Cutaneous and Oral Manifestations of HIV Infection. Charles Steinberg M.D

Cutaneous and Oral Manifestations of HIV Infection Charles Steinberg M.D. ©csteinberg2005 Skin manifestations in HIV    Extremely common Big ...
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Cutaneous and Oral Manifestations of HIV Infection Charles Steinberg M.D.

©csteinberg2005

Skin manifestations in HIV  



Extremely common Big psychological problem  Everyone can see it!  Stigma  Leading to depression, isolation etc. PLWHA with skin manifestations often need counseling and support!

Examination: LOOK EVERYWHERE MUCOSAL SURFACES PRIMARY LESIONS Macules, Papules, Nodules Vesicles, Bullae

DISTRIBUTION TIME COURSE ITCHING , PAIN COMMOM APPEARS UNCOMMON

African Histoplasmosis

Everyone deserves and unclothed exam

Primary Lesions

Secondary Changes

1 week of rash, fever, swollen glands and sore throat

Acute HIV infection

“SERO-CONVERSTION ILLNESS, ACUTE RETROVIRAL INFECTION”

What are typical skin manifestations?

Cutaneous Manifestations of HIV Infection  Scaly

rashes  Itchy macules, papules and nodules  Non-itchy macules, papules and nodules  Purple-brown lesions  Blisters, erosions, crusts  Pigmentary changes  Nail, Hair disorders

©csteinberg2005

Seborrheic dermatitis

Seborrheic dermatitis:  



Extremely common Cause: unclear, though the yeast Pytirosporum may play a role Treatment • Topical antifungal cream (eg ketoconazole) • Hydrocortisone 1%

What???

©csteinberg2005

©csteinberg2005

Tinea capitis

Onychomycosis

Itchy and painful. What??

©2007CSteinberg

Fungal skin infections in HIV  Dermatophyte 

Tinea corporis, tinea pedis, tinea unguium (onychomycosis)

 Yeast 

infections:

infections:

Candida intertrigo, oral candida

 Cutaneous

manifestations of systemic fungal infections: 

e.g. cryptococus

Dermatophyte infection: treatment (in RL)  Think

of local environment Clotrimazole cream  Griseofulvin for extensive disease or if nails are involved (Side Effects)  Ketokonazole/ Itraconazole if allergic to griseofulvin or if not responding. (Beware of drug interactions)  To diagnose for sure: scraping and microscopic examination with KOH 20% and/or culture

What ???

What???

©2005CSteinberg

Atopic eczema

Worsening of pre-existing dermatoses Atopic and contact eczema

3 Months on ARV’s

©2007CSteinberg

©2007CSteinberg

What other dermatoses can be affected by HIV?

©csteinberg2005

©csteinberg2005

Worsening of pre-existing dermatoses: psoriasis

Psoriasis  Made

worse by HIV infection  Patient may present psoriasis only after contracting HIV  Responds well to ARV therapy  Usual treatments for psoriasis including topical corticosteroids could be used  Check for systemic symptoms: iritis, joint involvement (Reiter Syndrome)

What is causing this rash ?

©csteinberg2005

©csteinberg2005

Drug hypersensitivity reaction  Whole

skin is inflamed and scaly  Face is swollen  There may be fever, lymphadenopaty, hepatitis, eosinophilia

Drug hypersensitivity reaction: drugs frequently involved  NNRTIs:

Nevirapine, Efavirenz  Anti-TB drugs  Cotrimoxazole  Abacavir

*****

Cutaneous manifestations of HIV Infection  Scaly

rashes  Itchy macules, papules and nodules  Non-itchy macules, papules and nodules  Purple-brown lesions  Blisters, erosions, crusts  Pigmentary changes  Nail, Hair disorders

©csteinberg2005

*

©csteinberg2005

Prurigo nodularis

Prurigo nodularis    

  

Cause: unknown PPE: Hypersensitivity to bites Common with CD4 < 200 cells Symptomatic treatment: sedating antihistamine (cetirizine), caladryl lotion, topical steroid ointment HAART DD: Folliculitis, warts, deep fungal infections Consider as marker of immune function?

Locations: finger webs, periumbilical, axillae, pubic

©2008CSteinberg

Itch Itch Itch

Scratch Scratch Scratch

Sarcoptes Scabiei

Scabies

Scabies  Worse

in HIV infection  Crusted “Norwegian,” scabies with massive scale  May resemble psoriasis but no underlying erythema (redness) of skin  May also involve scalp  Treat with benzyl benzoate for 24h and repeat after 72h or ivermectin

Dry skin (acquired ichthyosis)  Very

common in advanced HIV disease  May cause pruritus  Treatment:   



Avoid soap Wash with moisturizing soap substitute body oil in bath - or after shower, before drying Use copious moisturizing creams

Cutaneous manifestations of HIV Infection  Scaly

rashes  Itchy papules and nodules  Non-itchy papules and nodules  Purple-brown lesions  Blisters, erosions, crusts  Pigmentary changes  Nail, Hair disorders

©csteinberg2005

©csteinberg2005

Condyloma

©csteinberg2005

©csteinberg2005

Warts 

HPV (Human Papilloma Virus) infection



Somewhat worse in HIV infection



Often occur on genitalia, perianally, orally  Some strains are oncogenic  

Cervical Cancer Anal Carcinoma

Warts: treatment 

Podophyllin 20% weekly if no pregnancy, wash of after 4 hours



Podofilox (Condylox)



Cautery therapy, liquid nitrogen, laser



Imiquiod (Aldara) (expensive)

Common viral conditions presenting in uncommon ways

Common viral conditions presenting in uncommon ways

Moluscum contagiosum Facial

©csteinberg2005

©csteinberg2005

©csteinberg2005

Molluscum contagiosum

Molluscum contagiosum 

Very common when CD4 < 200



Small, hard, waxy-appearing papules often with central umbilification (hollow)



Caused by a pox virus



Often on face and spread by shaving

Molluscum contagiosum: treatment 

Cautery



Curretage and cautery for larger lesions



Liquid nitrogen



ART

Are all umbilicated papules M.C.?

Cryptococcal meningitis and molluscum-like lesions

Cutaneous manifestations of HIV Infection  Scaly

rashes  Itchy macules, papules and nodules  Non-itchy macules, papules and nodules  Purple-brown lesions  Blisters, erosions, crusts  Pigmentary changes  Nail, Hair disorders

Kaposi’s sarcoma

KS

©csteinberg2005

©csteinberg2005

115

©csteinberg2005

csteinberg2005



3 Week History  Fever  Hepatosplenomegaly  Feels Sick

Bacillary Angiomatosis  Infection

caused by Bartonella henselae  Often confused for KS  Diagnosed by skin biopsy and use of Warthin-Starry stain which shows bacteria  Reponds to treatment with azithromycin (Zithromax), erythromycin or other macrolides

Cutaneous manifestations of HIV Infection  Scaly

rashes  Itchy papules and nodules  Non-itchy papules and nodules  Purple-brown lesions  Blisters, erosions, crusts  Pigmentary changes  Nail, Hair disorders

©csteinberg2005

©csteinberg2005

Herpes zoster infection

Herpes zoster (Shingles) 



 

 

Often first clinical manifestation of HIV infection May be in multiple dermatomes simultaneously Seldom disseminates cutaneously Treat if possible with acyclovir 7 days (800 mg 5 times daily), as may disseminate to CNS Paracetamol-codeine 6 hourly Amitriptyline for post herpetic pain

©csteinberg2005

©csteinberg2005

Post zoster ophtalmica

HSV of one month duration

©2005CSteinberg

HSV six months duration…Patient refused to sit down in exam room

Private Parts?

©csteinberg2005

Herpetic Whitlow

Herpes simplex Very common If > 1 month-----> Stage IV 



Treatment with acyclovir 3 times 400 mg daily Long-term acyclovir 2 times 400 mg daily may be needed in people with recurring ulcers



Increases spread of HIV, so Herpes Rx to prevent HIV?



Steroids make worse

©2004CSteinberg

Steven Johnson

Steven Johnson

Warning Signs  Blisters  Mucous

Membrane Involvement  Systemic Illness: fever, elevated LFTs  Tender skin  Confluent lesions

Impetigo      

Caused by streptococcus or staphylococcus Thin walled blisters / bullae which break quickly leaving shallow ulcers Oozes yellow (“Honey colored”) serum with crusts Highly contagious Very pruritic (itchy) Treatment:  

Topical antibiotics Systemic antibiotics eg erythromycin

Examples of Impetigo

Google Search for Impetigo

Cellulitis  Deeper

skin infection in dermis - with staphylococcus or streptococcus, usually  Treated with systemic antibiotics

©2008CSteinberg

Syphilis  Secondary

syphilis may present with low

titer RPR  Treat as for HIV negative - or somewhat more aggressively  Rash may be minor – always examine palms and soles

©2008CSteinberg

Cutaneous manifestations of HIV Infection  Scaly

rashes  Itchy papules and nodules  Non-itchy papules and nodules  Purple-brown lesions  Blisters, erosions, crusts  Pigmentary changes  Nail, Hair disorders

Depigmentation after minor nevirapine rash, nevirapine was never stopped

Zidovudine nail coloration

©csteinberg2005

ORAL Manifestations

©csteinberg2005

YA SAMA

Oral candidiasis

Oral Hairy leucoplakia

Gingivitis

Oral manifestations of HIV  Oral

thrush (Candida)  Hairy leukoplakia (Ebstein Barr virus-EBV)  Aphthous ulcers  Herpes  KS  Gingivitis  Intra oral warts

Conclusions  Always

inspect a patient for skin, oral and genital lesions  Very important Issues to the patient   

Skin: Visible and Stigmatizing Oral: Can make it hard to eat, cause wasting Genital: Sexuality, HIV Spread

 Oral

and cutaneous lesions important for identifying OIs / staging a patient  Oral and cutaneous lesions important for monitoring ART

©csteinberg2006

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