SKIN MANIFESTATIONS IN SKIN MANIFESTATIONS IN AIDSAIDS

SKIN MANIFESTATIONS IN SKIN MANIFESTATIONS IN AIDSAIDS

Pornchai Chirachanakul M.D.Pornchai Chirachanakul M.D.

Bamrasnaradura InstituteBamrasnaradura Institute

ClassificationClassification

InfectionInfection Non-specific dermatitisNon-specific dermatitis NeoplasmNeoplasm

Bacterial infectionBacterial infection

Pyogenic diseases Pyogenic diseases Mycobacterial diseasesMycobacterial diseases NocardiosisNocardiosis Bacillary angiomatosisBacillary angiomatosis

Pyogenic diseasePyogenic disease

ImpetigoImpetigo Hemorrhagic ecthymaHemorrhagic ecthyma Ecthyma gangrenosumEcthyma gangrenosum FolliculitisFolliculitis FuruncleFuruncle

Pyogenic diseasePyogenic disease

AbscessAbscess CarbuncleCarbuncle CellulitisCellulitis PyomyositisPyomyositis PyodermaPyoderma Secondary infection of scabies, eczematous Secondary infection of scabies, eczematous

dermatitis & intravenous catheter sitedermatitis & intravenous catheter site

Pyogenic diseasesPyogenic diseases

Pathogen: Pathogen: -staphylococcus aureus-staphylococcus aureus**

--pseudomonas aeruginosapseudomonas aeruginosa PathogenesisPathogenesis: : -B-cell defect-B-cell defect

-neutropenia-neutropenia

-defective chemotaxis of -defective chemotaxis of

neutrophil neutrophil

Pyogenic diseasePyogenic disease

Diagnosis:Diagnosis: clinical featuresclinical features Gram stain & cultureGram stain & culture blood cultureblood culture skin biopsyskin biopsy

Treatment of pyogenic disease (Staphylococcus aureus) Treatment of pyogenic disease (Staphylococcus aureus) Semisynthetic penicillinSemisynthetic penicillin

dicloxacillin,cloxacillin,oxacillindicloxacillin,cloxacillin,oxacillin First-generation cephalosporinFirst-generation cephalosporin **Rifampicin 450-600 mg/d for 5-10 days Rifampicin 450-600 mg/d for 5-10 days

or topical mupirocin ointment or topical mupirocin ointment

Treatment of pyogenic disease (Pseudomonas aeruginosa)Treatment of pyogenic disease (Pseudomonas aeruginosa) debridementdebridement compress with 5% acetic acidcompress with 5% acetic acid oral ciprofloxacinoral ciprofloxacin i.v.imipenem i.v.imipenem

Mycobacterium tuberculosisMycobacterium tuberculosis

Clinical features:Clinical features: Neck mass (necrotic enlarged lymph node)Neck mass (necrotic enlarged lymph node) Folliculitis-like lesionFolliculitis-like lesion Necrotic papulesNecrotic papules

Diagnosis:Diagnosis: Acid fast staining of pus,skin,lymph nodeAcid fast staining of pus,skin,lymph node skin biopsyskin biopsy Culture & sensitivity testCulture & sensitivity test

Treatment of M. tuberculosisTreatment of M. tuberculosis

Standard short course regimen:Standard short course regimen: 2HRZE/4HR for 6 months2HRZE/4HR for 6 months

NocardiosisNocardiosis

Low incidence (0.2-1.8%)Low incidence (0.2-1.8%) Pathogen: Nocardia speciesPathogen: Nocardia species

NocardiosisNocardiosis

Clinical features:Clinical features: feverfever productive coughproductive cough hemoptysishemoptysis chest painchest pain dyspneadyspnea weight lossweight loss

NocardiosisNocardiosis

Clinical features:Clinical features: subcutaneous abscesssubcutaneous abscess cellulitiscellulitis pustulespustules pyodermapyoderma paronychiaparonychia ulcerulcer

NocardiosisNocardiosis

Diagnosis:Diagnosis: clinical featuresclinical features Gram stainGram stain modified acid fast stainmodified acid fast stain cultureculture

NocardiosisNocardiosis

Treatment: Treatment: TMP-SMZ (2.5-10 mg/kg of TMP) twice a dayTMP-SMZ (2.5-10 mg/kg of TMP) twice a day Sulfadiazine 4-6 g/dSulfadiazine 4-6 g/d Ceftriaxone 2 g/dCeftriaxone 2 g/d Amikacin 1 g/dAmikacin 1 g/d Minocycline 200 mg/dMinocycline 200 mg/d >6-12 months duration >6-12 months duration

Bacillary angiomatosisBacillary angiomatosis

Clinical features:Clinical features: Elevated friable bright red granulation tissue Elevated friable bright red granulation tissue

like papules 1-1,000 like papules 1-1,000 lesionslesions Subcutaneous nodulesSubcutaneous nodules Ulcerating tumorUlcerating tumor Cellulitic plaqueCellulitic plaque

Pathogen:Pathogen: Bartonella quintana (or B. henselae)Bartonella quintana (or B. henselae)

Bacillary angiomatosisBacillary angiomatosis

Diagnosis:Diagnosis: Histopathology: -Warthin-Starry stain orHistopathology: -Warthin-Starry stain or

-modified Brown-Hopp’s stain-modified Brown-Hopp’s stain Culture: -brain heart infusion agar orCulture: -brain heart infusion agar or

-trypticase soy agar with 5% sheep -trypticase soy agar with 5% sheep

bloodblood

Treatment of Bacillary angiomatosisTreatment of Bacillary angiomatosis Erythromycin 250-500 mg qid for 6 weeks Erythromycin 250-500 mg qid for 6 weeks

or until lesions clearedor until lesions cleared Doxycycline, minocycline, tetracyclineDoxycycline, minocycline, tetracycline Co-trimoxazoleCo-trimoxazole Rifampicin, isoniazidRifampicin, isoniazid Azithromycin, roxithromycinAzithromycin, roxithromycin Norfloxacin, ciprofloxacinNorfloxacin, ciprofloxacin

Viral infectionViral infection

Herpes simplex virus infectionHerpes simplex virus infection Varicella-Zoster virus infectionVaricella-Zoster virus infection Cytomegalovirus infectionCytomegalovirus infection Epstein-Barr virus infectionEpstein-Barr virus infection Human papillomavirus infection Human papillomavirus infection Poxvirus infectionPoxvirus infection

Herpes simplex virus infectionHerpes simplex virus infection

Clinical features:Clinical features: Deep seated (hemorrhagic) vesiclesDeep seated (hemorrhagic) vesicles Chronic ulcerative mucocutaneous lesionChronic ulcerative mucocutaneous lesion Exophytic lesionExophytic lesion Ulcerated tumor like lesionUlcerated tumor like lesion

Herpes simplex virus infectionHerpes simplex virus infection

Diagnosis:Diagnosis: ClinicalClinical featurefeature Tzanck smearTzanck smear HistopathologyHistopathology Viral cultureViral culture

Herpes simplex virus infectionHerpes simplex virus infection

Diagnosis:Diagnosis: Direct fluorescent Ab stainingDirect fluorescent Ab staining Polymerase chain reactionPolymerase chain reaction Electron microscopyElectron microscopy

Treatment of HSV infectionTreatment of HSV infection

Oral acyclovir 200-800 mg five times dailyOral acyclovir 200-800 mg five times daily I.V. acyclovir 5mg/kg/dose three times dailyI.V. acyclovir 5mg/kg/dose three times daily I.V. trisodium phosphonoformate I.V. trisodium phosphonoformate

(Foscarnet) 40mg/kg/dose two-three times (Foscarnet) 40mg/kg/dose two-three times daily or cidofovir (ACV resistant mutant)daily or cidofovir (ACV resistant mutant)

Treatment of HSV infectionTreatment of HSV infection

Oral valaciclovir 1,000 mg two times daily fOral valaciclovir 1,000 mg two times daily for 7-10 daysor 7-10 days

Oral famciclovir 250 mg three timesOral famciclovir 250 mg three times daily daily ffor 7-10 daysor 7-10 days

Varicella-Zoster virus infectionVaricella-Zoster virus infection

Varicella:Varicella: Clinical features (Clinical features (MonomorphismMonomorphism))

## hemorrhagic infarcted vesicleshemorrhagic infarcted vesicles

## clear vesicles clear vesicles Herpes zoster:Herpes zoster:

Clinical featuresClinical features

# # groups of vesicles in dermatomal distributiongroups of vesicles in dermatomal distribution

# # ecthymatous crusted punch out ulcerecthymatous crusted punch out ulcer

Varicella-Zoster virus infectionVaricella-Zoster virus infection

8-13% of HIV- infected patients had 8-13% of HIV- infected patients had previous history of herpes zosterprevious history of herpes zoster

incidence is more than normal population 7 incidence is more than normal population 7 timestimes

common in young adult (<60 years)common in young adult (<60 years)

Varicella-Zoster virus infectionVaricella-Zoster virus infection

post-herpetic neuralgia is uncommonpost-herpetic neuralgia is uncommon may be disseminated infectionmay be disseminated infection more skin necrosismore skin necrosis high risk cases have 73% positivehigh risk cases have 73% positive anti-HIV anti-HIV

AbAb

Varicella-Zoster virus infectionVaricella-Zoster virus infection

Diagnosis:Diagnosis: clinical featuresclinical features Tzanck smearsTzanck smears HistopathologyHistopathology Viral cultureViral culture

Varicella-Zoster virus infectionVaricella-Zoster virus infection

Diagnosis:Diagnosis: Direct fluorescent Ab stainingDirect fluorescent Ab staining Polymerase chain reactionPolymerase chain reaction Electron microscopyElectron microscopy

Varicella-Zoster virus infectionVaricella-Zoster virus infection

TreatmentTreatment Oral acyclovir 800 mg five times daily for 7-10 Oral acyclovir 800 mg five times daily for 7-10

daysdays Oral famciclovir 500 mg three times daily for 7-Oral famciclovir 500 mg three times daily for 7-

10 days10 days Oral valaciclovir 1,000 mg three times daily for Oral valaciclovir 1,000 mg three times daily for

7-10 days7-10 days I.V. acyclovir 10 mg/kg/dose three times dailyI.V. acyclovir 10 mg/kg/dose three times daily Foscarnet (resistance to ACV)Foscarnet (resistance to ACV)

Molluscum contagiosumMolluscum contagiosum

Incidence 10-20%Incidence 10-20% common at genitalia, face(periorbital common at genitalia, face(periorbital

area),axilla,groin & buttockarea),axilla,groin & buttock ่�่� may be larger than 1 cm.may be larger than 1 cm. CD4+ count <250 cells/cu.mm.CD4+ count <250 cells/cu.mm. Diagnosis:Diagnosis:

clinical featureclinical feature HistopathologyHistopathology

Treatment of molluscum contagiosumTreatment of molluscum contagiosum CurettageCurettage ElectrocoaggulationElectrocoaggulation CryosurgeryCryosurgery Carbon dioxide LASER vaporizationCarbon dioxide LASER vaporization

Treatment of molluscum contagiosumTreatment of molluscum contagiosum Topical wart agentsTopical wart agents Topical retinoic acidTopical retinoic acid Highly active antiretroviral therapyHighly active antiretroviral therapy CidofovirCidofovir 5% Imiquimod cream5% Imiquimod cream

Systemic fungal infectionSystemic fungal infection

PenicilliosisPenicilliosis CryptococcosisCryptococcosis HistoplasmosisHistoplasmosis

PenicilliosisPenicilliosis

Pathogen: Pathogen: - - Penicillium marneffei, a Penicillium marneffei, a dimorphic fungi dimorphic fungi

- endemic in Southeast Asiaendemic in Southeast Asia Reservoirs: Reservoirs: - - bamboo ratbamboo rat

PenicilliosisPenicilliosis

Clinical featuresClinical features: : skin lesions ~skin lesions ~ 71.2%71.2% Molluscum-like papulonecrotic lesionsMolluscum-like papulonecrotic lesions Crusted plaqueCrusted plaque Pustulo-nodular lesionsPustulo-nodular lesions Ulcer (oral or extraoral lesion)Ulcer (oral or extraoral lesion)

PenicilliosisPenicilliosis

Clinical features:Clinical features: Erythema nodosum-like lesionsErythema nodosum-like lesions Subcutaneous nodule (lymphadenopathy)Subcutaneous nodule (lymphadenopathy) Illusion of vesiculationIllusion of vesiculation

PenicilliosisPenicilliosis

Diagnosis:Diagnosis: Skin scrapingSkin scraping Skin biopsy touch smearSkin biopsy touch smear Skin biopsy (histopathology)Skin biopsy (histopathology) Culture:-blood sensitivity ~ 76%Culture:-blood sensitivity ~ 76%

-skin sensitivity ~90%-skin sensitivity ~90%

-bone marrow sensitivity ~100%-bone marrow sensitivity ~100%

Treatment of penicilliosisTreatment of penicilliosis

Initial therapy:Initial therapy: Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) & Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) &

follow with itraconazole 400 mg/d (~10 weeksfollow with itraconazole 400 mg/d (~10 weeks)) Suppressive therapy: Suppressive therapy:

Itraconazole 200 mg/dItraconazole 200 mg/d

HAART-induced penicilliosisHAART-induced penicilliosis

Pathogenesis:Pathogenesis: restoration of CD4+ and CD8+ T lymphocyterestoration of CD4+ and CD8+ T lymphocyte may be cytokine-mediated reactionmay be cytokine-mediated reaction

HAART-induced penicilliosisHAART-induced penicilliosis

Clinical feature:Clinical feature: shiny erythematous papulo-nodular plaquesshiny erythematous papulo-nodular plaques non pruritic lesionsnon pruritic lesions occur within the first 2 months after HAARToccur within the first 2 months after HAART

HAART-induced penicilliosisHAART-induced penicilliosis

Diagnosis:Diagnosis: history of previous treated penicilliosis history of previous treated penicilliosis history of HAARThistory of HAART skin biopsy (granulomatous dermatitis with yeaskin biopsy (granulomatous dermatitis with yea

st cells)st cells) skin culture for fungus skin culture for fungus

HAART-indued penicilliosisHAART-indued penicilliosis

Treatment:Treatment: Amphotericin B or itraconazoleAmphotericin B or itraconazole Short course systemic corticosteroidShort course systemic corticosteroid

CryptococcosisCryptococcosis

PathogenPathogen: : Cryptococcus neoformansCryptococcus neoformans Clinical featuresClinical features: : skin lesions ~ 10-20%skin lesions ~ 10-20%

Molluscum-like papulonecrotic lesionMolluscum-like papulonecrotic lesion Subcutaneous noduleSubcutaneous nodule Oral noduleOral nodule Oral ulcerOral ulcer Verrucous tumorVerrucous tumor Localized cellulitisLocalized cellulitis

CryptococcosisCryptococcosis

Diagnosis:Diagnosis: Skin scrapingSkin scraping Skin biopsy touch smearSkin biopsy touch smear HistopathologyHistopathology Culture: -skinCulture: -skin

--CSFCSF

-blood-blood

Treatment of cryptococcosisTreatment of cryptococcosis

Initial therapy:Initial therapy: Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) & Amphotericin-B 0.6-1.0 mg/kg/d (~2 weeks) &

follow with fluconazole 400 mg/d (~10 weeks)follow with fluconazole 400 mg/d (~10 weeks) Suppressive therapy:Suppressive therapy:

Fluconazole 200 mg/d Fluconazole 200 mg/d Itraconazole 200 mg/dItraconazole 200 mg/d

HistoplasmosisHistoplasmosis

PathogenPathogen: : Histoplasma capsulatumHistoplasma capsulatum Clinical featuresClinical features:: skin lesions ~ 10-20% skin lesions ~ 10-20%

exanthema-like maculopapular eruptionexanthema-like maculopapular eruption molluscum-like papulonecrotic lesionmolluscum-like papulonecrotic lesion oral ulcer or oral massoral ulcer or oral mass vegetative plaquevegetative plaque diffuse purpuradiffuse purpura panniculitispanniculitis

HistoplasmosisHistoplasmosis

Diagnosis:Diagnosis: Skin scrapingSkin scraping Skin biopsy touch smearSkin biopsy touch smear HistopathologyHistopathology Culture: -skinCulture: -skin

-blood-blood

-bone marrow-bone marrow

Treatment of histoplasmosisTreatment of histoplasmosis

Initial therapy:Initial therapy: Amphotericin-B 0.6-1.0 mg/kg/d (~ 2 weeks) & Amphotericin-B 0.6-1.0 mg/kg/d (~ 2 weeks) &

follow with itraconazole 400 mg/d (~ 10 weeks) follow with itraconazole 400 mg/d (~ 10 weeks) oror fluconazole 400 mg/d fluconazole 400 mg/d

Suppressive therapy:Suppressive therapy: Itraconazole 200 mg/d Itraconazole 200 mg/d oror Fluconazole 200 mg/dFluconazole 200 mg/d

Crusted (Norwegian) scabiesCrusted (Norwegian) scabies

PathogenPathogen: : Sarcoptes scabieiSarcoptes scabiei

Clinical features:Clinical features: generalized scaly hyperkeratotic nonpruritic generalized scaly hyperkeratotic nonpruritic

plaque(bark-like appearance)plaque(bark-like appearance) subungual hyperkeratosissubungual hyperkeratosis psoriasiform dermatitispsoriasiform dermatitis

DiagnosisDiagnosis: : skin scrapingskin scraping

Treatment of crusted scabiesTreatment of crusted scabies

1% gamma benzene hexachloride1% gamma benzene hexachloride 5% permethrin cream (lotion)5% permethrin cream (lotion) keratolytic agent (5%-6% salicylic acid keratolytic agent (5%-6% salicylic acid

oint.)oint.) oral ivermectin 200 microgram/kg as a oral ivermectin 200 microgram/kg as a

single dose (efficacy ~ 91 %)single dose (efficacy ~ 91 %)

Non-specific dermatitis

Pruritic papular eruption (PPE)Pruritic papular eruption (PPE) Seborrheic dermatitisSeborrheic dermatitis PsoriasisPsoriasis Exfoliative dermatitisExfoliative dermatitis Drug eruptionDrug eruption Prurigo nodularisPrurigo nodularis Miscellaneous skin diseasesMiscellaneous skin diseases

Pruritic papular eruption (PPE)Pruritic papular eruption (PPE)

chronic recall reaction to mosquito bitechronic recall reaction to mosquito bite excoriated hyperkeratotic hyperpigmented excoriated hyperkeratotic hyperpigmented

papules at extremities & lower backpapules at extremities & lower back severe itchsevere itch refractory to treatmentrefractory to treatment

Treatment of pruritic papular eruption (PPE)Treatment of pruritic papular eruption (PPE) high potent topical corticosteroid high potent topical corticosteroid short course systemic corticosteroidshort course systemic corticosteroid antihistamine (esp.oral doxepin HCl)antihistamine (esp.oral doxepin HCl) antibioticantibiotic( esp. excoriation)( esp. excoriation) UVB phototherapy or natural sunlightUVB phototherapy or natural sunlight systemic PUVAsystemic PUVA

Seborrheic dermatitisSeborrheic dermatitis

greasy scaly erythematous patchgreasy scaly erythematous patch more severe in late stage of diseasemore severe in late stage of disease refractory to treatmentrefractory to treatment

Treatment of seborrheic dermatitisTreatment of seborrheic dermatitis ketoconazole + hydrocortisone creamketoconazole + hydrocortisone cream clotrimazole creamclotrimazole cream ketoconazole shampooketoconazole shampoo selenium sulfide shampooselenium sulfide shampoo zinc pyrithione shampoozinc pyrithione shampoo ciclopirox olamine shampoociclopirox olamine shampoo

PsoriasisPsoriasis

Incidence ~ 5-13 % (normal ~ 1-2%)Incidence ~ 5-13 % (normal ~ 1-2%) more severitymore severity multiple types of lesionmultiple types of lesion often occur with seborrheic dermatitisoften occur with seborrheic dermatitis secondary infection withsecondary infection with candida albicans candida albicans

oror staphyllococcus aureus staphyllococcus aureus (esp. psoriatic (esp. psoriatic erythroderma)erythroderma)

Treatment of psoriasisTreatment of psoriasis

Acitretin 50-75mg/dAcitretin 50-75mg/d Low-dose MTX (should Low-dose MTX (should prophylaxis OI)prophylaxis OI) CyclosporinCyclosporin High-dose Zidovudine (1,200 mg/d)High-dose Zidovudine (1,200 mg/d) Highly active antiretroviral therapyHighly active antiretroviral therapy

Treatment of psoriasisTreatment of psoriasis

Topical tar & corticosteroid preparationTopical tar & corticosteroid preparation Topical calcipotriol preparationTopical calcipotriol preparation UVB phototherapyUVB phototherapy Narrow-band UVB phototherapyNarrow-band UVB phototherapy Systemic PUVASystemic PUVA

Exfoliative dermatitisExfoliative dermatitis

Etiology:Etiology: psoriasispsoriasis drug reactiondrug reaction cutaneous T-cell lymphomacutaneous T-cell lymphoma high grade non-Hodgkin’s lymphomahigh grade non-Hodgkin’s lymphoma unknown causeunknown cause

Exfoliative dermatitisExfoliative dermatitis

Diagnosis: Diagnosis: - - skin biopsyskin biopsy Treatment:Treatment:-- eliminate the causes eliminate the causes

- - if no causes, the drugs if no causes, the drugs areare

systemic corticosteroidsystemic corticosteroid

antihistamineantihistamine

emollient creamemollient cream

Drug eruptionDrug eruption

Incidence:Incidence: ~10 times of general population ~10 times of general population Etiology:Etiology:

multiple drugs treatmentmultiple drugs treatment abnormal immune responseabnormal immune response metabolic factormetabolic factor

Drug eruptionDrug eruption

Common causative drugs: sulfonamide (TMP-SMZ, sulfadiazine)sulfonamide (TMP-SMZ, sulfadiazine) dapsonedapsone anti-tuberculous drugs(INH, RFP)anti-tuberculous drugs(INH, RFP) ofloxacinofloxacin fluconazolefluconazole

Drug eruptionDrug eruption

Common causative drugs:Common causative drugs: pentamidinepentamidine carbamazepinecarbamazepine foscarnetfoscarnet nevirapinenevirapine efavirenzefavirenz indinavirindinavir

Drug eruptionDrug eruption

Clinical feature:Clinical feature: Morbiliform reactionMorbiliform reaction Fixed drug eruptionFixed drug eruption UrticariaUrticaria Photoallergic reactionPhotoallergic reaction

Drug eruptionDrug eruption

Clinical feature:Clinical feature: Exfoliative dermatitisExfoliative dermatitis Hypersensitivity syndrome Hypersensitivity syndrome Stevens-Johnson syndromeStevens-Johnson syndrome Toxic epidermal necrolysis Toxic epidermal necrolysis

Treatment of drug eruptionTreatment of drug eruption

Mild form:Mild form: offending drugoffending drug maymay be stopped be stopped topical corticosteroidtopical corticosteroid antihistamineantihistamine

Treatment of drug eruptionTreatment of drug eruption

Severe form:Severe form: offending drug offending drug mustmust be stopped be stopped short course high dose systemic corticosteroidshort course high dose systemic corticosteroid antihistamineantihistamine antibiotic if necessaryantibiotic if necessary

Prurigo nodularisPrurigo nodularis

Etiology:Etiology: arthropod reaction (esp. Mosquito)arthropod reaction (esp. Mosquito) pre-existing HIV-associated pruritic pre-existing HIV-associated pruritic

dermatosisdermatosis circulating pruritogenic factorcirculating pruritogenic factor emotional stressemotional stress

Prurigo nodularisPrurigo nodularis

Etiology:Etiology: malabsorption & malnutritionmalabsorption & malnutrition peripheral nerve infection with HIVperipheral nerve infection with HIV immunologic abnormalityimmunologic abnormality

Prurigo nodularisPrurigo nodularis

Clinical features:Clinical features: firm hyperkeratotic nodules & papulesfirm hyperkeratotic nodules & papules only 1-2 or more than 100 nodulesonly 1-2 or more than 100 nodules crusting & excoriationcrusting & excoriation perilesional pigmentary alterationperilesional pigmentary alteration symmetrical distributionsymmetrical distribution

Prurigo nodularisPrurigo nodularis

Diagnosis:Diagnosis: clinical featuresclinical features skin biopsy (to exclude skin biopsy (to exclude

pseudocarcinomatous inflammation in pseudocarcinomatous inflammation in cutaneous infectioncutaneous infection))

Prurigo nodularisPrurigo nodularis

Treatment:Treatment: thalidomide 50-300 mg qid thalidomide 50-300 mg qid high potent topical corticosteroidhigh potent topical corticosteroid antihistamine (e.g. doxepin, hydroxyzine) antihistamine (e.g. doxepin, hydroxyzine)

Miscellaneous skin diseasesMiscellaneous skin diseases

Recurrent Apthous Ulcer (RAU)Recurrent Apthous Ulcer (RAU) Xerostomia & exfoliative cheilitisXerostomia & exfoliative cheilitis Pigmentary skin changePigmentary skin change Patchy depapillation of the tonguePatchy depapillation of the tongue XerosisXerosis

Miscellaneous skin diseaseMiscellaneous skin disease

Chronic actinic dermatitisChronic actinic dermatitis VitiligoVitiligo Alopecia areataAlopecia areata Necrotizing vasculitisNecrotizing vasculitis

Recurrent apthous ulcer Recurrent apthous ulcer

CD4+ cell count:CD4+ cell count: <50 cells/cu.mm. <50 cells/cu.mm. Etiology:Etiology: - unknown - unknown Diagnosis:Diagnosis:

clinical featureclinical feature ulcer smearulcer smear ulcer biopsy ulcer biopsy

Recurrent apthous ulcerRecurrent apthous ulcer

Differential diagnosis:Differential diagnosis: histoplasmosishistoplasmosis cryptococcosiscryptococcosis herpes simplex virusherpes simplex virus cytomegalovirus cytomegalovirus mycobacterium avium complexmycobacterium avium complex klebsiella pneumoniaeklebsiella pneumoniae enterobacter cloacae enterobacter cloacae

Recurrent apthous ulcerRecurrent apthous ulcer

Treatment:Treatment: thalidomide 50 -300 mg/dthalidomide 50 -300 mg/d topical steroid in orabasetopical steroid in orabase intralesional injection of triamcinoloneintralesional injection of triamcinolone colchicine 1.5 mg/dcolchicine 1.5 mg/d prednisolone 30 -70 mg/dprednisolone 30 -70 mg/d G-CSF (neutropenic patient)G-CSF (neutropenic patient)

Xerostomia & exfoliative cheilitisXerostomia & exfoliative cheilitis Etiology: Etiology: - - salivary gland disease (parotid salivary gland disease (parotid

glandgland

- pathology look like Sjogren’s - pathology look like Sjogren’s

syndromesyndrome

Xerostomia & exfoliative cheilitisXerostomia & exfoliative cheilitisTreatment:Treatment: topical fluoridetopical fluoride topical glycerinetopical glycerine topical white petrolatumtopical white petrolatum

HIV-related vasculitisHIV-related vasculitis

Incidence:Incidence: lowlow

Etiology:Etiology: drug-induced hypersensitivitydrug-induced hypersensitivity infectious process (HIV,HBV,HCV & systemic infectious process (HIV,HBV,HCV & systemic

fungus) fungus) immunological disorder immunological disorder

HIV-related vasculitisHIV-related vasculitis

Clinical features:Clinical features: palpable purpura palpable purpura digital necrotic ulcersdigital necrotic ulcers swelling of hands & feetswelling of hands & feet arthralgiaarthralgia feverfever

HIV-related vasculitisHIV-related vasculitis

Diagnosis:Diagnosis: clinical featuresclinical features histopathologyhistopathology

HIV-related vasculitisHIV-related vasculitis

Treatment:Treatment: bed restbed rest antihistamineantihistamine NSAIDNSAID colchicinecolchicine avoid immunosuppressive agentavoid immunosuppressive agent eliminate the etiologic agenteliminate the etiologic agent

Chronic actinic dermatitisChronic actinic dermatitis

Prevalence:Prevalence: common in mencommon in men younger than 60 years oldyounger than 60 years old CD4+ cell count <200 cells/cu.mm.CD4+ cell count <200 cells/cu.mm.

Chronic actinic dermatitisChronic actinic dermatitis

Pathogenesis:Pathogenesis: reactive photoproduct + endogenous carrier reactive photoproduct + endogenous carrier

proteinprotein photohaptenphotohapten photosensitivityphotosensitivity

Chronic actinic dermatitisChronic actinic dermatitis

Clinical features:Clinical features: hypo & hyperpigmented patcheshypo & hyperpigmented patches lichenified plaqueslichenified plaques fissures & erosionsfissures & erosions confine to sun exposed areasconfine to sun exposed areas

Chronic actinic dermatitisChronic actinic dermatitis

Diagnosis:Diagnosis: clinical featuresclinical features phototestphototest

decreased MED of UVA & UVBdecreased MED of UVA & UVB

Chronic actinic dermatitisChronic actinic dermatitis

Treatment:Treatment: avoid sunlightavoid sunlight sunscreensunscreen topical corticosteroid preparationtopical corticosteroid preparation systemic antihistaminesystemic antihistamine

HIV-associated eosinophilic folliculitisHIV-associated eosinophilic folliculitisPathogenesis:Pathogenesis:

follicular hypersensitivity reaction to follicular hypersensitivity reaction to Pityrosporum yeast,Demodex folliculorum or Pityrosporum yeast,Demodex folliculorum or Leptotricia bucalisLeptotricia bucalis

change in cellular immune homeostasischange in cellular immune homeostasis

HIV-associated eosinophilic folliculitisHIV-associated eosinophilic folliculitisClinical features:Clinical features:

common in male patientscommon in male patients advanced stage of HIV infectionadvanced stage of HIV infection groups of edematous erythematous pruritic groups of edematous erythematous pruritic

follicular papules at face, upper trunk, arms & follicular papules at face, upper trunk, arms & (thighs)(thighs)

HIV-associated eosinophilic folliculitisHIV-associated eosinophilic folliculitisDiagnosis:Diagnosis:

clinical featuresclinical features histopathologyhistopathology peripheral blood eosinophilia (~ 35%)peripheral blood eosinophilia (~ 35%) elevated serum IgEelevated serum IgE CD4+ cell count < 200 cells/cu.mm.CD4+ cell count < 200 cells/cu.mm.

HIV-associated eosinophilic folliculitisHIV-associated eosinophilic folliculitisTreatment:Treatment:

metronidazole 250 mg t.i.d. for 3-4 weeksmetronidazole 250 mg t.i.d. for 3-4 weeks itraconazole 200-300 mg/d for 4 weeksitraconazole 200-300 mg/d for 4 weeks isotretinoin 0.5-1.2 mg/kg/disotretinoin 0.5-1.2 mg/kg/d 5% permethrin cream apply once a day for 4 5% permethrin cream apply once a day for 4

weeksweeks

HIV-associated eosinophilic folliculitisHIV-associated eosinophilic folliculitisTreatment:Treatment:

Prednisolone 60mg/d (tapered over1-2week)Prednisolone 60mg/d (tapered over1-2week)

or or 60mg/d (one day/week)60mg/d (one day/week) UVB phototherapyUVB phototherapy Systemic PUVASystemic PUVA

Kaposi’s sarcoma (KS)Kaposi’s sarcoma (KS)

Classic KSClassic KS Endemic KSEndemic KS KS in iatrogenically immunocompromised KS in iatrogenically immunocompromised

patientspatients HIV-associated KSHIV-associated KS

HIV-associated KSHIV-associated KS

Epidemiology:Epidemiology: 95% in homosexual or bisexual men95% in homosexual or bisexual men low incidence in thailandlow incidence in thailand

Etiology:Etiology: genetic markergenetic marker immune dysregulationimmune dysregulation retrovirus retrovirus HHV-8 (Human Herpes Virus-8)HHV-8 (Human Herpes Virus-8)

HIV-associated KSHIV-associated KS

Clinical features:Clinical features: common at nose,eyelids & pinnacommon at nose,eyelids & pinna skin lesions may be numerous & disseminatedskin lesions may be numerous & disseminated bleeding ulcersbleeding ulcers symptom & sign of respiratory & symptom & sign of respiratory &

gastrointestinal tractgastrointestinal tract Diagnosis:Diagnosis:

histopathology & immunopathologyhistopathology & immunopathology

HIV-associated KSHIV-associated KS

Treatment:Treatment: simple excisionsimple excision Cryotherapy, RadiotherapyCryotherapy, Radiotherapy Carbondioxide Carbondioxide or or Argon LASERArgon LASER Photodynamic therapy,ChemotherpyPhotodynamic therapy,Chemotherpy Interferon alpha & betaInterferon alpha & beta Highly active antiretroviral therapyHighly active antiretroviral therapy

Merkel cell carcinomaMerkel cell carcinoma

originate from cutaneous Merkel cell originate from cutaneous Merkel cell (neuro(neuroendocrine cell)endocrine cell)

no reported case until nowno reported case until now clinical features:clinical features: - - raised reddish blue raised reddish blue

nodulenodule

- occur at any site- occur at any site

Merkel cell carcinomaMerkel cell carcinoma

Diagnosis:Diagnosis: histopathologyhistopathology electron microscopy (specific dense core electron microscopy (specific dense core

granule)granule) special stainspecial stain

Treatment: Treatment: - - surgical excisionsurgical excision

Prognosis: Prognosis: - - poorpoor

LymphomaLymphoma

Non-Hodgkin LymphomaNon-Hodgkin Lymphoma Hodgkin’s diseaseHodgkin’s disease Cutaneous T-Cell Lymphoma (CTCL)Cutaneous T-Cell Lymphoma (CTCL)

Cause of HIV-related LymphomaCause of HIV-related Lymphoma Polyclonal proliferation & lymph node Polyclonal proliferation & lymph node

follicular hyperplasiafollicular hyperplasia Chromosomal abnormalitiesChromosomal abnormalities Epstein-Barr Virus (EBV) infectionEpstein-Barr Virus (EBV) infection

Treatment of lymphomaTreatment of lymphoma

chemotherapy immunostimulator antiviral agentantiviral agent