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With immune reconstitution
Some diagnostic categories are disappearing: Kaposi's sarcoma, molluscum, staph folliculitis
Other diagnostic categories are filling the void: Warts, squamous cell carcinoma-in-situ of the anal area
Diseases that were controlled are erupting: Eosinophilic folliculitis, drug reactions to antibiotics
Diseases that were never seen are rearing their heads: Sarcoid, morphea, fat redistribution
The constants: Psoriasis, eczema, photodermatitis, prurigo nodularis, scabies
Kaposi's Sarcoma-making new diagnoses in gay men who are not on HAART
-CD4 count 300 - 700
-initiate HAART and stay on 3-6 months before
-KS on HAART - ? time to
Molluscum
- melts away w/CD4 >100
- recalcitrant warts - LN2 or curretting
- Cidofavir Gel not that promising
Staph Folliculitis/Staph Pyodermas/Ce!luliti-top dermatology diagnosis 1991
-now seen in persons who are not on Septra
Treatment: Dicloxacillin/Keflex
Rifampin for eradication of staph (don't use with PIs)
Bactroban intranasally
Differential for Staph: Helicobacter Cinidiae
Warts
Increased prevalence?
Other diagnoses disappearing?
People living long enough to develop these?
Warts - Treatment
Mouth - laser/surgical ablation + Aldara
Genitals - not as responsive to Aldara LN2 + Podophyllin Caution - Hydroxyurea
Flat Warts - Retin A
Hands/Feet - LN2 Bleamycin DNCB
Pulsed Dye Laser
Genital Squamous Cell Carcinoma-in-situ (Bowen's)
- HPV induced
- ? what is the natural history
- anal pap smears useful in finding dysplastic cells
THEN WHAT?- we don't have treatment to prevent progression to invasive SCC
- identify high risk individuals
- serial biopsies every 3-4 months
- surgical ablation/laser - usually too extensive- Aldara - promising but not always efficacious can cause irritation/infection
- BIG PUBLIC HEALTH QUESTION
Eosinophilic Folliculitis- previously controlled cases flare up
w/HAART
- before HAART, occurred CDn <200- now occurring within the whole range of CD4 counts
Treatment
Itraconazole 100-400 qd
Elimite qod
UV light
Accutane - caution TGs
Drug Reactions - patients taking Septra/ Clarithromycin for years getting drug rash w/effective HAART treatment
- do not stop HAART treatment- treat through if rash is maculopapular
- D/C antibiotics first if rash is urticarial/Stevens Johnson
- with the exception of Nevirapine drug rashes to other HAART drugs very rare
Sarcoid, morphea
- now emerging on HAART treatment
- these are immunologically-based diseases- theory is that you had to be able to mount an immune response
- never saw these diseases before HAART
Fat Redistribution
- buccal atrophy
- zygomatic hypertrophy
- neck size changes
- buffalo humps
- increased abdominal girth
In our cohort
- occurred in 35% of patients- started HAART earlier and were responding better
Treatment:
- liposuction recurrences reported
- fat transfer to cheeks - fat disappears- cheek implants
- continued atrophy makes implants pop through skin-face lifts have been successful
-awaiting drug therapy
Psoriasis
same prevalence but less recalcitrant to treatment
etretinate - oral therapy - now replaced by acetretin - may be more potent -watch triglycerides
Eczema
- continues at same prevalence
- lubrication and mid-potency steroids
- decrease water exposure
Photodermatitis
- persons of color at high risk antibiotics/NSAIDS increase risk- begins in photo distributed areas and then involves non-photo-exposed areas very itchy
- itch can create nodules prurigo nodules + loss of pigment
Treatment
Sunblock
Potent antihistamines
(Doxepin 25mg po qhs)
Potent topical steroids (clobetasol)
Thalidomide
- highly effective
- decreased itch within 1 month
- teratogenic - 2 forms of birth control
- 30% peripheral neuropathy advise baseline nerve conduction exams and monthly neuro questionnaires
- other side effects drowsiness weight gain have not seen drug reactions
- dose: 50 - 100 mg qd
Scabies- Kwell contraindicated in HIV
- Norwegian scabies =~ Elimite one day + Eurax 6 days. Repeat cycle until