HIV AND THE SKIN DR. FREDAH MALEKA DERMATOLOGY UNIVERSITY OF PRETORIA:KALAFONG
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1 KEY FEATURES HIV AND THE SKIN DR. FREDAH MALEKA DERMATOLOGY UNIVERSITY OF PRETORIA:KALAFONG Atypical presentation of common disorders Severe or exaggerated presentations Sudden acute exacerbations Treatment failure VIRAL INFECTIONS Exanthem of primary HIV infection Herpes simplex virus (HSV) Varicella Zoster virus (VZV) Molluscum contagiosum (Poxvirus) Human papillomavirus (HPV) Epstein Barr virus (EBV) Cytomegalovirus (CMV) EXANTHEM OF PRIMARY HIV INFECTION Acute retroviral syndrome Morbilliform rash (exanthem) : 2-4 weeks after HIV exposure Typically generalised Pronounced on face and trunk, sparing distal extremities Associated : fever, lymphadenopathy, pharyngitis DDX: drug reaction other viral infections EBV, Enteroviruses, Hepatitis B virus 1
2 HERPES SIMPLEX VIRUS(HSV) Vesicular eruption due to HSV 1&2 Primary lesion: painful, grouped vesicles on an erythematous base HIV: attacks are more frequent and severe : chronic, non-healing, deep ulcers, with scarring and tissue destruction CLUE: severe pain and recurrences DDX: syphilis, chancroid, lymphogranuloma venereum Tzanck smear, Histology, Viral culture HSV Treatment: Acyclovir 400mg tds 7-10 days Alternatives: Valacyclovir and Famciclovir In setting of treatment failure, viral isolates tested for resistance against acyclovir Alternative drugs: Foscarnet, Cidofovir Chronic suppressive therapy ( >8 attacks per year) 2
3 VARICELLA Chickenpox Presents with erythematous papules and umbilicated vesicles, may become pustular Starts on face and scalp, spreads caudally Presenation varies from typical course to fatal pulmonary involvement Have 7-15X greater risk of developing HZ HERPES ZOSTER Shingles In HIV, interval between chickenpox and HZ is much shorter Dermatomal, but can be multidermatomal Ulcerative, chronic, verrucous +/- widely disseminated Systemic involvement is common Can also occur in the immune recovery syndrome Treatment: until clinical resolution Acyclovir 800mg 5Xdaily for 7days Systemic involvement : IVI Acyclovir ( Paeds 10mg/kg 8hrly IVI ) 3
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5 MOLLUSCUM CONTAGIOSUM Occurs in significantly reduced CD4+ cell counts Classic dome-shaped umbilicated papules, and larger coalescent plaques >1cm in diameter HIV: tend to be widespread, giant lesions, severe facial involvement Resistant to therapy Can recur with initiation of therapy (IRIS) RX: destructive modalities curettage/electrotherapy - cryotherapy every 2-3 weeks Topicals like Imiquimod + topical cidofovir VIRAL WARTS Caused by human papillomavirus (HPV) Isolated warts are common in immunocompetent individuals Numerous lesions are a sign of immunodeficiency More extensive Skin coloured flat-topped papules large plaques (c. accuminata genital area) May develop Bowenoid papulosis, Acquired Epidermodysplasia verruciformis( AEDV), SCC in association with EDV Increased risk of developing cancer CIN, AIN, Penile cancer, 5
6 TREATMENT:WARTS Depend on size and location of lesions Often challenging with high relapse rate Genital warts: 25% Podophyllin, wash off after 4-6 hours, repeat weekly for 6/52 Imiquimod 3X weekly until resolution Verruca vulgaris: 2% salicylic acid face, 5% salicylic acid body, cryotherapy if available 6
7 ORAL HAIRY LEUKOPLAKIA Due to Epstein-Barr virus (EBV) Presents as an early sign of HIV infection Asymptomatic, corrugated white plaques with hair-like projections along lateral aspect of tongue No associated malignant degeneration RX: unnecessary topical/oral antiviral agents, Podophyllin resin, ARV s may lead to regression of plaques CMV Despite ART, remains NB cause of serious opportunistic infection in patients with advanced AIDS Common presentation: retinitis, oesophagitis, colitis Cutaneous disease relatively uncommon Presentation: ulcers ( esp anogenital and mucosal surfaces) verrucous and hyperpigmented plaques, purpuric papules, vesicles, morbilliform eruptions Biopsy more sensitive than viral cultures May get co-infection with HSV, VZV BACTERIAL INFECTIONS Staphylococcus aureus infections Bacillary angiomatosis Mycobacterial infections Syphilis 7
8 STAPHYLOCOCCUS AUREUS INFECTIONS Most common bacterial pathogen in patients infected with HIV Impetigo, folliculitis, furunculosis and cellulitis NB: increased incidence of MRSA (6fold) Treatment: antibiotics Flucloxacillin 500mg qid 10 days incision and drainage Temporary eradication of bacterial colonization chlorhexidine gluconate washes, beach baths, intranasal Mupirocin applications Unusual presentations may be refactory to treatment BACILLARY ANGIOMATOSIS Rare infection caused by gram-negative bacilli Bartonella (B.henselae, B.quintana) Transmitted to humans by cat scratches/ flea bites/ body louse Red to purple vascular-appearing papules and nodules and ulcers Lesions vary from one to more than hundreds Affects skin, all organs including liver, bone Confused with Kaposi s sarcoma Skin biopsy will confirm the diagnosis RX: Erythromycin/Doxycycline for minimum 2months 8
9 MYCOBACTERIA:CUTANEOUS TB Increased risk of presenting with cutaneous hypersensitivity reactions Skin lesions variable: ulcers verrucous plaques erythematous papules and nodules deep nodules Common practice of TB prophylaxis as well as ART has led to the decrease in frequency of cutaneous TB SYPHILIS Lesions same as in immunocompetent patients Ulcerated papules and nodules involving skin and mucosae are common in HIV infected individuals Classic secondary syphilis with unusual presentations such as Noduloulcerative forms Papular eruptions that mimic molluscum contagiosum Syphilitic palmoplantar keratoderma Lues maligna (severe ulcerations,pustules + constitutional symptoms) 9
10 SYPHILIS LUES MALIGNA: aggressive widespread variant of secondary syphilis prodrome of fever, headaches and myalgia followed by an eruption of papulopustular or necrotic lesions CNS involvement (neurosyphilis) occurs more frequently Confirmation: serological tests skin biopsy RX: Benzathine benzylpenicillin IMI 2,4 MU once weekly for 3 weeks Erythromycin 500mg qid/ Doxycycline 100mg bd for 14 days 10
11 FUNGAL INFECTIONS Superficial fungal infections: Candidiasis Dermatophytosis (Tinea) Pityriasis versicolor Systemic fungal infections: Cryptococcosis Histoplasmosis Coccidioidomycosis Sporotrichosis CANDIDIASIS Most frequently encountered fungal infection in HIV Correlates with lower CD4+ cells 90% patients with HIV develop oropharyngeal candidiasis Presentation: Perleche painful fissures at oral commissures Intertriginous candida infection Chronic paronychia RX: oral fluconazole (in addition to ARV S) DERMATOPHYTOSIS:TINEA Tinea faciei, pedis and corporis Common manifestation of HIV atypical in appearance, more widespread, resistant to therapy Presents as erythematous, scaly patches with a well-defined edge Nails proximal white onychomycosis Dx KOH preparation in the lab RX Localized: topical azoles Extensive: Griseofulvin 1g daily for 4 weeks in adults, 20mg/kg daily for 4 weeks in children 11
12 SYSTEMIC FUNGAL INFECTIONS In patients with CD4 count <250 cells/mm3 CRYPTOCOCCOSIS: translucent dome-shaped papules with central umbilication CNS involvement common HISTOPLASMOSIS: commonly on the face with oral ulcerations Skin biopsy and culture of dermal tissue is mandatory Cryptococcal Ag detection in CSF and serum is helpful RX: IV Amphotericin B Antifungal agents like Itraconazole, fluconazole, variconazole Relapses are common 12
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14 SCABIES CRUSTED/NORWEGIAN SCABIES Generalised hyperkeratotic lesions Subungual debris with marked nail thickening (mites) Thousands of mites may be present in a single patient, therefore, extremely contagious RX: Topical Permethrin,multiple courses may be required Oral Ivermectin, highly effective Treat contacts as well Wash bed linens + clothing at high temperatures Children: salicylic acid 5% in UE DEMODICOSIS Caused by mites Demodex folliculorum and D.brevis Presents with folliculitis or rosacea-like eruption Usually affects the head and neck region Microscopic exam of skin scrappings or skin biopsy demonstrates mites in hair follicle RX: Topical Permethrin Gamma benzene hexachloride Metronidazole gel or oral Refractory cases: Ivermectin 14
15 NON-INFECTIOUS HIV-RELATED CUTANEOUS DISORDERS Development of non-inflammatory disorders with unusual presentation should alert one to consider HIV infection PAPULOSQUAMOUS DISORDERS Seborrhoeic dermatitis Psoriasis Reactive Arthritis (Reiter s Disease) Others: Acquired Ichthyosis Pityriasis Rubra Pilaris Atopic dermatitis 15
16 NON-INFECTIOUS PAPULAR PRURITIC ERUPTIONS Papular pruritic eruption of HIV Eosinophilic Folliculitis These eruptions are common in HIV infection Extreme itch which can be debilitating Pathogenesis of these dermatoses is not entirely clear DDX : Hypersensitivity to drugs/parasites Systemic disorders e.g hepatobiliary/renal disease, lymphoma 16
17 PAPULOPRURITIC ERUPTION OF HIV EOSINOPHILIC FOLLICULITIS Intensely pruritic, urticarial papules Non-follicular and symmetrically distributed On face and trunk Advanced immunosuppression, CD4 COUNTS <50 IN 70% of patients? Exaggerated response to arthropod Ag s Skin biopsy: eosinophils throughout the dermis Rx: oral antihistamines topical steroids Recalcitrant cases - Phototherapy Intensely pruritic urticarial lesions resembling insect bites Concerntrated on face, neck, upper trunk and proximal parts of upper limbs Secondary changes like excoriations and PIH may mask features Histologic features: peri- and intrafollicular eosinophilic infiltrate Rx: similar to PPE ERYTHEMA ELEVATUM DIUTINUM Chronic form of cutaneous leukocytoclastic vasculitis Occurs in low CD4 count < 200 cells/mm3 Persistent erythematous papules and nodules Favour extensor surfaces of limbs Responds to Dapsone 17
18 PHOTOSENSITIVITY REACTIONS Prone to developing eczema in sun-exposed sites On the face, nape of the neck, anterior V of the chest and forearms Causes may be: HIV, Drugs(antiTB, tetracyclines, NSAIDS), Pellagra Presentation: pruritic, lichenoid, violaceous plaques Mx: Remove offending drug Topical steroids, Sunscreen Oral antihistamines In Pellagra Nicotinamide 100mg daily, until there s clinical improvement 18
19 PHOTOSENSITIVE DISORDERS IN HIV Are common, affecting 5% of HIV-positive patients Conditions include: photosensitive drug eruptions, chronic actinic dermatitis (CAD), pellagra, lichenoid photoeruptions, porphyria cutanea tarda (PCT) Actinic lichenoid leukomelanoderma of HIV is a photosensitive condition specific to South Africa HIV-RELATED CUTANEOUS NEOPLASTIC DISORDERS HIV-infected individuals have a 3- to 5 fold higher risk of developing non-melanoma skin cancers BCC and SCC Appear at a younger age, are more multifocal, are located on trunk and limbs Have a high risk of recurrence and metastasis HPV infection increases risk of anogenital, oral, digital SCC Aggressive Rx is often required to prevent recurrences and metastases KAPOSI S SARCOMA Most common neoplasm associated with HIV Incidence has declined significantly with use of ART Due to HHV-8 Can occur at any stage of HIV infection Present as violaceous patches, plaques and nodules Involving the skin and oral mucosal surfaces like gingivae and hard palate Systemic involvement is common: Lymph nodes (lymphoedema), GIT and lungs 19
20 KAPOSI S SARCOMA: TREATMENT LYMPHOMAS Rx depends on extent of disease and comorbidities NB to be on ART Flares can occur as IRIS KS is radiosensitive, therefore, radiotherapy for local destruction Systemic disease, chemotherapy Avoid radiotherapy for oral lesions ( non-healing ulcers and stomatitis) HIV-infected persons are at increased risk of developing lymphomas B-cell lymphomas are considered AIDS-defining Pathogenesis involves EBV and HHV-8 infection Occurs in the setting of significant immunesuppression with CD4 < 200 cells /mm3 Presents as pink to violaceous papules and nodules, with ulceration, sometimes simulates panniculitis Skin and LN biopsy mandatory Referral to Haematology and Oncology for chemotherapy 20
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