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Dermatologic Manifestations of HIV Infection
Infectious cutaneous conditions
Staphylococcus aureus infections
Staphylococcus aureus is the most common bacterial skin infection in persons with HIV disease.
Bullous impetigo. Bullous impetigo is most common in hot, humid weather, presenting as very superficial blisters or erosions, most commonly seen in the
Ecthyma is an eroded or superficially ulcerated lesion with an adherent crust. Purulent material is present under this crust.
Folliculitis
Folliculitis due to S. aureus occurs most commonly in the hairy areas of the trunk, groin, axilla, or face. Gram’s stain and culture of
Often the follicular lesions of the trunk are intensely pruritic and may be mistaken for scabies. About 50% of HIV-infected persons with scabies have coexistent S. aureus folliculitis.
Treatment of cutaneous staphylococcal lesions
Very superficial lesions, like bullous impetigo, often respond to an antistaphylococcal antibiotic, such as dicloxacillin (500 mg given PO qid) or 7-10 days. Combinations of antibiotics, especially a
Washing the infected area once daily or every other day with an antibacterial agent (Hibiclens, Betadine) helps
Loculated abscesses must be incised and drained when fluctuant. Intravenous antibiotics are required when significant cellulitis of or symptoms of bacteremia are present, appropriate. Intranasal
Bacillary angiomatosis
Bacillary angiomatosis is an infection caused by two species of Bartonella - B. henselae and B. quintana. These bacteria are extremely difficult to culture. One of the agents causing bacillary angiomatosis, B. henselae, is associated with cat scratch disease. Cat exposure and cat scratches are risk factors for acquiring bacillary angiomatosis.
Visceral disease may
Clinical Features
Bacillary angiomatosis is characterized by pyogenic granulomas -- fleshy, friable, protuberant papules-to-nodules that tend to bleed very easily. In addition, deep cellulitic plaques and subcutaneous
Fever, night sweats, weight loss, and anemia are common. Involvement of the liver and spleen is the most commonly diagnosed form of visceral disease. These patients present with abdominal pain,
Treatment. Erythromycin (500 mg orally 4 times daily) or doxycycline (100 mg orally twice daily) is effective. Therapy
Herpes simplex virus
Chronic persistent infection with herpes simplex virus (HSV) is common in patients with advanced HIV disease and is a Centers for Disease Control (CDC)-defined index infection in establishing an AIDS diagnosis.
Lesions may appear as grouped blisters that rupture, crust, and heal in 7 to 10 days. Once severely immunosuppressed, HIV-infected persons often experience chronic lesions that continue to expand and form large, painful ulcers and crusted erosions, 2 to 10 cm or larger.
Periungual infection is another characteristic manifestation of HSV-2 infection in the HIV-infected patient; all paronychial lesions should be cultured for HSV.
Fluorescent antibody testing or viral culture of fresh lesions are diagnostic.
Treatment
Acyclovir ( Zovirax, 200 to 400 mg orally 5 times daily) should be prescribed until the ulcers heal, which may take several weeks. Chronic suppressive therapy may be instituted with acyclovir (400
Varicella zoster infection
Varicella zoster virus (VZV) infection is commonly seen early in the course of HIV infection.
This dermatomal eruption may be particularly bullous, hemorrhagic, necrotic, and painful in HIV-infected persons. The
Treatment
Oral acyclovir. If the patient has a reasonably intact immune system and does not have clinical features of
Molluscum contagiosum
Molluscum contagiosum is a superficial cutaneous viral infection manifesting as 2- to 3-mm flesh-colored hemispheric papules. A faint whitish core usually is visible at the center of each papule, some of which may be slightly umbilicated. This eruption is seen commonly in immunocompetent young children (ages 3 to 8 years), whose lesions are scattered
Treatment. Light cryotherapy using liquid nitrogen can treat individual lesions. If this is not available, pricking the
Human papillomavirus (warts)
Superficial cutaneous infection with human papillomavirus (HPV) occurs with increased frequency in immunosuppressed patients. The warts seldom cause symptoms, except when on the soles of the feet and around
Relapse of warts after treatment is common, especially in advanced HIV disease. Liquid nitrogen cryotherapy can be
Topical treatment of genital warts with podophyllin or trichloroacetic acid may be applied weekly for 6 to 10 weeks. Liquid nitrogen freezing has a slightly greater response rate. Recurrence is almost universal.
Acute HIV exanthem and enanthem
In acute primary HIV infection, a rash may develop along with a mononucleosis-like illness. The rash may be exanthematous or pityriasis rosea-like, usually does not itch, is distributed over the upper trunk and proximal limbs, and may involve palms and soles. An associated enanthem of oral erythema or superficial erosions may be present. The exanthem and enanthem spontaneously resolve within 1 to 2 weeks.
Detection of HIV antigen by enzyme immunoassay may confirm the diagnosis of acute HIV infection in
Syphilis
Cutaneous presentations of primary and secondary syphilis in HIV-infected persons are usually similar to those in non-HIV-infected persons. HIV may delay development of serologic evidence of Treponema pallidum, resulting in
Inflammatory skin conditions
Eosinophilic folliculitis
Eosinophilic folliculitis typically occurs in HIV-infected persons with helper T cell counts below 200. Intensely pruritic, edematous, urticarial papules and pustules appear in crops on
Astemizole ( Hismanal), 10 mg daily has been used with limited success, but concurrent imidazole or erythromycin therapy is contraindicated with astemizole because of the risk of
Drug reactions
The incidence of adverse reactions TMP-SMX is very high. Most reactions occur in the second week of therapy, and the rash is a maculopapular/morbilliform reaction, beginning in the groin and pressure areas and quickly generalizing.
The use of systemic corticosteroids in treating PCP reduces the rate of drug eruption from TMP-SMX. Other drug-induced hypersensitivity reactions include urticarial reactions, exfoliative erythroderma, fixed-drug eruption, erythema multiforme, and toxic epidermal necrolysis. These reactions are most often due to antibiotics, especially TMP-SMX and the penicillins.
Scabies
Scabies usually presents with pruritic papules with accentuation in the intertriginous areas, genitalia, and fingerwebs. Gamma-benzene hexachloride (lindane) applied from the neck down for 8 to 24 hours is usually curative; however, that lindane may result in peripheral neuropathies in HIV-infected patients, particularly in those with CD4 < 200. In
True crusted ( Norwegian) scabies may occur in patients with advanced HIV disease. Norwegian scabies is nonpruritic and appears as thick crusts. The crusts are highly contagious. Treatment with Elimite should be repeated at
Kaposi’ s sarcoma
Kaposi’s sarcoma is a neoplasm of endothelial cells within the skin and other organs. Most KS patients are homosexual men. KS may be present in up to 46% of homosexual men with advanced HIV disease at initial diagnosis. The
KS may affect any portion of the cutaneous surface. Initially, it appears as red-to-brown flat macules. Papules, nodules, and tumors may also be present or develop later. Numbering from one to hundreds, they range in size from
Biopsy of the skin establishes the diagnosis. A 3.5- to 4.0-mm punch biopsy should be taken from the center of the
Treatment. If treatment is necessary, radiation and systemic alpha-interferon or chemotherapy may be