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Didactic Series

HIV related Dermatologic Manifestations

Ankita Kadakia, MD UC San Diego, Owen Clinic

April 26, 2018

Learning Objectives

1) Recognize common dermatologic manifestations associated with HIV and underlying disorders

2) Understand diagnosis and treatment of dermatologic manifestations

3) Review immunologic factors related to skin manifestations

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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 3

American Academy of Dermatology

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Classifications Infectious Dermatoses • Bacterial • Mycobacterial • Fungal • Viral • Parasitic

Noninfectious Dermatoses • Systemic and Cutaneous Malignancy • Drug reactions • Epidermal disorders • Papular and follicular eruptions • Pigment disorders

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https://www.aids.gov.hk/pdf/g190htm/21.htm

Infectious Dermatoses

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Bacterial

Fungal

Viral

Parasitic

Case Presentation

• 50 y homeless M, CD4 22, VL 110K, not on ARVs, living in a tent under a bridge, recently took in a female cat and her kittens. He presents to the ER 3 months later with fever, weight loss, and dark red papules on his arms and trunk.

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9 Left: P. Volberding, MD, UCSF Center for HIV Information Image Library Right: G. Beatty, MD; A. Lukusa, MD, HIV InSite

Poll Question

• What could the lesions be due to?

• A. Syphilis • B. Kaposi’s sarcoma • C. Sporotrichosis • D. Bacillary angiomatosis (Bartonellosis)

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Bacillary Angiomatosis • CD4 <50 • Bartonella henselae / Bartonella quintana • kitten scratches and fleas • Systemic lesions in Liver, spleen, bone,

lymph nodes • Bartonella PCR or blood culture • Doxycyline, macrolides have activity • MAC prophylaxis is protective 11

Bacterial Dermatoses

• Staph aureus (skin abscess,folliculitis, carbuncles)

• Syphilis ( secondary syphilis, gumma, chancre)

• Bacillary angiomatosis • Nocardia • Mycobacterial – TB and NTM

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• 52 participants, HIV +/-, MRSA+/-,measured MRSA-specific CD4 T-cell responses including IFN-gamma in skin biopsies and blood

• Lower frequency of IFNγ+ producing CD4 memory T cells compared to HIV-uninfected participants with MRSA SSTIs

• Increasing CA-MRSA causing skin and soft tissue infections • MRSA colonizes 8.8% PLWHIV in North America • PLWHIV were 18-fold more likely to have CA-MRSA infections than

uninfected and twice as likely to have recurrences • Lower CD4 counts and low nadir CD4 • Higher peak RNA levels • Not on ART • Close contact in MSM and multiple sex partners

Fungal Dermatoses • Primary Cutaneous

– Seborrheic dermatitis of scalp and face – Tinea/onychomycosis

• Muco-cutaneous – Oropharyngeal candidiasis

• Invasive Fungal with cutaneous lesions – Cryptococcus – Histoplasma – Penicillium – Cocci – Blastomycosis – Sporotrix

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Candidiasis

• Acute pseudomembranous candidiasis (thrush): The classic multiple white-flecks on the tongue, buccal mucosa, and palate

• Chronic hyperplastic candidiasis: Thick white plaques on the buccal mucosa

• Acute atrophic (erythematous) candidiasis: Erythematous patches on the palate

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Courtesy of Dr.Stephen Raffanti

Pearly flesh colored papules indicate disseminated cryptococcosis

Raised red papules of disseminated Histoplasmosis

Poll Question • 35y M with HIV, CD4 250, VL ND, on ART c/o of

recurrent painful ulcerations in the anal cleft. Took acyclovir 5x’s/day for 10 days with no relief. Similarly 3 months ago did not respond to acyclovir. You confirm HSV by PCR of a lesion. What should you do next?

• A. Test for Thymidine Kinase mutation and empirically start Valganciclovir

• B. Test for VZV Ab and give IVIG • C. Start Foscarnet immediately

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Viral Dermatoses

• HSV • VZV/Herpes Zoster • Molluscum

contagiosum • CMV • HPV

• Vesicles- grouped in HSV and VZV

• Umbilicated in Molluscum

• Ulcerations in HSV, CMV

• Verrucous growth in HPV

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Scabies

webmd.com

Norwegian (Crusted) Scabies

Parasitic Dermatoses

Scabies

• Superinfestation in Norwegian scabies occurs in advanced AIDS, HTLV co-infection

• 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

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Non-Infectious Dermatoses

Systemic and Cutaneous Malignancy

Drug Reactions

Epidermal Disorders

Papular and Follicular Eruptions

Pigment Disorders

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Most Common Non-infectious Dermatoses

• Psoriasis • Eosinophilic Folliculitis • Seborrheic Dermatitis • Atopic Dermatitis • Xerosis • Prurigo nodularis • Drug reaction

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

Systemic and Cutaneous Malignancy

• Kaposi’s sarcoma • Lymphoma • Melanoma • Basal cell carcinoma • Squamous cell Carcinoma

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Kaposi’s Sarcoma

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http://visualsonline.cancer.gov

Kaposi’s Sarcoma • Decreased prevalence with more ART • Associated with HHV-8 • More extensive disease at low CD4 counts • ART can prevent / regress lesions unless

extensive cutaneous disease • Extensive cutaneous disease requires

adjunct chemo with Doxorubicin • Radiation therapy for localized lesions

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Kaposi’s Sarcoma • Have to look for mucocutaneous lesions-

Oral and rectal exam • MC visceral site is GI tract followed by

pulmonary • Workup for visceral lesions includes

EGD/Colonoscopy , CT Chest • Steroids worsen KS so avoid systemic

steroids including steroid inhalers and topical

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Poll Question • 45 y M, new HIV diagnosis, CD4 255, VL 55K, starts

Triumeq. 3 days later he develops painful blisters on his arms and trunk, 5 days later the skin starts to peel near the blisters and he feels like he has a bad sunburn. What do you do?

• A. Prescribe Acyclovir for Herpes Zoster since he is likely reconstituting his immune system

• B. Test for HLA B5701, if negative then continue Triumeq

• C. Stop Triumeq immediately and give fluids and steroids

• D. Treat for MRSA skin infection with Bactrim

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Drug Eruption • Increased due to ART, 20 to 100 times

more common • Can occur with any ART or OI prophylaxis

( Nevirapine/sulfa) • Mild form: Maculopapular exanthem or

morbiliform rash • Toxic epidermal necrolysis • Stevens Johnson syndrome • DRESS ( drug reaction with eosinophilia

and systemic symptoms) 28 Dermatol Res Pract. 2017; 2017: 6216193.

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Dermnet NZ

• SJS <10% BSA • TEN >30% BSA • HLA types like B5701 with abacavir hypersensitiviy syndrome • Drug specific CD8+ cytotoxic lymphocytes can be detected in the early

blister fluid. They have some natural killer cell activity and can probably kill keratinocytes by direct contact. Cytokines implicated include perforin/granzyme, Fas-L and tumour necrosis factor alpha (TNFα).

Epidermal Disorders

• Psoriasis • Xerosis ( severe generalized itching and

dryness) • Seborrheic dermatitis

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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

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

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Inverse Psoriasis

http://psoriasismedication.org/flexural-or-inverse-psoriasis/

Classic Psoriasis

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American Academy of Dermatology

Well circumscribed erythematous plaques with silver scaling

Papular and Follicular Eruptions

• Eosinophilic folliculitis • Prurigo nodularis- pruritic nodules on

extremities • Pruritic Papular Eruption- papular and

pustular eruptions on extensor surfaces and dorsum of hands

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Courtesy of Dr.Stephen Raffanti

Raised pruritic nodules with pustular head on erythematous base

Eosinophilic Folliculitis

Eosinophilic Folliculitis • Elevated IgE, peripheral eosinophilia • CD4 < 300 • Inflammatory condition and often diffuse • Th2 cytokine response to an unknown

antigen (Pityrosporum ovale or Demodex folliculorum)

• elevation of IL-4, IL-5 and chemokines that mediates chemotaxis, recruits eosinophils in the allergic late phase reaction

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Eosinophilic Folliculitis

• Skin biopsy: Intense infiltration of eosinophils around sebaceous glands/hair follicles, no PMNS or organisms

• Improves with ART • Topical steroid creams,oral antihistamines

for mild disease • Isotretinoin, Itraconazole, Phototherapy,

moderate to severe disease

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Prurigo nodularis

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http://bestpractice.bmj.com/topics/en-gb/855

Pigment Disorders

• Hyperpigmentation ( Zidovudine) • Vitiligo- unknown pathogenesis but

thought to be autoimmune and possibly viral trigger to melanocytes

• Vitiligo treatment: topical corticosteroids, vitamin-D derivatives, calcineurin inhibitors, photochemotherapy

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4360494/

Vitiligo

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https://en.wikipedia.org/wiki/Vitiligo#/media/File:Vitiligo2.JPG

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

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