Table 1.

Summary of Ancillary Therapy and Supportive Care Interventions

Organ System	Organ-Specific Intervention*
	Prevention	Treatment
Skin and appendages	Photoprotection e sun avoidance and physical sunblocks (eg, protective clothing, UVA, and UVB sunscreens). Avoidance of photosensitizing agents (eg, voriconazole). Surveillance for malignancy [2,3].	For intact skin e topical emollients including urea containing products, corticosteroids, antipruritic agents, and others (eg, PUVA or narrow band UVB, calcineurin inhibitors).
		For erosions/ulcerations e microbiologic cultures, topical antimicrobials, protective films or other dressings, debridement, hyperbaric oxygen, wound care specialist consultation.
Mouth and oral cavity	Maintain good oral/dental hygiene. Routine dental cleaning and radiographs. Surveillance for infection and malignancy. Nutritional counseling, if needed.	Topical high and ultra-high potency corticosteroids and topical calcineurin inhibitors. Topical analgesics. Therapy for oral dryness (eg, salivary stimulants, sialogogues) and for prevention of related complications (ie, dental decay).
Eyes	Photoprotection. Surveillance for infection, cataract formation, and increased intraocular pressure.	Artificial tears, ocular ointments, topical corticosteroids or cyclosporine, punctal occlusion, humidified environment, occlusive eye wear, moisture chamber eyeglasses, cevimeline, pilocarpine, gas-permeable scleral contact lens, autologous serum, microbiologic cultures, topical antimicrobials, doxycycline.
Vulva and vagina	Surveillance for estrogen deficiency, infection (HSV, HPV, yeast, bacteria) and malignancy [3].	Water-based or silicone lubricants, topical estrogens, topical corticosteroids or calcineurin inhibitors, dilators or vibrators, surgery for extensive synechiae or obliteration, early gynecology consultation. Avoid glycerin, paraben, fragrance, and other additive products,
Gastrointestinal tract and liver	Surveillance for infection (viral, bacterial, fungal, parasites)	Rule out other potential etiologies. Dietary modification, enzyme supplementation for pancreatic insufficiency, bile salt resins, gastroesophageal reflux management, esophageal dilatation, ursodeoxycholic acid, topical glucocorticoids, limitation of ethanol intake, avoidance of hepatotoxins.
Lungs	Surveillance for infection (Pneumocystis jiroveci, viral, fungal, bacterial).	Rule out other potential etiologies (eg, infection, gastroesophageal reflux). Inhaled corticosteroids, bronchodilators, supplementary oxygen, pulmonary rehabilitation. Consideration of lung transplantation in appropriate candidates.
Hematopoietic	Surveillance for infection (CMV, parvovirus)	Rule out other potential etiologies (eg, drug toxicity, infection). Hematopoietic growth factors, immunoglobulin for immune cytopenias
Neurologic	Calcineurin drug level monitoring. Seizure prophylaxis as indicated, including blood pressure control, electrolyte replacement, anticonvulsants. EMG monitoring and staging in symptomatic patients taking medications known to cause neuropathy. Close monitoring of distal extremities for wounds in insensate patients.	Occupational and physical therapy to prevent falls and improve function, treatment of neuropathic syndromes with tricyclic antidepressants, SSRI, or anticonvulsants [4]. Orthotics and assistive devices (canes and walkers). Bracing, splinting or surgical release for entrapment neuropathies.
Immunologic and infectious diseases	Immunizations and prophylaxis against Pneumocystis jirovecii, VZV, and encapsulated bacteria based on CDC guidelines. Consider immunoglobulin replacement based on levels and recurrent infections. Surveillance for infection (viral, bacterial, fungal, atypical).	Organism-specific antimicrobial agents. Empiric parenteral broad-spectrum antibacterial coverage for fever.
Musculoskeletal	Surveillance for decreased ROM, bone densitometry, calcium levels and 25-OH vitamin D. Physical therapy, calcium, vitamin D, and bisphosphonates. Flexion-extension x-rays to look for instability.	Physical therapy, bisphosphonates for osteopenia, and osteoporosis. Spinal orthosis for instability and/or intractable pain. Walking program, resistance training, core strengthening.

SSRI indicates selective serotonin reuptake inhibitors; CDC, Centers for Disease Control.

^*In general, close serial monitoring of all organ systems is recommended to promote early detection and intervention directed toward reversing or preventing progression of chronic GVHD manifestations and treatment-associated toxicities. Ancillary and supportive care therapies are commonly employed in addition to systemic GVHD treatment, although in some cases their use may circumvent the need for systemic treatment or allow doses of systemic agents to be reduced.