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Dermatologic Manifestations of HIV Infection
Dermatologic Manifestations of HIV Infection
Toby A. Maurer, MD
The International AIDS Society–USATA Maurer, MDPresented at IAS–USA/RWCA Clinical Conference, June 2005.
Slide #2
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
• As pts immune reconstituted, decreased incidence of most of the diseases-seborrheic dermatitis, fungal diseases, psoriasis, opportunistic infections with skin manifestations.
• Who are the pts who still develop skin diseases and why?
Slide #3
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
CD4 Under 200 and not on ART
• Psoriasis over 50% of body surface area
• Extreme photodermatitis
• Prurigo Nodularis
• Molluscum
• Recurrent drug reactions
Slide #4
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Psoriasis
• With ART, HIV psoriasis easily controlled with topicals (clobetasol and calcipotriene) and ultraviolet light.
• Until ART kicks in or for more complex psoriasis-acitretin 10-25 mg /day
Slide #5
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Photodermatitis• HIV makes pts sensitive to the sun
• Pts with CD4 under 200 on photosensitizing drugs
• Either ART allows pts to go off photosensitizing drugs or immune reconstitution decreases reaction
• Tx: sunscreen, tx the dermatitis with potent topical steroids and lubricants, doxepin 25 mg qhs (as antihistamine)
Slide #6
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Prurigo Nodularis
• Pts consumed by itch
• CD4 50 and under
• May be a photocomponent to this
• ART helpful
• Potent topical steroids
• Thalidomide
Slide #7
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Pruritic Papular Eruption in Uganda
• Study done to evaluate pts and their biopsies of new onset prurigo nodularis
• 86/102 biopsies showed evidence for bug bites
• The more severe the eruption, the lower the CD4 count (p< 0.001)
• Persons on ART appear to improve
• Hypersensitivity to bug bites may be secondary to altered immune response of HIV
Resneck J, et al JAMA DEC 1, 2004
Slide #8
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Molluscum
• Seen frequently in young women not on ART
• 1st line therapy is ART
• Liquid nitrogen only temporary
• Curretage of large molluscum
Slide #9
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Recurrent Drug Reactors
• Group of persons who have drug reactions to everything including antibiotics, ART, etc.
• Challenge is to get them on ART and bring CD4 count over 50
• Prednisone with slow taper (over 12 weeks) while introducing drugs
Dolev J et al Arch Derm Sept 2004
Slide #10
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Drug Reactions
• When do you use steroids in a reaction?
If the patient has a hypersensitivity reaction marked by elevation of LFT’s or creatinine
If patient is a chronic drug reactor-reacts to every med so that you cannot get pt on ART
Not in erythema multiforme or Stevens Johnson or urticaria
Slide #11
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Diseases that just don’t go away with ART
• Eczema/ Xerosis-if CD4 nadir was below 200, will always be recurrent
• Tx: mid-potency steroids (ointment better than cream), antihistamines, can use the newer topicals -tacrolimus and pimecrolimus
Slide #12
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Warts
• Past evidence showed a low nadir was important in determining course of warts; i.e., warts would not resolve over 24 month period with treatment if nadir CD4 under 50
Rodriguez L, et al
Slide #13
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Wart treatment
• All about 50% efficacyLN2PodophyllinImiquimod (genital)-new study-once warts
eradicated by surgery or cryotherapy, imiquimod works to prevent recurrence
Duct tape?LaserSurgeryTreat every three weeks-ave. no. of tx=12
Slide #14
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
• Trying to look at persons who are reconstituted with warts or eczema to see if CD38 as marker of decreased immune function is useful
Slide #15
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Is KS in this category
• KS seen throughout spectrum of CD4 counts (0-800)
• First line therapy is ART-do you start ART is pts with KS who have high CD4 count?
• Seeing KS erupting in persons on ART with excellent control-why?
• Do they have abnormal function of T cells in spite of high CD4 counts?
Slide #16
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
KS Treatment from Derm Perspective
• KS with CD4 above 400 and undetectable VL-careful monitoring of CD4 and VL, topical treatments (alitretinoin)
• ART for CD4 under 400
• Eruptive KS or lymphadema on ART-start doxorubicin HCI liposome injection/paclitaxel-IV infusions
Slide #17
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Cutaneous Lymphoma
• See it in CD4’s under 200• Work-up necessary to R/O systemic
lymphoma• If just cutaneous, radiotherapy or
surgery• Before ART era, cutaneous lymphoma
had tendency to metastasize • Improves with ART (limited
experience)
Slide #18
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
With immune reconstitution:diseases that we never used to see
• Acne-differentiate from eosinophilic folliculitis
• Staph infections-differentiate for HSV and fungal diseases
• Erythema nodosum-differentiate from helicobacter cinaedii
Slide #19
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Acne
• Acne vulgaris
• Acne rosacea
• Perioral/periorbital dermatitis
Tx: TCN, doxycycline, minocycline, accutane for cystic acne
Slide #20
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Eosinophilic folliculitis
• Itchy, urticarial bumps face, neck, SCALP, chest and back
• Usually in CD4 counts under 200 or in pts within 3-6 months of initiating ART
• Itraconazole 200-400 mg /day• Permethrin from waist up• Wait for immune reconstitution to
settle (3-6 months after starting ART)
Slide #21
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Staph infections• Increased incidence since patients no longer
require prophylaxis with trimethoprim/sulfamethoxazole or other antibiotics (CD4>200)
• Staph in form of abcesses, ulcers, folliculitis
• Consider methicillin resistant staph in pts with recurrent staph or not improving on antibiotics
• Culture when possible for organism and sensitivities (Still sensitive to doxycycline, trimethoprim/sulfamethoxazole, ciprofloxacin and clindamycin)
Slide #22
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Approach to Treatment
• Culture where you can-if you have pus, that is great
• Incise and drain when appropriate (Abcesses)
Slide #23
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
If no pus:
• Tx with methicillin sensitive drugs-first line but have pt return to evaluate for resolution
• If recurrent infection, tx with methicillin sensitive antibiotics right off the bat (trimethoprim/sulfamethoxazole , doxycycline, ciprofloxacin/levofloxacillin, clindamycin)
• Consider adding rifampin 600 qd for 5 days or mupirocin ointment for staph eradication
Slide #24
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
For recurrent disease
• Also look for underlying skin disease that could be portal of entry
• Dry skin-lubricate with grease• Eczema-TAC and lubrication• Psoriasis-staph exacerbates psoriasis
and psoriasis portal of entry• Tinea- portal of entry-tx with
antifungals
Slide #25
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
If not improving
• Was patient treated long enough?
Once hair structures are involved or deep tissues, treatment time may be longer
Slide #26
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Was it bacterial in the first place?
• Remember HSV-culture and/or Direct Fluorescent Antibody
• Skin biopsy for histology and tissue culture
Slide #27
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Erythema nodosum
• Can be part of immune reconstitution in patients with diagnosis of sarcoid
• Can be associated with other etiologies: strep, cocci, yersinia, inflammatory bowel disease
• Biopsy diagnosis
• Tx: bedrest, prednisone, SSKI
Slide #28
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Helicobacter cinaedi• Mimics erythema nodosum• Caused by gram negative rods• Fever/bacteremia/diarrhea• Blood cx can be positive without fever• Stool can be culture positive• Skin biopsy shows suppurative process• Tx: 8 weeks of doxycycline or
erythromycin• Recent report of campylobacter causing
similar picture-cultured from blood-tx: ciprofloxacin
Slide #29
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
HIV and HCV
• Co-infection rate high and leads to many skin problems:
l) Lichen planus
2) Xerosis
3) Leukocytoclastic vasculitis
4) Itch without a rash
Slide #30
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Xerosis
• Pts noting that skin barrier changing and more dry
• Lubricants, steroids
Slide #31
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Leukocytoclastic Vasculitis
• R/O reactions to drugs• R/O infection-strep, endocarditis, Hep A, B,
C• R/O collagen vascular disease and
cryoglobulinemia• R/O leukemia, lymphoma• HCV viral load and LFT’s are not
necessarily increased in active cutaneous vasculitis
• Tx: colchicine, steroids?, treat the Hep C
Slide #32
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Itch without a rash
• Seems to be central itch
• Naltrexone (opoid antagonist) may be helpful. ?Dose-start with 50 mg qhs.
• Antihistamines not helpful
• Ultraviolet light not helpful
• Treatment for HCV helpful unless pt gets the ribavirin itch