CUTANEOUS MANIFESTATIONS OF HIV

CUTANEOUS MANIFESTATIONS OF HIV AUTHOR: DR M.H. MOTSWALEDI - MBCHB, MMED(DERM), FCDERM(SA) CONTENTS Introduction 4 Suspicion of HIV in patients w...
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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).

10 | 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

2.1.4 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

11 | 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

Fig 11 Papular syphilis

Fig 12 Overlapping of primary and secondary syphilis. Note the penile ulcer

12 | 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

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.

13 | 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 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.

15 | 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

2.2.3 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

16 | 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

2.3 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.

18 | 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

2.3.2.2 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

19 | 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

2.4 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

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