a primary health approach to hiv skin disease - awacc mosam - a primary healthcare approach to...

A Primary Health Approach to HIV Skin Disease

Anisa MosamAssociate Professor

MBChB, FC Derm, MMed, PhDNRMSOM, UKZN

AWACC 6-7th October 2016

HIV and Skin

• Common 36-52%

• Prevalence rates 85% in SSA

• 37% present skin as marker of HIV

• 90% will develop skin problems during HIV

• CD4 count decreases, severity increases, multiple skin lesions, frequent relapses

Lowe Paed Infect Dis J 2010; 29(4):346-51Int Jnl Dermatol 1990;29:24-29

Plaques Solid elevated lesions with a diameter of > 2 cm

SCALP

scaling

alopecia

cervical nodes

Tinea Capitis

KOH or culture

Scalp and flexures

( axilla, groin)

Seborrhoeic eczema

scalp greasy crusted

flexural lesions weepy

Psoriasis

Scalp has silvery scales,

plaques on extensors

joint and nail changes

Seborrhoeic Eczema

• Commonest condition associated with HIV

• Although it can occur at any level of CD4 count, it tends to become more severe and recalcitrant to therapy as the CD4 count declines.

• .

Treatment• If infected ( weepy and malodorous):

– systemic broad spectrum antibiotic – Potassium permanganate soaks: dry lesions

• Topical corticosteroids:– 1% hydrocortisone for the face– 1/3 betamethasone valerate cream for the body

• Scalp shampoos: – Ketoconazole– Tar shampoos

• Sedating oral antihistamines control pruritus

Psoriasis• Face, flexures, hands and feet and scalp:

– Topical steroids

• Scalp– Tar shampoos– Topical steroids (shampoos and lotions)

• Body – 6% Tar in 2% salicylic acid – Emulsifying Ointment ( 50:50 WSP/LP)

• Vitamin A derivatives ie Acitretin indicated for extensive disease and erythrodermic forms.

Plaques

Photodermatitis

face, V of the neck and

extensors

Icthyosis

If on lower limbs( extensors)

crazy paving appearance

no specific distribution

plaques are annular

Itchy

Drug eruption

truncal eruption

drug history

Tinea infection

central clearing, active

edge. confirm with KOH

Not Itchy

Secondary syphilis

Peri-oral and nasal, palms

and soles, oral mucosa,

WR, VDRL, TPHA

Treatment

• If localized, topical antifungal creams twice daily for 14 days eg econazole, miconazole, clotrimazole or terbinafine cream.

• If extensive skin involvement, hair or nail involvement, systemic antifungal Fluconazole 200 mg daily for 14 days

• For tinea unguium ( nail infection) the duration is longer• Fluconazole 200 mg weekly for 6-9 months

• However, if a few nails are affected ( <3), then it is cost-effective to use topical therapy. A combination of 2% clotrimazole in 40% urea

Drug reactions

• Drug eruptions occur 100 times more often in HIV infected individuals and the probability of drug reactions increases with advancing immunodeficiency

• The commonest drugs implicated are the antibiotics, specifically cotrimoxazole and the penicillin-containing antibiotics.

• Other common offending agents: – anticonvulsants – antituberculous drugs– NNRTI’s

• morbilliform patterns, urticarial reactions

Drug reactions

• Examining the mucosal surfaces; conjunctivae, oral and genitals is important

• Therapy is aimed at identifying the offending drug and withdrawing it

• For mild reactions, therapy can be symptomatic with antihistamines and topical steroids

Secondary syphilisasymptomatic

papulosquamous truncaleruption

– annular plaques especially of the “muzzle” area of the face

– split papules involving the angles of the mouth

– snail track ulcers of the tongue

– hyperpigmentedpapules of the palms and soles.

– Moth eaten alopecia

Nodulessolid elevated lesions with a diameter of >0.5cm with substantial depth

Itchy

PPE/ Prurigo

extensors of

upper and lower

limbs

Not Itchy

Violet

coloured

Kaposis

sarcoma: Palate,

limbs,

symmetrical,

lymphoedema

Umbilicated

Cryptococcosis

nodules with

haemorrhagic

crusts,

meningitis,

LP

Histoplasmosis

ill patient, chest

infiltrates, mucosal

lesions,

Abn FBC

Treatment

• Symptomatic Rx limited to antihistamines, topical steroids

• Tetracyclines ( Doxycycline 100bd x 12 weeks)

• HAART Rx

• Recurrence associated with virologic failure

PapulesSolid elevated lesion with a diameter of <0.5cm

Papules that are itchy

Distribution

Lesions on web spaces of

hands and feet, wrists and

ankles, axilla, umbilical area

and groin

Scabies

plaques and nodules may present in

severe cases

Symmetrical on

limbs, involvement

of face and trunk

PPE/EF

urticarial and

prurigo-like lesions

may be present

Exposed sites ie

face, arms, legs;

lesions maybe in a

linear distribution

Papular urticaria

history of insect

bites

linear

Therapy

• Benzoyl benzoate

• Repeated applications required

• Debridement with keratolytics

• 2%, 5%, 10% Salicylic acid

• 5% Sulphur ointment < 2 yrs

• Ivermectin for crusted scabies 200µg/kg stat and repeat after 14 days

Papules Solid elevated lesion with a diameter of <0.5cm

Non-itchy papules

Verrucous

flat topped

hypopigment

ed

Warts

Umbilicated

Molluscum contagiosum

necrotic centres

extensors

acral

earlobe

PNT

Mantoux test

chest X-ray

Tender, pus and

pustules may be

present

Bacterial

folliculitis

Pus swab for

microscopy

culture and

sensitivities

Therapy for Molluscum

• 1st line salicylic/lactic acid prep Duofilm

• Cautery/ cryo effective is surgical facilities available

• Cantharadin 0,7% application ( Blister Beetle)

• Scratching discouraged to prevent transmission and autoinoculation

Therapy for warts

• 1st line salicylic acid/lactic acid preparations Duofilm

• Genital warts podophyllin 20%

• Imiquimod effective in facial, genital and extragenital warts

Impetigo

• Bacterial infection with Staph aureus

• Or Streptococcus

• Vesicles rupture to form honey coloured crusts

• Peri-nasal and peri-oral

• Pus swab

• Topical antibiotic: mupirocin, fucidin

• If extensive, pyrexia: oral antibiotic (flucloxacillin)

BlistersPainful Blisters

Generalized

Varicella

Drug reactions

Localized

Oral or genital

involvement

HSV

Dermatomal in

distribution

Herpes zoster

Therapy

• Aciclovir effective

• 200 5x dly x 10d

• Recurrence duration ↓ to 5 days

• Severe oral involvement

• IVI 5mg/kg 8 hourly

Therapy

• HSV

• Acyclovir 200mg 5X dly X 7 d

• VZV

• Acyclovir 800mg 5Xdly X7d

Management

• Topical steroids

• Antihistamines

• Monitor for

• Fever, blisters, lymphadenopathy, mucosal involvement

• Eosinophilia, hepatitis

SJS/TEN

• Admit

• Stop most likely offending drug

• If blisters, IVI hydrocortisone 200 mg 8hrly 24-48 hrs

• Analgesia

• Wound care

• Vigilance for sepsis

• Fluid and electrolyte

SJS/TEN

• Temperature control

• Eye care

Ulcers

Duration less than

one month

Ecthyma

Drug

reactions

Duration more than a

month

HSV

Deep fungal

infections

TB, atypical

mycobacteria

Immune Reconstitution

• Successful HAART, ↓VL, ↑CD4 and CD8

• Skin manifestations in 54-78%

• Commonest being:

• HSV

• VZV

• Warts

• Molluscum

Conclusion

• Skin conditions are an early warning of HIV/AIDS

• Increased frequency as HIV advances

• Unusual anatomical sites, clinical appearance, increased severity, treatment failure

• HAART has reduced the prevalence of muco-cutaneous disorders and improved QOL of patients with HIV/AIDS

• Continue to witness IRIS and adverse drug reactions

Thank you

Mosam A, Mankahla A. Identification and management of cutaneous manifestations of HIV in adults and children. In Marlink RG, Teitelman SJ eds. From the ground up: building comprehensive HIV/AIDS programs in resource limited settings, Washington DC. Elizabeth Glazer paediatric AIDS foundation; 2009