Didactic Series. Dermatologic Manifestations Associated with HIV/AIDS. Ankita Kadakia, MD UCSD Owen Clinic 12/11/2014

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1 Didactic Series Dermatologic Manifestations Associated with HIV/AIDS Ankita Kadakia, MD UCSD Owen Clinic 12/11/2014 ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. 1

2 Learning Objectives 1) Recognize common dermatologic manifestations associated with HIV 2) Understand diagnosis of dermatologic manifestations 3) Understand treatment modalities for dermatologic manifestations 2

3 HIV Dermatology Presenting sign of HIV infection is skin manifestations HIV positive individuals due to defects in cell immunity are predisposed to certain bacterial, fungal, viral, and mycobacterial disease with skin manifestations Skin diseases which are common in general population are exacerbated in HIV with increased prevalence American Academy of Dermatology 3

4 HIV Dermatology Infectious Dermatoses Noninfectious Dermatoses CD4 count 4

5 HIV Skin Manifestations by CD4 CD4 < 50: Bacillary angiomatosis, Cryptococcus CD4 < 150: Histoplasma CD4 any count: mycobacterium, Kaposi s sarcoma, HSV, Herpes Zoster, HPV 5

6 Infectious Dermatosis 6

7 Infectious Dermatosis Syphilis Cryptococcus Histoplasma Herpes Zoster Kaposi s Sarcoma Bacillary Angiomatosis Scabies Molluscum contagiosum HPV S.aureus HSV Tinea Onychomycosis 7

8 Case 1 50 y homeless M, CD4 22, VL 48K, not on ARVS for several years, lives next to a dumpster where a pregnant cat has been living. Presents with weight loss, fever, and skin lesions present for 6 months. 8

9 What is this disease? Bacillary Angiomatosis or Bartonellosis Neovascular nodular lesions either single or in clusters with a reddish or violacious color Left: P. Volberding, MD, UCSF Center for HIV Information Image Library Right: G. Beatty, MD; A. Lukusa, MD, HIV InSite 9

10 CD4 <50 Bacillary Angiomatosis Bartonella henselae / Bartonella quintana B.henselae associated with cats, cat scratch, and fleas B.quintana associated with crowded low income area and louse infestation Systemic lesions in Liver, spleen, bone, lymph nodes 10

11 Bacillary Angiomatosis B.henselae can cause Peliosis hepatica Tissue biopsy shows lobular proliferation of small blood vessels, Warthrin Starry stain shows clusters of bacilli Can isolate using PCR, blood culture Doxycycline 100mg po BID Erythromycin 500mg po QID( macrolides) 11

12 Bacillary Angiomatosis IV for bacteremia, endocarditis, bone Four months or longer, may need chronic suppressive therapy MAI prophlylaxis with Azithromycin appears to be protective against BA 12

13 Case 2 43 y MSM with HIV, CD4 250, not on ART for 1 year because he wanted to take a drug holiday presents with 2 months of R leg edema from thigh to foot and new skin lesions on his R heel. 13

14 What is this disease? Kaposi s Sarcoma Similar in appearance to BA, slightly raised to nodular, red to violeceous color, can also be flat and more brown 14

15 Kaposi s Sarcoma Occurs at lower CD4 counts but can occur at ANY CD4 count HHV-8 associated with all 4 forms Higher prevalence in MSM regardless of HIV status Cutaneous and systemic lesions including Lymphedema 15

16 Kaposi s Sarcoma Look similar to Bacillary Angiomatosis Advanced disease lesions coalesce to form large plaques especially on upper thigh MC visceral site is GI tract Pulmonary involvement >50 lesions but can happen with little to minimal lesions, ominous sign 16

17 Kaposi s Sarcoma ART can prevent / regress lesions More extensive disease Heme/Onc consult for Chemotherapy Radiation therapy for localized lesions Avoid steroids 17

18 Case 3 22 y MSM, CD4 18, VL 5000, sexually active with multiple partners presents with diffuse small papules which initially appeared on his trunk but have spread to his axillae and face. 18

19 What is this disease? 2-5 mm painless flesh colored or pearly papules Molluscum with umbilicated Contagiosum center usually in singles but can be grouped near each other 19

20 Molluscum Contagiosum Any CD4 count but worse with advanced AIDS Poxvirus infects epidermal keratinocytes Spread via skin to skin contact, contact with shavers, sex toys, contaminated towels/linens Can be located in groin, trunk, axilla, face, more widespread in HIV 20

21 Molluscum Contagiosum Improves with ART but can be difficult to eradicate Cryotherapy with liquid nitrogen Local excision with curretage Topical Imiquimod Tretinoin Trichloroacetic acid Laser therapy 21

22 Case 4 55 y homeless M with CD4 11, taking his ART intermittently, has been living in a shelter for 3 weeks c/o of crusty pruritic skin which got worse after using hydrocortisone cream 22

23 What is this disease? Scabies Norwegian (Crusted) Scabies webmd.com 23

24 Scabies Can occur at any CD4 count Scaly pruritic papules or hyperkeratotic plaques on palms, soles, trunk, extremities Infestation with mite Sarcoptes scabiei Burrows between fingers and toes Occurs in crowded areas, institutionalized, homeless Skin scraping of burrow, skin biopsy 24

25 Scabies Superinfestation in Norwegian scabies occurs in advanced AIDS, MSM, HTLV coinfection Permethrin 5% cream once, can reapply after 14 days Need to treat household contacts Ivermectin 200 mcg/kg oral, at least 2 doses taken 7 days apart 25

26 Non-Infectious Dermatoses 26

27 Non-infectious Dermatoses Psoriasis Eosinophilic Folliculitis Seborrheic Dermatitis Atopic Dermatitis Xerosis Prurigo nodularis Hypersensitivity to insect bites 27

28 Cedeno-Laurent et al. Journal of the International AIDS Society 2011, 14:5 28

29 Case 5 48 y M newly diagnosed with HIV, CD4 150, VL 76K, presents with 4 months of raised red pruritic lesions often with a pustule. 29

30 What is this disease? Courtesy of Dr.Stephen Raffanti Raised pruritic nodules with pustular head on Eosinophilic Folliculitis erythematous base 30

31 Eosinophilic Folliculitis Occurs at CD4 counts 250 or lower Lesions look similar to bacterial folliculitis Inflammatory condition and often diffuse Skin biopsy: Intense infiltration of eosinophils around sebaceous glands/hair follicles, no PMNS or organisms Peripheral eosinophilia 31

32 Eosinophilic Folliculitis Improves with ART Topical steroid creams,oral antihistamines for mild disease Isotretinoin, Itraconazole, Phototherapy, moderate to severe disease 32

33 Case 6 48 y M newly diagnosed with HIV, CD4 275, c/o of stiffness of his knee joints and multiple scaly patches of skin covering his arms and trunk. He noticed a couple of patches 2 years ago when his HIV test was negative. 33

34 What disease is this? American Academy of Dermatology Psoriasis Well circumscribed erythematous plaques with silver scaling 34

35 Psoriasis Any CD4 count Worsening of psoriasis with HIV Increase prevalence of psoriatic arthritis Inverse psoriasis occurs in body folds, smooth shiny red lesions Topical steroids, retinoids, vitamin D replacement not as effective in HIV Responsive to ART 35

36 Cedeno-Laurent et al. Journal of the International AIDS Society 2011, 14:5 36

37 What is this disease? Courtesy of Dr.Stephen Raffanti Pearly flesh colored papules indicate disseminated Cryptococcus disease 37

38 What is this disease? aidsetc.org Herpes Zoster Dermatomal pattern, can be multiple dermatomes, CD , recurrent outbreaks 38

39 What is this disease? hivguidelines.org Rash is contagious (spirochetes), Can Secondary be more severe Syphilis in lower CD4 counts 39

40 References American Academy of Derm- HIV module Mandel, Douglas and Bennet s Principles and Practice of Infectious Disease ed.2011 aidsetc.org Cedano et.al, New Insights into HIV-1 Primary Skin Disorders; Journal of the International AIDS Society 2011, 14:5 40