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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.

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.

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.

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.

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.

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.

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.

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.

Treatment

Oral acyclovir. If the patient has a reasonably intact immune system and does not have clinical features.

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.

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.

Relapse of warts after treatment is common, especially in advanced HIV disease. Liquid nitrogen cryotherapy.

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.