Dermatologic Manifestations of HIV Infection

Dermatologic Manifestations of HIV Infection

Toby A. Maurer, MD

The International AIDS Society–USATA Maurer, MDPresented at IAS–USA/RWCA Clinical Conference, June 2005.

Slide #2

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

• 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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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

CD4 Under 200 and not on ART

• Psoriasis over 50% of body surface area

• Extreme photodermatitis

• Prurigo Nodularis

• Molluscum

• Recurrent drug reactions

Slide #4

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #5

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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)

Slide #6

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Prurigo Nodularis

• Pts consumed by itch

• CD4 50 and under

• May be a photocomponent to this

• ART helpful

• Potent topical steroids

• Thalidomide

Slide #7

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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 (p< 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

Slide #8

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Molluscum

• Seen frequently in young women not on ART

• 1st line therapy is ART

• Liquid nitrogen only temporary

• Curretage of large molluscum

Slide #9

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #10

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Drug Reactions

• When do you use steroids in a reaction?

If the patient has a hypersensitivity reaction marked by elevation of LFT’s 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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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Diseases that just don’t 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

Slide #12

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Wart treatment

• All about 50% efficacyLN2PodophyllinImiquimod (genital)-new study-once warts

eradicated by surgery or cryotherapy, imiquimod works to prevent recurrence

Duct tape?LaserSurgeryTreat every three weeks-ave. no. of tx=12

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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #15

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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?

Slide #16

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #17

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Cutaneous Lymphoma

• See it in CD4’s 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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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

With immune reconstitution:diseases 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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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Acne

• Acne vulgaris

• Acne rosacea

• Perioral/periorbital dermatitis

Tx: TCN, doxycycline, minocycline, accutane for cystic acne

Slide #20

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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)

Slide #21

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Staph infections• Increased incidence since patients no longer

require prophylaxis with trimethoprim/sulfamethoxazole or other antibiotics (CD4>200)

• 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)

Slide #22

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Approach to Treatment

• Culture where you can-if you have pus, that is great

• Incise and drain when appropriate (Abcesses)

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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #24

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #25

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Was it bacterial in the first place?

• Remember HSV-culture and/or Direct Fluorescent Antibody

• Skin biopsy for histology and tissue culture

Slide #27

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #28

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #29

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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

Slide #30

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

Xerosis

• Pts noting that skin barrier changing and more dry

• Lubricants, steroids

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TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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 LFT’s are not

necessarily increased in active cutaneous vasculitis

• Tx: colchicine, steroids?, treat the Hep C

Slide #32

TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

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