CUTANEOUS MANIFESTATIONS OF HIV
AUTHOR: DR M.H. MOTSWALEDI - MBCHB, MMED(DERM), FCDERM(SA)
CONTENTS Introduction
4
Suspicion of HIV in patients with skin diseases
4
Classification of skin diseases in HIV
5
1. Seroconversion stage/illness with its associated skin rash.
6
2. Infections
7
2.1 Bacterial infections
7
2.1.1 Staphylococcal
7
2.1.2 Bacillary angiomatosis
8
2.1.3 Mycobacteria
9
2.1.4 Syphilis
11
2.2 Viral infections
14
2.2.1 Herpes simplex
14
2.2.2 Herpes Zoster
15
2.2.3 Molluscum contagiosum
16
2.3 Fungal
17
2.4 Parasitic
20
2.4.1 Scabies
20
2.4.2 Norwegian scabies
20
3. Papulosquamous disorders and other related conditions
21
Seborrhoeic dermatitis
21
Psoriasis
22
Reiter’s syndrome
23
4. Photosensitivity disorders
24
Photosensitive dermatitis
24
Porphyria cutanea tarda
25
5. Oral cavity diseases
26
6. Follicular eruptions
28
Papulopruritic eruption
28
Eosinophilic Folliculitis of HIV
28
2|Cutaneous Manifestations of HIV
7. HIV Associated Neoplasia
29
Kaposi Sarcoma
29
Lymphomas
31
Squamous cell carcinoma
31
Basal cell carcinoma
31
8. Cutaneous adverse drug eruptions
32
Maculopapular rash
32
Erythema multiforme minor
33
Erythema multiforme major (Stevens –Johnson syndrome)
33
Toxic epidermal necrolysis
34
9. Immune reconstitution inflammatory syndrome (IRIS)
3|Cutaneous Manifestations of HIV
35
INTRODUCTION
Skin disorders are very common in the setting of HIV and AIDS.
About 80-95% of HIV and AIDS patients will have skin manifestations at one stage or another during the course of their illness.
The skin may be the first and the only organ to be affected in HIV.
Suspicion of HIV in patients with skin diseases
If a patient presents with a skin disease which is known to be an AIDS defining illness.
If a patient presents with a common disease in an unusual setting
If there is a florid rash
If a patient presents with unusual clinical features
If the skin disease is resistant to standard form of therapy, despite adequate dosages and good compliance
4|Cutaneous Manifestations of HIV
CLASSIFICATION OF SKIN DISEASES IN HIV
1)
Seroconversion stage/illness with its associated skin rash.
2)
Infections: bacterial, viral, fungal, parasitic
3)
Papulosquamous disorders
4)
Photosensitivity disorders
5)
Oral cavity diseases
6)
Follicular eruptions
7)
HIV associated neoplasia
Kaposi Sarcoma
Lymphomas
Squamous cell carcinoma
Basal cell carcinoma
8)
Drug eruptions
9)
Immune reconstitution inflammatory syndrome (IRIS)
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1. ACUTE SEROCONVERSION SYNDROME
Usually occurs 2-6 weeks post transmission.
Usually occurs with CD4 count of between 500 and 1000 cells/mm³
Symptoms are fever, sore throat, malaise, lymphadenopathy and skin rash.
The exanthematous rash occurs in 25% of patients and may be morbilliform, or maculopapular and may also affect palms and soles.
FIG 1 Maculopapular seroconversion skin rash
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2. INFECTIONS 2.1 BACTERIAL INFECTIONS
2.1.1 Staphylococcus aureus
It is the commonest bacterial pathogen in HIV Clinically it may cause skin diseases like folliculitis, impetigo, ecthyma and skin abscesses
Fig.2 Staphylococcal Folliculitis
Fig.3 Staphylococcal Folliculitis. Note the yellowish pustular nature of the lesions.
Management of staphylococcal skin diseases:
Do Pus swabs for microscopy, culture and sensitivity. Cloxacillin 500mg p.o qid for at least 1 week. Topical antibiotic like Bactroban, Fucidin or Flammazine. Use antiseptics like Savlon in bath water.
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2.1.2 Bacillary angiomatosis It is caused by Bartonella Henselae and presents with angiomatous papules and nodules in AIDS patients with severe immunosuppression. Kaposi sarcoma and cutaneous cryptococcosis should be considered as differential diagnoses. Skin biopsy confirms the diagnosis. Visceral involvement can occur.
Fig 4 Bacillary Angiomatosis
Fig 5 Bacillary Angiomatosis. Note the friable, angiomatous nature of the lesions.
Management of Bacillary Angiomatosis It responds well to antibiotic therapy. In some cases response to treatment is quiet dramatic with the following antibiotics: Doxycyclin 100 mg twice daily or Erythromycin 500 mg four times daily. Duration as per response.
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2.1.3 Mycobacterium tuberculosis Both true cutaneous tuberculosis and the tuberculides can occur in the setting of HIV. True cutaneous tuberculosis occurs by way of inoculation or by haematogenous spread. Tuberculides occur as a result of immunological reaction to mycobacterial DNA elsewhere in the body. Lupus vulgaris is the commonest type of true tuberculosis. Lesions can be plaques, nodules and destructive ulceration. Scrofuloderma is also common. It occurs as ulcerating plaques on the skin due to involvement of an underlying organ like lymph node, bone or from a joint. The commonest tuberculide is called Papulonecrotic tuberculide which presents as papules or pustules which later have necrotic centres and heal with atrophic scarring.
Fig 6 Lupus Vulgaris with ulcerative plaques
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Fig 7 Scrofuloderma
Fig 8 Papulonecrotic tuberculide
Diagnosis of cutaneous tuberculosis may be difficult and may need referral to a Dermatologist. Treatment of cutaneous tuberculosis is anti TB treatment for 9 months. (Not for 6 months like in pulmonary TB).
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2.1.4 Syphilis
It is caused by Treponema pallidum. There is increased incidence of syphilis in HIV. In the setting of HIV different stages of syphilis may overlap and progress rapidly. Secondary syphilis is a disease of the skin and may be difficult to diagnose as it can mimic anything. Skin lesion may be papulosquamous, papules, nodules, plaques, ulcerative, acneiform, and erythema multiforme – like.
Diagnosis of secondary syphilis in HIV may be difficult as serology is unreliable. One needs to have a very high index of suspicion. Suspected cases may need referral to a Dermatologist.
Fig 9 Acneiform lesions of secondary syphilis
Fig 10 Nodulo-ulcerative lesions of secondary syphilis
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Fig 11 Papular syphilis
Fig 12 Overlapping of primary and secondary syphilis. Note the penile ulcer
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Fig 13 Lues maligna
MANAGEMENT OF SYPHILIS
Benzathine penicillin 2,4 mu imi weekly x3 or
Erythromycin 500mg qid in penicillin sensitive patients or
Doxyclin 100mg BD
It is very important to screen and treat sexual contacts as well.
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2.2 VIRAL INFECTIONS
2.2.1 Herpes Simplex virus
Muco-cutaneous HSV infection lasting for 1 month strongly suggests underlying HIV infection.
There may be multiple lesions which are deep and painful.
Lesions may be non-healing ulcers periorally or perianally
Fig 14 Deep painful, non-healing ulcers of HSV
Fig 15 Chronic non healing ulcers of HSV perianally
Note serrated edges.
Management of Herpes Simplex Topical and systemic antivirals like Acyclovir 14 | C u t a n e o u s M a n i f e s t a t i o n s o f H I V
2.2.2 Herpes Zoster (Shingles) In the setting of HIV Herpes zoster is
Usually multi-dermatomal
Recurrent episodes
Ophthalmological/ neurological complications
Chronic hyperkeratotic forms
Fig 16 Herpes Zoster affecting Maxillary and Mandibular divisitions of trigerminal nerve
Fig 17 Herpes Zoster on the trunk
Management of Herpes Zoster Strong Analgesics and NSAIDS Those who present within 72 hours of the onset of these painful vesicles should be given Zelitrex 1g p.o tds x7days.
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2.2.3 Molluscum Contagiosum Caused by a pox virus Lesions are dome shaped papules and nodules with a central umbilication
Fig 18 Molluscum Contagiosum
Management of Molluscum Cryotherapy Imiquimod Cream Preferably patients must be on ARV’s
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2.3 FUNGAL INFECTIONS 2.3.1 Dermatophytes (Tinea infections)
. These are superficial fungal infections of the skin caused by yeasts and moulds
. Occur in increased severity of HIV and AIDS
. There may be recurrent episodes
Fig 19 Tinea Corporis in HIV
Fig 20 Tinea Cruris in HIV
Management of Tinea Infections 1. Topical antifungals for mild disease 2. Systemic and topical antifungals for severe disease
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2.3.2 Deep Fungal Infections 2.3.2.1 Cryptococcosis
Caused by cryptococcus neoformans which has a predilection to the skin and the central nervous system.
It occurs in advanced immunodeficiency states and is an AIDS defining illness
Skin lesions occur in 10% of cases and may be papules and nodules which may be ulcerated.
Cryptococcal meningitis presents with severe headache, mental confusion, neck stiffness and coma in severe cases.
It is important to note that some patients may have meningeal involvement with no clinical signs of meningitis.
Fig 21 Cutaneous cryptococcosis
Management of Cryptococcosis
Biopsy to confirm the diagnosis and Lumbar puncture, whether there are clinical signs of meningitis or not.
Systemic antifungals, preferably Amphoterium B 0,75mg/kg IV for 2weeks then fluconazole 200mg orally twice a day until lesions heal.
Patients with cryptococcal meningitis may need prolonged therapy to avoid recurrences.
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2.3.2.2 Histoplasmosis
Caused by Histoplasma capsulatum
There may be systemic involvement, usually acute or chronic pulmonary histoplasmosis
Disseminated form is AIDS defining
Skin lesions may be papules, nodules, chronic ulcerations, plaques and molluscum contagiosum – like lesions
Bone marrow involvement can occur.
Fig 22 Cutaneous histoplasmosis
Fig 23 Same patient with ulcers on the trunk and arms
Management of Histoplasmosis
Biopsy to confirm the diagnosis
Fungal cultures
Chest X –Ray to exclude pulmonary involvement
Bone marrow aspiration if indicated
IV Amphoterium B for 2weeks then oral fluconazole
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2.4 PARASITIC INFESTATIONS 2.4.1 Scabies Caused by sarcoptes scabiei
Classic scabies presents as small pruritic papules and burrows
Common sites include webspaces of hands, fingers, wrists and trunk
The severe form called Norwegian or crusted scabies is common in HIV/AIDS especially with CD4 counts of