Lect 26

• 90% HIV-infected persons suffer from skin diseases

  
• One or more cutaneous disorders
• Most common skin disorders

  • Fungal infection
  • Eczema
  • Seborrheic dermatitis
• Spectrum of skin disorders depends on

  • Immunologic stage as reflected by CD4 count
  • Concurrent use of HAART
  • Pattern of endemic infections
• Classification of HIV dermatoses

  • Morphology of primary lesion
  • Drug history
  • CD4 count

  
• Early HIV can be easily recognized
• Difficulty diagnosing: skin biopsy
• Skin Infections


  • Viral
  • Fungal
  • Bacterial
  • Parasitic
• Warts


  Dull-colored papules that erupt anywhere on the skin, including the anal mucous membrane, vagina, scrotum, penis and mouth
• Warts are caused by

  Human Papilloma Virus (6, 11)
• Management of warts


  1. Small: podophyllum, trichloroacetic acid, liquid nitrogen

  2. Large: surgical / excision, laser

  3. Other (home tx): podofilox, imiquimod, 5FU
• Herpes Simplex Virus


  Approximately 70% of persons with HIV are HSV-2 seropositive, and 95% are seropositive for either HSV-1 or HSV-2

  
• HSV-2 infection


  Increases the risk of HIV acquisition two- to three-fold, and in coinfected patients, HSV-2 reactivation results in increases in HIV RNA levels in blood and genital secretions

  
• Management of Herpes Simplex Virus

  1. Orolabial / recurrent GH (5-10 days); GH (7-10 days)

  2. Valacyclovir 1 g PO twice a day, or

  3. Famciclovir 500 mg PO twice a day, or

  4. Acyclovir 400 mg PO three times a day
• Varicella Zoster Virus


  A zoster infection is considered "disseminated" when it contains more than 20 nondermatomal lesions or involves the eye
• A significant number of people with HIV disease may also develop Herpes meningoencephalitis secondary to disseminated zoster

  
• Management of Varicella Zoster Virus

  Uncomplicated zoster outbreaks should be treated with acyclovir (Zovirax) 800 mg five times a day or famciclovir (Famvir) 500 mg three times a day, both for ten days
• Molluscum Contagiosum


  A very common benign self-limiting mucocutaneous viral infection caused by molluscum contagiosum virus (MCV) belonging to the Pox virus family
• Treatment of Molluscum Contagiosum

  1. Surgical: electrodessication, cryosurgery, laser

  2. Cytodestructive: cantharidin, trichloroacetic acid, phenol

  3. Chemo tx & antiviral: cidofovir, interferon, imiquimod

  4. PDT
• Oral Hairy Leukoplakia (OHL)


  The pathogenesis includes an interplay of persistent Epstein–Barr virus replication and virulence, systemic immunosuppression and suppression of the local host immunity
• Oral hairy leukoplakia can be diagnosed clinically and does not require a confirmatory biopsy
• Oral hairy leukoplakia does not require specific treatment and frequently resolves under HAART, if associated with HIV infection
• Mucocutaneous Candidiasis


  Mucosal candidiasis (oral, oesophageal or vaginal infections) is common in HIV/AIDS

  
• Management of Mucocutaneous Candidiasis

  1. Oral fluconazole 100–150 mg for seven to 14 days is recommended as the preferred treatment

  2. When fluconazole is not available or contraindicated, alternatives include topical therapy with nystatin suspension or pastilles, or clotrimazole troches
• Bacterial Skin Infections


  • Staphylococcus Aureus
  • Syphilis
  • Bacillary angiomatosis
• Scabies


  In immune deficiency, the number of scabies can jump dramatically and cause a treatment challenge
• Management of Scabies


  1. Mild/ moderate: permethrin 5% (topical), ivermectin (oral) 200 µ/kg

  2. Severe: two doses (with one to two weeks in-between) of oral ivermectin; if ivermectin is not available, then treat with topical permethrin 5% (or alternative)
• Scabies


  • Caused by Sarcoptes scabiei mite
  • Erupts on wrists, skin folds, between fingers, face/scalp in HIV
  • Itchy red papules sometimes mistaken for folliculitis
  • Linear furrows with papules are visual cue
  • Hypersensitivity reaction can cause vesicular component
  • Severe variant is Norwegian scabies with large crusted plaques

  
• Scabies treatment


  1. Mild/moderate: permethrin 5% topical, ivermectin 200 µ/kg oral

  2. Severe: two doses oral ivermectin 1-2 weeks apart, or topical permethrin 5% (or benzyl benzoate) until clinically clear
• Seborrheic dermatitis


  • More frequent in HIV, affects 85-95% of HIV patients
  • Caused by hypersensitivity to fungi in hair follicles
  • Characterized by erythema, rounded itchy scaly plaques on scalp, face, chest, groin

  
• Seborrheic dermatitis management


  1. Mild: topical ketoconazole 2% 2-3 times/week for 4 weeks, then maintenance once/week

  2. Severe: Mild + topical corticosteroid
• Pruritic papular eruption (PPE)


  • Chronic pruritus, symmetric papular eruptions on extensor surfaces, trunk, face
  • Common in HIV-infected tropics, 11-46% prevalence
  • In HIV: ART as primary treatment, antihistamines and topical corticosteroids for symptoms, UVB phototherapy effective
• Kaposi's sarcoma (KS)


  • Multifocal systemic tumor of endothelial origin
  • 4 variants: classical, endemic African, immunosuppression-associated, AIDS-associated
  • Most common malignancy in HIV, accelerates HIV, occurs at CD4 <200 cells/mm3
  • Investigations: skin biopsy, imaging
  • Management: radiotherapy, cryosurgery, photodynamic therapy, excision, intralesional chemotherapy
• Non-Hodgkin's lymphoma (NHL)


  • Second most frequent malignancy in AIDS, >90% B-cell derived, majority high-grade
  • Extranodal presentation most frequent in HIV, 70-80% of cases
  • Symptoms: fever, weight loss, night sweats, swollen lymph nodes, chest fullness, neurological symptoms
• Acute seroconversion syndrome


  • Incubation 2-6 weeks, duration 1-2 weeks
  • 50-70% of patients have acute syndrome, 25% severe enough for medical attention
  • Infectious mononucleosis-like picture: fever, sore throat, myalgia, malaise, headache, lymphadenopathy
  • May be complicated by hepatitis and neurological symptoms
• Drug reactions


  • Drug eruptions common in HIV, especially with trimethoprim-sulfamethoxazole
  • Stevens-Johnson syndrome fairly frequent in HIV
  • In HIV, suspected causative drug should be discontinued, supportive therapies offered
• Skin manifestations can be the first sign of HIV

  
• Diagnosis involves anamnesis and morphology of skin lesions

  
• Management involves treating the underlying disease