Why the basics? Back to Basics HIV Dermatology Immune reconstitution Acne. The HIV infected pt who starts ARV s 12/12/2012

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1 Why the basics? Back to Basics HIV Dermatology 2012 Toby Maurer, MD University of California, San Francisco 1) The depleted low CD4 counts 2) The repleted aging pts 3) The group who starts ARV s at high CD4 counts The HIV infected pt who starts ARV s at high CD4 s Immune reconstitution Acne Not at low CD4 counts In fact, need CD4 cells to mount this response Tx with oral antibiotics doxycycline 100 bid is great antiinflammatory May have to add prednisone for 3 weeks Isotretrinoin may be helpful 1

2 Eosinophilic Folliculitis Used to seeing this with CD4 counts that are low (under 200) especially when just starting ARV s immune reconstitution Also seeing it with CD4 counts that are higher especially RESTARTING ARV s and with underlying fungal or mycobacterial diseases 2

3 Inflammatory Syphilis Herpes zoster First episode occurs around CD4 of 315 Can be very monomorphic umbilicated pustules Can disseminate from zosteriform lesions or in HIV can present as chickenpox Can have multiple episodes in HIV 3

4 Seems to occur when adherence to ARV s is less than perfect and not because CD4 counts drop or VL increases drastically Can also occur as part of IRIS so pt may actually be adherent with sudden decrease of VL Treatment of Zoster High dose antivirals Acyclovir 800 mg 5x/day or Valcycolivir 1 gm tid Post herpetic neuralgia not usually a problem unless V1 distribution If V1 Hospitalize pt prevents blindness and IV tx may be better absorbed and there may be less post herpetic neuralgia 4

5 Genital Warts Big burden of disease not dependent on CD4 count The earlier pts enter care, the more genital warts we will see and possibly treat Are we preventing anything by treating existing warts? Quadrivalent vaccine is recommended for males and females before they are sexually active Australian study demonstrates that prevalence of warts in females greatly decreased, in heterosexual men decreased substantially Evidence of herd immunity 5

6 Women over age 30, not a significant decrease in warts. Not a significant decrease in warts in MSM over age 30 Waiting to see if vaccine shows decrease in warts in MSM when given earlier in patient s sexual history recruiting subjects through Joel Palefsky studies Genital Wart Evidence THESE DATA NOT FROM HIV INFECTED COHORTS Imiquimod easy to use but not as effective as cryotherapy and still expensive Cryotherapy and podopylin 25% most effective at clearing warts partial clearance noted after 2 session may take up to 12 sessions Recurrence rate is high What to do? Anything at all? 1) Anal pap smears should be offered to look for dysplasia 2) Admit that we are not great at clearing disease and preventing recurrence of warts 3) Our treatment will not get rid of HPV field effect 6

7 Epidermodysplasia verruciformis 1 study notes that imiquimod might be helpful to prevent recurrent warts but no data on how long to use and what the long term results are? HPV 5 and 8 Often mimics tinea versicolor Exacerbated by immune reconstitution In congenital form associated with SCC SCC not reported in HIV acquired epidermodysplasia Treatment: low dose acitretin 10 mg qd 7

8 HCV treatment in the HIV infected pt Telaprevir and Boceprevir pts are on various trails with these protease inhibitors directed against Hep C In non immunosuppressed host 55% pts had drug reaction mostly eczematous does not require stopping of drug treat through with topical steroids but see pt back 6% had serious drug reaction drug hypersensitivity with fever, eosinophilia, redness or erythema multiforme like reaction Stop drug The reaction gets a little worse after stopping drug is it the riboviran NO Takes some time for drug reaction to resolve 8

9 The Successfully Treated Aging HIV Infected Patient Actinic Keratoses Ravages of chronic sun exposure showing up 3 10% of AK s turn into SCC s Treatment: cryotherapy 9

10 SCC s Higher incidence of SCC s and BCC s in 2 HIV cohorts Recurrent SCC s on skin at UCSF cohort 17% in HIV infected men compared to 3% in non HIV infected group Appeared in ½ the time and in younger than expected age group Premature aging???? Chren M et al. Prednisone use Aging HIV population need it for joint aches, backaches, etc Where we were hesitant in past, now giving it to pts who are on ARV s and seem fully reconstituted Watch the HHV8 virus seem to turn it on!!! Kaposis sarcoma Seeing a group of HIV infected and non HIV infected gay men getting KS temporally related to receiving systemic steroids 10

11 KS what is new Clinical trials 2 new trials 1:maraviroc added to existing regimen being used to block CCR5 which we saw increased in a group of KS patients. 2: lenolidomide through AIDS Malignancy Consortium Doxil has returned Lymphedema is a problem 11

12 Lymphedema Even in pts whose KS is no longer active, lymphedema seems permanent Leads to infection, skin breakdown 12

13 What do we do for lymphedemacompression? Lymphatic massage? From literature on filiriasis and podoconiosis pts manage the skin get rid of tinea, get rid of maceration and protect 2 cm decrease in edema Davey et al Lancet March

14 The Depleted Patient Seb derm Tinea molluscum Staph infections A couple of Opportunistic Infections ALL IN THE SAME Patient Tinea Look for the red well dermarcated rim especially around the neck or face Pts will usually have onychomycosis and tinea pedis as well If on neck, going down hair follicles or inflamed treat with oral antifungals lamisil 250 qd for 1 month 14

15 Skin conditions good motivator to start and keep pts on ARV s! THANK YOU Happy Holidays 15