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A Primary Health Approach to HIV Skin Disease
Anisa MosamAssociate Professor
MBChB, FC Derm, MMed, PhDNRMSOM, UKZN
AWACC 6-7th October 2016
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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
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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
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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.
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• .
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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
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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.
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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
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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
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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
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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
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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
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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
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Treatment
• Symptomatic Rx limited to antihistamines, topical steroids
• Tetracyclines ( Doxycycline 100bd x 12 weeks)
• HAART Rx
• Recurrence associated with virologic failure
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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
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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
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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
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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
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Therapy for warts
• 1st line salicylic acid/lactic acid preparations Duofilm
• Genital warts podophyllin 20%
• Imiquimod effective in facial, genital and extragenital warts
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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)
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BlistersPainful Blisters
Generalized
Varicella
Drug reactions
Localized
Oral or genital
involvement
HSV
Dermatomal in
distribution
Herpes zoster
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Therapy
• Aciclovir effective
• 200 5x dly x 10d
• Recurrence duration ↓ to 5 days
• Severe oral involvement
• IVI 5mg/kg 8 hourly
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Therapy
• HSV
• Acyclovir 200mg 5X dly X 7 d
• VZV
• Acyclovir 800mg 5Xdly X7d
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Management
• Topical steroids
• Antihistamines
• Monitor for
• Fever, blisters, lymphadenopathy, mucosal involvement
• Eosinophilia, hepatitis
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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
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SJS/TEN
• Temperature control
• Eye care
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Ulcers
Duration less than
one month
Ecthyma
Drug
reactions
Duration more than a
month
HSV
Deep fungal
infections
TB, atypical
mycobacteria
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Immune Reconstitution
• Successful HAART, ↓VL, ↑CD4 and CD8
• Skin manifestations in 54-78%
• Commonest being:
• HSV
• VZV
• Warts
• Molluscum
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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
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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