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Dermatologic Manifestations
of HIV Infection
Toby A. Maurer, MD
The International AIDS Society–USA
TA Maurer, MD
Presented...
Slide #2
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
• As pts immune reconstituted,
decreased...
Slide #3
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
CD4 Under 200 and not on ART
• Psoriasis...
Slide #4
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Psoriasis
• With ART, HIV psoriasis easi...
Slide #5
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Photodermatitis
• HIV makes pts sensitiv...
Slide #6
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Prurigo Nodularis
• Pts consumed by itch...
Slide #7
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Pruritic Papular Eruption in
Uganda
• St...
Slide #8
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Molluscum
• Seen frequently in young wom...
Slide #9
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Recurrent Drug Reactors
• Group of perso...
Slide #10
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Drug Reactions
• When do you use steroi...
Slide #11
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Diseases that just don’t go away
with A...
Slide #12
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Warts
• Past evidence showed a low nadi...
Slide #13
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Wart treatment
• All about 50% efficacy...
Slide #14
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
• Trying to look at persons who are
rec...
Slide #15
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Is KS in this category
• KS seen throug...
Slide #16
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
KS Treatment from Derm
Perspective
• KS...
Slide #17
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Cutaneous Lymphoma
• See it in CD4’s un...
Slide #18
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
With immune reconstitution:
diseases th...
Slide #19
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Acne
• Acne vulgaris
• Acne rosacea
• P...
Slide #20
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Eosinophilic folliculitis
• Itchy, urti...
Slide #21
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Staph infections
• Increased incidence ...
Slide #22
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Approach to Treatment
• Culture where y...
Slide #23
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
If no pus:
• Tx with methicillin sensit...
Slide #24
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
For recurrent disease
• Also look for u...
Slide #25
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
If not improving
• Was patient treated ...
Slide #26
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Was it bacterial in the first place?
• ...
Slide #27
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Erythema nodosum
• Can be part of immun...
Slide #28
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Helicobacter cinaedi
• Mimics erythema ...
Slide #29
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
HIV and HCV
• Co-infection rate high an...
Slide #30
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Xerosis
• Pts noting that skin barrier ...
Slide #31
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Leukocytoclastic Vasculitis
• R/O react...
Slide #32
TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
Itch without a rash
• Seems to be centr...
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    1. 1. Dermatologic Manifestations of HIV Infection Toby A. Maurer, MD The International AIDS Society–USA TA Maurer, MD Presented at IAS–USA/RWCA Clinical Conference, June 2005.
    2. 2. 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?
    3. 3. Slide #3 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
    4. 4. 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
    5. 5. 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)
    6. 6. 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
    7. 7. 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 ResneckJ,etalJAMADEC1,2004
    8. 8. 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
    9. 9. 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 JetalArchDermSept2004
    10. 10. 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
    11. 11. Slide #11 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
    12. 12. 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,etal
    13. 13. Slide #13 TA Maurer, MD. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Wart treatment • All about 50% efficacy LN2 Podophyllin Imiquimod (genital)-new study-once warts eradicated by surgery or cryotherapy, imiquimod works to prevent recurrence Duct tape? Laser Surgery Treat every three weeks-ave. no. of tx=12
    14. 14. Slide #14 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
    15. 15. 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?
    16. 16. 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
    17. 17. 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)
    18. 18. Slide #18 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
    19. 19. Slide #19 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
    20. 20. 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)
    21. 21. 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)
    22. 22. 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)
    23. 23. Slide #23 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
    24. 24. 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
    25. 25. 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
    26. 26. Slide #26 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
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. Slide #31 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
    32. 32. 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
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