HIV Dermatology2003

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Dermatologic Manifestations of HIV Infection
Toby A. Maurer, MD
TA Maurer, MDPresented at IASUSA/RWCA Clinical
Conference, June 2005.
The International AIDS SocietyUSA
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• As pts immune reconstituted, decreased incidence
  of most of the diseases-seborrheic dermatitis,
  fungal diseases, psoriasis, opportunistic
  infections with skin manifestations.
• Who are the pts who still develop skin diseases
  and why?

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CD4 Under 200 and not on ART

• Psoriasis over 50 of body surface area
• Extreme photodermatitis
• Prurigo Nodularis
• Molluscum
• Recurrent drug reactions

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Psoriasis

• With ART, HIV psoriasis easily controlled with
  topicals (clobetasol and calcipotriene) and
  ultraviolet light.
• Until ART kicks in or for more complex
  psoriasis-acitretin 10-25 mg /day

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Photodermatitis

• HIV makes pts sensitive to the sun
• Pts with CD4 under 200 on photosensitizing drugs
• Either ART allows pts to go off photosensitizing
  drugs or immune reconstitution decreases reaction
• Tx sunscreen, tx the dermatitis with potent
  topical steroids and lubricants, doxepin 25 mg
  qhs (as antihistamine)

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Prurigo Nodularis

• Pts consumed by itch
• CD4 50 and under
• May be a photocomponent to this
• ART helpful
• Potent topical steroids
• Thalidomide

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Pruritic Papular Eruption in Uganda

• Study done to evaluate pts and their biopsies of
  new onset prurigo nodularis
• 86/102 biopsies showed evidence for bug bites
• The more severe the eruption, the lower the CD4
  count (plt 0.001)
• Persons on ART appear to improve
• Hypersensitivity to bug bites may be secondary to
  altered immune response of HIV
• Resneck J, et al JAMA DEC 1, 2004

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Molluscum

• Seen frequently in young women not on ART
• 1st line therapy is ART
• Liquid nitrogen only temporary
• Curretage of large molluscum

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Recurrent Drug Reactors

• Group of persons who have drug reactions to
  everything including antibiotics, ART, etc.
• Challenge is to get them on ART and bring CD4
  count over 50
• Prednisone with slow taper (over 12 weeks) while
  introducing drugs
• Dolev J et al Arch Derm Sept 2004

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Drug Reactions

• When do you use steroids in a reaction?
• If the patient has a hypersensitivity reaction
  marked by elevation of LFTs or creatinine
• If patient is a chronic drug reactor-reacts to
  every med so that you cannot get pt on ART
• Not in erythema multiforme or Stevens Johnson or
  urticaria

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Diseases that just dont go away with ART

• Eczema/ Xerosis-if CD4 nadir was below 200, will
  always be recurrent
• Tx mid-potency steroids (ointment better than
  cream), antihistamines, can use the newer
  topicals -tacrolimus and pimecrolimus

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Warts

• Past evidence showed a low nadir was important in
  determining course of warts i.e., warts would
  not resolve over 24 month period with treatment
  if nadir CD4 under 50
• Rodriguez L, et al

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Wart treatment

• All about 50 efficacy
• LN2
• Podophyllin
• Imiquimod (genital)-new study-once warts
  eradicated by surgery or cryotherapy, imiquimod
  works to prevent recurrence
• Duct tape?
• Laser
• Surgery
• Treat every three weeks-ave. no. of tx12

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• Trying to look at persons who are reconstituted
  with warts or eczema to see if CD38 as marker of
  decreased immune function is useful

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Is KS in this category

• KS seen throughout spectrum of CD4 counts (0-800)
• First line therapy is ART-do you start ART is pts
  with KS who have high CD4 count?
• Seeing KS erupting in persons on ART with
  excellent control-why?
• Do they have abnormal function of T cells in
  spite of high CD4 counts?

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KS Treatment from Derm Perspective

• KS with CD4 above 400 and undetectable VL-careful
  monitoring of CD4 and VL, topical treatments
  (alitretinoin)
• ART for CD4 under 400
• Eruptive KS or lymphadema on ART-start
  doxorubicin HCI liposome injection/paclitaxel-IV
  infusions

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Cutaneous Lymphoma

• See it in CD4s under 200
• Work-up necessary to R/O systemic lymphoma
• If just cutaneous, radiotherapy or surgery
• Before ART era, cutaneous lymphoma had tendency
  to metastasize
• Improves with ART (limited experience)

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With immune reconstitutiondiseases that we
never used to see

• Acne-differentiate from eosinophilic folliculitis
• Staph infections-differentiate for HSV and fungal
  diseases
• Erythema nodosum-differentiate from helicobacter
  cinaedii

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Acne

• Acne vulgaris
• Acne rosacea
• Perioral/periorbital dermatitis
• Tx TCN, doxycycline, minocycline, accutane for
  cystic acne

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Eosinophilic folliculitis

• Itchy, urticarial bumps face, neck, SCALP, chest
  and back
• Usually in CD4 counts under 200 or in pts within
  3-6 months of initiating ART
• Itraconazole 200-400 mg /day
• Permethrin from waist up
• Wait for immune reconstitution to settle (3-6
  months after starting ART)

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Staph infections

• Increased incidence since patients no longer
  require prophylaxis with trimethoprim/sulfamethoxa
  zole or other antibiotics (CD4gt200)
• Staph in form of abcesses, ulcers, folliculitis
• Consider methicillin resistant staph in pts with
  recurrent staph or not improving on antibiotics
• Culture when possible for organism and
  sensitivities (Still sensitive to doxycycline,
  trimethoprim/sulfamethoxazole, ciprofloxacin and
  clindamycin)

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Approach to Treatment

• Culture where you can-if you have pus, that is
  great
• Incise and drain when appropriate (Abcesses)

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If no pus

• Tx with methicillin sensitive drugs-first line
  but have pt return to evaluate for resolution
• If recurrent infection, tx with methicillin
  sensitive antibiotics right off the bat
  (trimethoprim/sulfamethoxazole , doxycycline,
  ciprofloxacin/levofloxacillin, clindamycin)
• Consider adding rifampin 600 qd for 5 days or
  mupirocin ointment for staph eradication

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For recurrent disease

• Also look for underlying skin disease that could
  be portal of entry
• Dry skin-lubricate with grease
• Eczema-TAC and lubrication
• Psoriasis-staph exacerbates psoriasis and
  psoriasis portal of entry
• Tinea- portal of entry-tx with antifungals

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If not improving

• Was patient treated long enough?
• Once hair structures are involved or deep
  tissues, treatment time may be longer

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Was it bacterial in the first place?

• Remember HSV-culture and/or Direct Fluorescent
  Antibody
• Skin biopsy for histology and tissue culture

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Erythema nodosum

• Can be part of immune reconstitution in patients
  with diagnosis of sarcoid
• Can be associated with other etiologies strep,
  cocci, yersinia, inflammatory bowel disease
• Biopsy diagnosis
• Tx bedrest, prednisone, SSKI

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Helicobacter cinaedi

• Mimics erythema nodosum
• Caused by gram negative rods
• Fever/bacteremia/diarrhea
• Blood cx can be positive without fever
• Stool can be culture positive
• Skin biopsy shows suppurative process
• Tx 8 weeks of doxycycline or erythromycin
• Recent report of campylobacter causing similar
  picture-cultured from blood-tx ciprofloxacin

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HIV and HCV

• Co-infection rate high and leads to many skin
  problems
• l) Lichen planus
• 2) Xerosis
• 3) Leukocytoclastic vasculitis
• 4) Itch without a rash

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Xerosis

• Pts noting that skin barrier changing and more
  dry
• Lubricants, steroids

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Leukocytoclastic Vasculitis

• R/O reactions to drugs
• R/O infection-strep, endocarditis, Hep A, B, C
• R/O collagen vascular disease and
  cryoglobulinemia
• R/O leukemia, lymphoma
• HCV viral load and LFTs are not necessarily
  increased in active cutaneous vasculitis
• Tx colchicine, steroids?, treat the Hep C

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Itch without a rash

• Seems to be central itch
• Naltrexone (opoid antagonist) may be helpful.
  ?Dose-start with 50 mg qhs.
• Antihistamines not helpful
• Ultraviolet light not helpful
• Treatment for HCV helpful unless pt gets the
  ribavirin itch