Cutaneous and Oral Manifestations of HIV Infection Charles Steinberg M.D.
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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
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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???
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Tinea capitis
Onychomycosis
Itchy and painful. What??
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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???
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Atopic eczema
Worsening of pre-existing dermatoses Atopic and contact eczema
3 Months on ARV’s
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©2007CSteinberg
What other dermatoses can be affected by HIV?
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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 ?
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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
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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
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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
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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
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©csteinberg2005
Condyloma
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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
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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
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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
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©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
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Post zoster ophtalmica
HSV of one month duration
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HSV six months duration…Patient refused to sit down in exam room
Private Parts?
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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
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ORAL Manifestations
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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
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