior field treatments, HPV-associated lesions, radiation therapy, relevant family history), and history of immunosuppression.

For patients with a history of melanoma, Merkel cell carcinoma, and high-risk squamous cell carcinoma, a consensus opinion from ITSCC has been published for recommended waiting periods prior to transplant in 2016 [4]. More recently in 2021, the delay time for patients with a pre-transplant diagnosis of melanoma has been revised by the American Society of Transplantation [10]. The physical exam should ideally be in-person, including mucosal regions (oral and genital) and an overall photodamage assessment. Counseling can be introductory and tailored to the patient to include a preventative therapy plan and education regarding skin cancer risk and prevention. Following the pre-transplant visit screening, referring transplant teams should receive documentation from the visit including any necessary delay time, the treatment status and risk profile of any known skin cancers, actinic burden and any plans for field therapy and/or chemoprevention, and surveillance recommendations (Figure 1).

To determine transplant candidacy for each individual patient, the primary transplant team has numerous tasks to complete. Dermatologists play a critical role in the pre-transplant screen as the most qualified providers to fully assess a patient’s eligibility based on their history of skin cancer and their current skin exam. Therefore, providing a pre-transplant screening visit in a timely manner is a valuable contribution to the transplant team and establishes a patient-provider relationship that will continue post-transplant. While we recommend seeing these patients within 1 month of receiving the referral from the primary transplant team as a professional courtesy, the timeline can be tailored to each patient’s case depending on the transplant team’s timeline and dermatologist availability. Furthermore, follow-up dermatology visits may be indicated if the patient is waiting for an organ for an extended period.

After a transplant patient or transplant candidate has undergone an in-person evaluation by a dermatologist at a HRTC, subsequent follow-up appointments may be performed either at the HRTC or by their local dermatologist. The frequency of follow-up visits and the recommendation for an appropriate physician is based on the high-risk transplant dermatologist’s discretion. These will be patient-specific and will depend on the patient’s skin cancer risk factors and practical considerations, including travel, patient preference, and out-of-pocket costs. For patients deemed at low risk for skin cancer or with barriers to frequent HRTC visits, follow-up visits can be scheduled alternating between HRTC and their local community dermatologist or with their local community dermatologist only and HRTC as needed.