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SKIN AND MUCOUSMEMBRANE MANIFESTATIONSIN HIV DISEASE PechdauTohmeena,Bsc.,MD.,Dip Derm.' LaddawanNualchaem,Bsc,MD.,Dip Derm.' Danny A. Hermawan,MD,Dip.Derm."

Abstract Theskin changesoccuring in HIV infectionare mostlyqttributableto alterations in immunefunction. TheassociationbetweenHIV infectionand increasedof opportunisticinfectionand Kaposi's sarcomafirst recognize by Dermatologistin NewYorkin I98L The disorder is causeby a human immunode.ficiency virus (HIV), known (HTLV as the human T-cell lymphotrophic virus III IID. This retrovirus hes predilectionfor CD4 T-helper cells, monocytesand Langerhan's cells. Skin problem qre very commonamong individuals infected with HIV if T-helper cells are lessthan 100 cells/mm2. Skin manifestotionsof HIV diseasemay be divided into 3 main groups : I. Infections e.g. bacteria, virus,fungus and protozoa. 2. Non-specific dermatitisgroup or miscellaneousgroup e.g.papulo-squamous, papular, vascular and drug related skin disorder. 3. Neoplasme.g. Kaposi's sqrcoma,CutaneousT-cell lymphomaGTCD and squamouscell carcinoma(SCC). This brief review outlinessomeof the commondermatoseswith HIV infection in SouthEastAsia (1996)and somefrom lhe Instituteof Dermarologt, Bangkok, Thailand (199I - I 995).

Introduction Apart from the primary infection, the skin changesoccuring in HIV infection are mostly atfibutable to alterationsin immune fi.mction.Theseinclude t

Instituteof Dermatology.Bangkok,Thailand.

**

Medical Faculty,Krida WacanaChristianUnivenity, JakartaIndonesia.

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irfecticlns of increasedseverity or atypical morphology with recogniziedskin of someothers,however,is uncertain.Dermatologists pathogens. The pathogenesis uere the first to recognizean associationbetweenHiV infection and increasedof opportunisticinfectionand Kaposi'ssarcomain New York andCalifomiain 1981. The disorder is causedby a hr"unanimmurodeliciencyvirus (-IIV), known as the humanT-cell lyrnphotrophicvins III (IJTLV-III). This reffovimshaspredilection cells. for CD4 T-helpercells,monocl4eandLangerhan's arcverycommonernongindividualsinfectedwith HIV. Skin manifestation with HIV associated This brief review outlinessomeof the commondermatoses (1996) from Institute and some data of infection in SEA, South East Asia Dennatology,Bangkok,Thailand( 1991-1995).

Skin Manifestationsof HIV Disease 87o/oof I-IIV patientwill presentedwith skin manifestationswhen T-helpercell (absoluteCD4' count) < 100cmlmm2.Skin manifestations of HIV diseasemay be dividedinto 3 main groups: f . infectione.g bacteria,virus,fungusand protozoa groupe.gpapulosquamous, 2. Non-specificdermatitisor rniscellaneous skin disorder. papular,vascularand drug-related 3. Neoplasme.g Kaposi'ssarcoma,CutoneousT-cell Lymphoma(CTCL) and SquamousCell Carcinoma(SCC). Bacterial Infection l. The conunon bacterial infections include impetigo, folliculitis, ecthym4 infectionof scabies. cellulitis.secondary 2. Mycobacterialdiseasecommonlycausedby Mycobacteriumhtberculosisand with smallpapulopushrle cwiumintracellulare.Patientpresented Mycobacterium similarto folliculitisor lymphadenopathy. Treatment: Standardshod courseregimenwtth2ELRZ4HR for 6 months(M tuberculosis).In case of atypical Mycobacteriurntreat with Clarithromycin 500-1,000mg twice a day for 7 days,Ciprofloxacin750 mg hrice a day and Rifampicin600mg perday). 3. Svnhilis

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Viral inl'ection l. Herpessimpler andpersistant FIIV infectedpatientsoltenhavclocal[ydestructive HSV manil'estations. lt commonly inf-ection. t'rutrare11,shou'generalized occurat 1heusualsitessuchas : lip, mouth.genitaiiaandanus. Untreated,theseicsionsbecomelarge,deep,confluentulcerswhich are often cnrst. corercdrvithnccrotrc 7i'eutment: oral acyclovir200 mg 5 timesa day for 7-10days(if no response increaseddosc 800 mg). In ca-seof acyclovir resistantmutant Trisodium (fjoscarnet) phosphonolbmrate is given.It'svirostatic.{0rng/kgq 8-12lu, side gcnitalulcer) effects: rcnallaihue. 2. Herpeszostcr Fourd in moclelatedegreeof immurodeficiency.Thc incidenceof Herpes Zosterin I IIV inlcctionis about7 timeslnolc comnlonthannomralpcople.The purulent. ulcerative or necrotic. cruptionma1'bc bulloushirctnorrhagic. Treutmenl:Oral acyclovirtt00 nrg 5 timesiday10-14daysor intravenous(lV) acyclovir10mg4igthrcetirnesa dayor Foscamet. 3. Cytomcgalovirus It can be fourd itr 90o/oof AIDS patient.Most cormnonlyoccur in the eyes (retinitis)zurdcolitis. Skin rnanifestatiorucan be presentedwith orofacialor penural ulceration.nraculiuplupura"vmculitisor srnallkeratclticverrucous lesron. Foscamct. Trcutment' giurciclovir. 4. Epstein-Barrvirus Orai Hairy l-euiioplaliia(OHL). Burkitt'slymphornaand EBV-positivelarge ceillymphoma. Usuallyoccur5-10 OHl. is a lesionspeci{icto FIIV inducermmunodeficiency. it noted has been in > 50% of ycars al1er primal'n,lllV inlbction and andbisexualmales with HIV disease. hornosexual u'hite patch,usuallyseenalongthe lateralborderof the tongue Clinical leeiture: 'lhe lesions are hairy appearance,comrgatedor and iieclucntly bilaleral. It cur notrerlloveby mbbingwith gauze. ma'kedly'lblded. Dillerential diagnosis:Oral candidiasis.lichen planus,geographictongueor ('cll ('nrciuourr. Squanrrlus

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Treatrnent: May occasionallyimprovedspontaneousty in 10.8%of thepatients or r.vithzidowdine. If therapyis indicated,acyclovir may proveusefi.rl. 5. Human papilloma virus ([IPV) Presentedwith genital wart (condylomatouspapules). Now increasedin incidence and resistant to featrnent. The incidence of cervical in femalepatientis incerased dysplasia-neoplasia about5-10time. Recurrentis patient. conilnonin very low immunodeficiency 6. Molluscumcontagiosum It causedby Pox vinrs. Multiple lesionsarc very cofitmon (> 100 lesions) usuallyat genitialia,groin,suprapubic areaandface. Treatmenl'cryosurgery,curettage,topical retinoicacid apply on the facebefore bedtirrieor 0.05o/o tretinoinsolutiontwice a day for 4 days,25-35%TCA follow by podophyllinleaveit for 4 hoursandwashoS andtopical5 FluoroUracyl. Fungal infection l. Dermatophytosis Most commonaretineapedis,tineacorporisandonychomycosis. The organism is Trichophl4onrubrum. Theseinfectionsare usually sirnilar in appearance to thoseseenin non-HIV infectedpersonsbut aremorewidespread. Treatment: Topicalbroad-spectrum antifi.rngal e.g. topicalterbinafine Systemicantifirngaltherapye.g.griseofulvin Resistantcase, itraconazznle200 mg/day for 3 months or terbinafine 250 mg/dayfor 3 months 2. Pityrosporum infection a) Sebonheicdermatitis Behareen 30-80%of patientswith AIDS haveseborrheic dermatitis.Patients often have thick, greasy,scalypapulesand plaqueson the scalp,face and chest. Treatrnentwith ketoconaznlecrearnand shampoohasbeenfoturd to reduce the population of organisms.It is oftenappearsearlyin HIV infection,and HIV infection shouldbe suspectedin any yoLulgpersonfrom an 'at risk' groupwho hasseborrheicdermatitis.

Aa --

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b) Tineavenicolor Other manifestationof pityrosponun infection treatrnentsame as above, relapserateare high especiallyin HIV infection. 3" Candidiasis Oral candidiasisis the mostcommonoral opportunisticinfectionseenin patients with HIV infection,occuringin than90% of HIV positivepatients.The infection backgroundwith superficialerosion appea$aswhite plaqueson an ery.thematous commonly occuringon the buccalmucos4 the palateor the dorsalsurfaceof the tongue. Oropharyngealcandidiasiscanbe dividedinto 4 types: a) Pseudomembranous b) Atophic @rythematorrs) c) Hyperplastic d) AngularCheilitis 4. Systemicfungal infection a) Cryptococcosis - disseminated histoplasmosis b) Hi stoplasmosis c) Sporotrichosis d) Penicilliosis marnffii is an ursual dimorphic fimgus that can causehuman infectionin compromisedhosts.This is endemicin SEA and Southempart of China.In Thailandpenicilliosismarneffeiinfectionis classifiedasoneof the AlDS-definingcondition. The characteristiceruptionis a generalizedpapularrashwith predilectionfor the face. upper trurk and arms. The papules have central necrotic umbilicationresemblinglesionsof Molluscumcontagiosum. 5. Arthropod infestafion (Norwegian) scabiescausedby an acan$ or mite, Sarcoptes Scabies-crusted scabiei var. hominis. The HIV patient presented with generalized scaly hyperkeratosis.

Non - SpecificDermatitis disorder 1. Papulosquamous

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a) Pruritic papulareruption(PPE) PPEis commonmanifestationof HIV infectionin topical climates.It appearsas excoriatedhyperkeratotichyperpigmentedpapuleswhich involve exhemities, trunk or facein varying degrees.The causeof theselesionsis unknownandthey areonly partially responsiveto ffeatmentwith antihistamineor corticosteroids. b) Psoriasisrulgaris Tlre incidenceis about 5-13% (in normal populationis about l-2%).In HIV patients,the lesionsare more severeand usually associatedwith sebrorrhoeic and sheptoccots dermatitis.Secondarfinfection from candida staphylococcus cornmon. are c) Exfoliative erytlroderma d) Drug reactions In HIV infectionpatients.drug reactionsare l0 timesmore comrnoncompareto normal population. The common drugs are; sulfonamide. Phenytoin hy'persensitivityreaction.Zidowdine and antituberculousdrug (lNH and rifampicin). 2. Miscellaneousskin lesion a) Acquiredtichomegaly of the eyelashes b) Recurrentaphthousulcers gingivitisandperiodontitis c) HlV-associated d) Pigmentarychange e) Xerostomia

Neoplasm 1.Kaposi'ssarcoma 95% of the Kaposi'ssarcomapatientsareamonghomosexualor bisexualman. It is very corrrmon neoplasm in Hlv-infected patients in the Wesq is rarely in this region. with HIV disease associated 2. Lymphoma Non-Hodgkin'sB - cell lymphoma-CTCL (Cr-r&rneousT-cellLyrnphoma)

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3. SquamousCell Carcinoma ( SCC ) and BasalCell Carcinoma( BCC ) in Thailand: Result of the l5th Round, June 1997 HIV Serosurveillance @ivision of Epidemiology,Ministy of PublicHealth.Thailand.). HIV prevalenceamong direct female commercialsex workers (CSWs) in the last surveywas at 26.Lyoand amongindirectCSWswas 8.3%.Prevalence of both groupsis lower than last yearand showdecliningfend over the last three years. Male sex workers in four tourist provinces(Pattaya Chonburi: Chiang Mai: Bangkok:Phuket)showedmedianprevalentof 15.8%. Among male STDs the prevalenceshoweda little decreasefrom around8%oin recentyearto 7o4this year. The resultsof IDUs, from 31 provinces,showedthe rate of 40Yowhich was samelevelasbefore. in Thailandhas beendone sinceJune 1989 until now HfV serosurveillance (Almost 9 years).This preliminaryresultconfirmedthe stabilizedanddownward hend of HIV prevalencein the high risk and generalpopulation.It is important now for the National AIDS progftImto maintainthe momentumof prevention program especiallyduring the economiccrisis of the courtry and pay close attentionto provinceswith high prevalent.With effectivepreventionthe nation cansavea lot of is budsetfor careof AIDS cases.

of Skin Disordersin 248 HIV-PositiveThai Patient(1996) Table l. Prevalence Prevalence Prevalence Skin Diorder Skin Disorder (%) (%) Jral candidiasis

34.3Psoriasis

6.)

Pruriticpapulareruption

3 2 . 1F o l l i c u l i t i s

5.6

Seborrhoeic dermatitis

2 l Genitalwarl

I{erpeszozter

16.r Penicilliosismarneffei

Oralhairy leukoplakia

t4.9 Drug eruption

Herpessimplex

1 0 . 9Scabies

J.Z

3.2 2 1.6

Jnvchomvcosis

9 . 3 M o l l u s c u mc o n t a g i o s u m

t.2

3utaneousringrvorm

7 . 7 Pityriasisversicolor

0.4

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Table II. Prevalenceof Skin Disorderin 525 HIV-PositiceFrom Instituteof Dermatology, B a n g k o k( 1 9 9 1 - 1 9 9 5 ) Skin Disorder

No Candidiasis

Prevalence (%)

t4.3

2 Herpeszoster

9.t

) Tinea

3.9

A T

Follicultis

3.8

5 Secondarysyphilis

J.J

6 Oral hairv leukonlakia

t.7

7 Scabies

1.3

8 Herpessimplex

0.91

I Condvlomaacuminata

0.52

l 0 Penicilliosismameffei ll

Histoplasmosis

12 Molluscumcontagiosum

0.4 0.3 0.3

Table III. AIDS in Thailand(1984-1997) Most Common Opportunistic InfestionAre Vy'astinsSvndrom

t9,414

L

Mycobacterium

r 8 , 10 7

J

Pneumocystis Carinii

12,668

q

Cryptococcosis

12,007

5 Candidiasis

4,496

Total :72,775 patients Death: 19.265(26.5%)

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References 1. Anthony du Vivier, Atlas of clinical dermatology,secondedition 1986 by Gower MedicalPublishingLondon.New York. 2. Dermatology2000,Holistic PublishingBangkokThailand,Jan1997 in Thailand,Resultof the I5th Round,June 1997, 3. HIV Serosurveilance Division of Epidemiology,Ministry of PublicHealth. 4. Rook, Wilkinson, Ebling., TextBook oJ Dermatology,fith edition 1992 Blackwell Scientific Publications 5. SivayathornA, tr/iralTherapyfor GPs,A Focttson HIV, issueVII May 1996.

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