The skin is the first and most common place where graft-versus-host disease (GVHD) symptoms strike. Cutaneous GVHD (skin GVHD) occurs when a person’s immune system attacks donor cells they received after undergoing a stem cell transplant. Generally, this reaction leads to itchiness, followed by a rash.

As with other types of GVHD, skin rashes may be treated with corticosteroid ointments, oral steroids like prednisone, or other treatments that work by suppressing the immune response. Some signs can help identify a posttransplant rash as GVHD, but it’s important to see a doctor to confirm the diagnosis. Knowing what to look for can help you get treatment early and prevent serious, potentially life-threatening complications.

How Does GVHD Rash Appear on the Body?

A GVHD rash can show up anywhere on the body. For many people, it looks similar to a sunburn. However, acute GVHD and chronic GVHD affect the skin in different ways:

• Acute GVHD may cause itchy, dry, and sensitive skin, along with a flat or slightly raised rash.
• Chronic GVHD can lead to darkened, thickened, or bumpy skin and may also cause skin to become thin and fragile.

Acute GVHD Rash

Typically, acute graft-versus-host disease produces a rash that has flat and raised areas. It starts in the neck, upper chest, shoulders, palms of the hands, or soles of the feet. Sometimes, it happens on distant parts of the body, then spreads and runs together.

GVHD Rash Staging

Doctors classify GVHD rashes into four stages based on how much of the body is affected:

• Stage 1 — Rash covers less than 25 percent of the body
• Stage 2 — Rash covers 25 percent to 50 percent of the body
• Stage 3 — Rash covers more than 50 percent of the body
• Stage 4 — Rash covers nearly the entire body and may include bullae (fluid-filled blisters)

Chronic GVHD Rash

In chronic graft-versus-host disease, the rash can also resemble a sunburn, but the skin may become thinner and more fragile or thicker and more rigid (“woody”). Chronic GVHD is also associated with skin color changes. Discolored skin may appear darker, lighter, or reddish compared to the surrounding skin.

Sclerotic GVHD

Thickened skin from chronic GVHD is called sclerotic GVHD. This condition doesn’t directly cause a rash but can cause:

• Skin ulcers and lesions, especially on the legs
• A tight and itchy feeling
• Restricted movement if it affects the joints.

Other Skin-Related GVHD Symptoms

GVHD doesn’t just affect the skin — it can also change the nails, hair, and mouth. Nail and hair changes are more common in chronic GVHD. Mouth lesions can occur in both acute and chronic GVHD.

How Do the Symptoms Feel and Progress?

A graft-versus-host disease (GVHD) rash can be uncomfortable and irritating, often causing dryness, itching, and pain. Like a severe sunburn, GVHD can lead to blistering and peeling skin, increasing the risk of skin infections.

Managing GVHD symptoms as soon as possible can help prevent complications. Treating itching and irritation early may reduce the risk of secondary infections and damage to deeper tissues.

In more advanced cases, GVHD can cause bullous lesions, large, fluid-filled blisters that resemble second-degree burns. Severe skin symptoms can:

• Lower a person’s quality of life
• Change a person’s appearance and affect self-esteem
• Make daily activities more difficult
• Lead to long-term skin damage if untreated

Living with visible GVHD symptoms can be challenging. A strong support network — including friends, family, or others who understand GVHD — can make a big difference in emotional well-being and resilience.

When Should You Call the Doctor?

If you or your child develops a skin rash and you suspect GVHD, contact a dermatologist (skin specialist) or your transplant team right away. They can guide you on how to care for your skin and recommend the best treatment.

While waiting for medical advice, some general skin care tips include:

• Protecting your skin by wearing long-sleeve tops and long pants
• Applying sunscreen (Cleveland Clinic recommends sunscreen with an SPF of at least 50 for GVHD rash)
• Avoiding scratching to prevent irritation and infection
• Applying moisturizers and creams to keep the skin hydrated (avoid lotions, which can be more irritating)

Always be sure to seek guidance from a medical expert before trying to treat skin symptoms at home. Other skin conditions may be mistaken for a GVHD rash and might require a different treatment approach. These conditions include:

• Side effects of radiation therapy or medication
• Viral infections that cause rashes
• Skin inflammation from chemotherapy

How Is a GVHD Rash Diagnosed?

To confirm GVHD, a doctor may perform a skin biopsy — a simple procedure where a small sample of skin cells is removed and examined under a microscope.

Once GVHD is diagnosed, starting treatment early gives you the best chance of managing symptoms and preventing complications.

What’s the Treatment for a GVHD Rash?

The treatment for graft-versus-host disease rashes depends on how severe the rash is and how well it responds to therapy. Steroids are usually the first-line treatment. For smaller areas and mild rashes, topical steroids (creams or ointments) may be enough. If the rash is widespread or more severe, doctors may prescribe oral steroids like prednisone or steroid injections to control inflammation.

However, steroid treatment isn’t right for everyone. People who can’t take steroids or don’t respond to them may be prescribed topical tacrolimus, an immune-suppressing cream that helps reduce inflammation. Another option for treating skin GVHD is phototherapy, which uses ultraviolet (UV) light to calm the immune response in the skin.

A more advanced light-based treatment, called extracorporeal photopheresis (ECP), may be used when steroids aren’t working, GVHD affects a large area, or multiple organ systems are involved. ECP removes blood cells, treats them with UV light outside the body, and then returns them to help regulate the immune system.

If you have open wounds from GVHD, seek medical attention right away to prevent infections.

Your healthcare provider can help reduce the risk of complications, including bloodstream infections like sepsis. Your healthcare provider can apply special wound dressings to help the skin heal safely.

Other treatments for GVHD rashes depend on whether the disease is acute or chronic and how it responds to steroids. Belumosudil (Rezurock) is approved for chronic GVHD that doesn’t improve with other treatments. Ruxolitinib (Jakafi) is used for steroid-refractory GVHD (GVHD that doesn’t respond to steroids). Some early clinical trials suggest mesenchymal stem cell therapy may help treat steroid-resistant GVHD, but more research is needed. Scientists continue to explore new treatments through clinical trials, offering hope for more options in the future.

Talk With Others Who Understand

On myGVHDteam, the site for people and their loved ones living with graft-versus-host disease, people come together to ask questions, give advice, and share their stories with other stem cell transplant recipients who understand what it’s like.

Have you experienced skin rashes, sclerosis, or other symptoms of GVHD? How does GVHD impact your daily life? Share your insights in the comments below.