Hiv and the skin


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Hiv and the skin

  1. 1. Mucocutaneous MANIFESTATIONS OF HIV/AIDS
  2. 2. EPIDEMIOLOGY HIV infection/AIDS is a pandemic that still poses one of the greatest challenges in global public health. Approximately 40 million people in the world are currently living with HIV infection and 25 million have died since 1981. Thirteen million children have been orphaned.
  3. 3. PATHOGENESIS  HIV is an enveloped RNA virus. The incubation period ranges from 3 to 6 weeks.  Upon initial infection, the virion binds to CD4 + T lymphocytes, monocyte-macrophages and dendritic cells.  Changes in conformation induce fusion of the viral envelope with the plasma membrane.  Next, its outer coat is removed and the virus particle is internalized.
  4. 4. Pathogen…….  The DNA copy is then integrated into the host DNA and can be expressed as a cellular gene.  there is transcription of viral RNA into DNA  Cleavage of some of viral genome into the structural components of the virus is accomplished by proteases.  Intact viruses are then produced and host cells are destroyed.
  5. 5. INTRODUCTION • Up to 92% of HIV/AIDS patient will have one or more skin disorders during the course their illness. • Recognizing HIV-related skin changes may lead to the diagnosis of HIV infection in the early stages &clincal staging of HIV/AIDS which allows initiation of antiretroviral therapy .
  6. 6. INTRODUCTION • Dermatological manifestations are seen at every stage of HIV/AIDS • Some of the conditions are unique and virtually pathognomonic for HIV disease like bacillary angiomatosis and oral hairy leukoplakia.
  7. 7. Acute Retroviral Syndrome • 80 percent of cases • Occurs during seroconversion . • IP 3 to 6 weeks • Constitutional symptoms are followed by exanthematous rash. • Some recommend initiation HAART .
  8. 8. SeborrhoeicDermatitis •Commonest inflammatory dermatosis seen • affects 32-83% of HIV/AIDS patients •usually present as sever or atypical forms. •Atypical forms: erythroderma, secondary bacterial infection.
  9. 9. Xerosis • Generalized dry skin is more frequently observed in patients with HIV infection. • It is often accompanied by severe generalized itching.
  10. 10. Acquired ichthyosis generalized acquired ichthyosis with large plate-like scales on the legs. Severe form of Atopic dermatitis is a frequent problem in children or adults with HIV/AIDS and is often difficult to control with conventional therapy.
  11. 11. 2 .Psoriasis It may develop at any stage of HIV infection . Like seborrheic dermatitis, a rapid onset of 'eruptive' psoriasis can serve as an important clue to an underlying HIV infection.  The psoriasis is often severe and may be associated with significant nail dystrophy, arthritis and Reiter's disease.  It tends to worsen with declining immune status.
  12. 12. Pruritic Papular eruption  (PPE) of AIDS is characterized by marked pruritus and a greater involvement of the extremities than the trunk or face.  It is more prevalent in Africa as compared to North America or Europe.  Propsed possibility that it is an exaggerated response to arthropod antigens.  Clinically, the lesions are symmetrically distributed, non-follicular papules often with secondary change(excoriation,prurigo nodularis)
  13. 13. Pruritic papular eruption (PPE) • Common and relatively specific manifestation, 60% have advanced immunosuppression. • The cause is not known. • Emollients, steroid and antihistamines give temporary relief
  14. 14. Bacterial infections • Pyodermas are very common in HIV/AIDS patients. Recurrent Staph &streptococal infections •Cellulitis •Ecthyma •Erysipelas •Furunculosis •Folliculitis •Impetigo • abscess
  15. 15. 3 .Bacillary angiomatosis is a bacterial infection that may involve virtually any body site, but it favors the skin and subcutaneous tissue.  Lesions of variable size and shape may be seen, including red to purple 'vascular appearing‘ papules or nodules & ulcers.  The number of lesions ranges from one to more than hundreds.  Gram-negative bacilli in the genus Bartonella are responsible for this disease,
  16. 16. Bacterial infection……. Diagnosis is usually based on histologic features i.e. characteristic vascular proliferation and numerous bacilli visualized by Warthin- Starry staining.
  17. 17. Treatment. • TTC 500mg QID for 2m. • Doxacycilline 100mg BID until it resolve. • erythromycine
  18. 18. Fungal Infections • Wide spread &extensive fungal infections which are resistant to treatment can be related to underlying immunosupression.
  19. 19. Fungal Infections • Recurrent and severe oropharyngeal candidiasis, usually extending to the esophagus is the presenting symptom and indicates immunosupression .
  20. 20. Fungal Infections • Deep and rare fungal infections like cryptococcosis, coccidiomycosis, and histoplasmosis affecting the systemic organs and the skin are unique features of advanced AIDS.
  21. 21. Systemic fungal infection • Indicates Profound immunodeficiency • Histoplasmosis, Cryptococcosis • Sporotrichosis •high index of suspicion is very important •treat with Systemic antifungals for longer periods.
  22. 22. Common viral skin infections in HIV/AIDS patients • Herpes simplex virus 1,2 • Varicella zooster • Human papilloma virus • Epistein bar virus • Hepes simplex virus 8.
  23. 23. Herpes Simplex Virus Infection • Chronic persistent infection with herpes simplex virus (HSV) is AIDS defining illness. • Ulceration is the usual finding with or with out prior history of blisters. • Dissiminated forms with meningitis may occur in advanced immunosupression.
  24. 24. HSV….. • Once significant immune suppression develops, lesions may progress to chronic, non-healing, deep ulcerations involving  the perianal,lips  The genitalia and tongue.  frequent recurrences are usually seen.
  25. 25. Diagnosis of HSV 1&2 • Serology • Tzank smear • PCR • Viral culture
  26. 26. Treatment of HSV • Acyclovir 200mg po q5hrs for 7 to 10days • Topical treatments for herpes are much less effective • Prolonged treatment with intravenous acyclovir is needed for HSV Encephalitis.
  27. 27. Varicella zoster virus primary varicella infection (chicken pox )occur during childhood, it may be subclinical.  In HIV-infected individuals, primary varicella may be severe,prolonged &complicated by pnumonia ,hepatitis ,encephalitis &death.  HIV infected pts.have a 10 times risk of developing H.zoster.
  28. 28. Herpes Zoster • Commonly seen early in the course of HIV infection, particularly in healthy-appearing individuals • It is due to reactivation of the latent virus that resides in the dorsal ganglion in immunosupressed indviduals. • The lesions starts as painful grouped vesicles which follows dermatomal distribution. • Recurrences and multidermatomal involvement is common.
  29. 29. Treatment of herpes zoster • Acyclovir 800mg po 5 times daily for 7days. • The drug is effective only during the active stage of the disease.
  30. 30. Oral Hairy Leukoplakia • Very specific manifestation of HIV infection • presenting as filiform white papules usually on the edge of the tongue. • it is due to Epstein-Bar virus infection. • May be the initial sign of progressive immunosuppression
  31. 31. Mollescum contangiosum • Caused by poxvirus. • It Affects Young children Sexualy active adult Immunosuppresed persons • Involvment of oral and genital mucosa indicate advanced AIDS(CD4<50)
  32. 32. Molluscum Contagiosum • Occurrence of MC on the face of an adult is an indication to screen for HIV • The character of the lesions are Centrally umbilicated skin coloured papules. • Spontaneous healing is rare • No hematogenous spread
  33. 33. Treatment • Recalcitrant • Surgery • Curettage • Cryotherapy/ electrocautery • 50 % trichloraceticacid • Saliycilic acid • 10%Potassium hydroxide solution •usually it Will recur but resolves with continuing ART.
  34. 34.  HPV is transmitted by close, repeated contact from infected individual.  HPV-induced lesions are common in the general population more prevalent in HIV-infected individuals  Lesions may be • widespread with multiple verrucated papules on the face, • limbs and genitalia that may coalesce into large plaques.  In addition, HIV-infected patients have • Higher risk of developing cervical intraepithelial neoplasia (CIN) and • anal intraepithelial neoplasia (AIN). human papilloma virus
  35. 35. human papilloma virus  With increasing immunodeficiency, cutaneous and/or mucosal HPV infection recur from latency, presenting clinically as verruca, condyloma acumintatum,insitu or invasive squamous cell cancer. .
  36. 36. human papilloma virus The increased prevalence of HPV-induced lesions in HIV disease is related to deficient cell mediated immunity . Increased HPV replication of the more oncogenic HPV types occurs with more advanced immunosuppression.
  37. 37. human papilloma virus  The degree of immunosuppression correlates with the presence of HPV DNA,extent of HPV inf.& potential for malignent transformation.  Individuals with CD4 cell counts <200/mL being at greatest risk.  Potential for malignant transformation varies considerably according to the type& site of HPV-infected epithelium being greatest for the transitional epithelium of the cervix and anus,  lesser for vulvar epithelium,  And least for the epithelium of the male genitalia, perineum, inguinal folds, and perianal rigion.
  38. 38. Warts • Lesions may be extensive and resistant to therapy. • warts usually look like those seen in nonimmunosuppressed patients, but are more extensive. • Flat warts on adult face are typical features of HIV infection. •
  39. 39. Warts • Condyloma acuminata are of special significance in persons with HIV infection. • They are very difficult to eradicate. • Cervical dysplasia and carcinoma are more frequent and invasive cervical ca is AIDS defining illness.
  40. 40.  Oropharyngeal HPV-induced lesions resemble anogenital condylomata, pink or whit in color.  Extensive intraoral condyloma acuminatum (oral florid papillomatosis) presents as multiple large plaques, analogous to anogenital giant C.acuminata of Buschke- Lowensten >>> verrucous carcinoma.
  41. 41. Monitoring should include serial physical examinations,  colposcopy/ proctoscopy, cervical and anal HPV determination and cytology.  histologic confirmation when indicated.
  42. 42. Human papiloma virus treatment  Treatment decisions are based upon the size and location of the lesions as well as histologic grade. Treatment options are imiquimod, podophyllin , podophyllotoxin, trichloroacetic acid, cryotherapy, electro desiccation, CO2 laser and surgical excision.
  43. 43. Kaposi’s Sarcoma • The first reported malignancy in association with HIV infection • Appears as red-to-brown flat macules in any site, mainly above the trunk • Prognosis is poor and kills the patient unless HAART is instituted immediately
  44. 44. Treatment.  The choice of treatment of KS depends on the extent and the localization  It often improves with HAART.
  45. 45. Treatment……  Certain patients with rapidly progressive disease require (poly)chemotherapy with cytotoxic drugs. In addition to the vinca alcaloids vinblastin and vincristin, which are administered by the intravenous.
  46. 46. Parasitic Infections 1 .Leishmaniasis  HIV-associated leishmaniasis may occur in both endemic and nonendemic regions of the world.  Diffuse cutaneous leishmaniasis can be significantly associatied with hiv infection.
  47. 47. 2.Scabies • Frequency the same • Norwegian (crusted) scabies, which is characterized by wide spread hyperkeratotic plaque occurs on palms and soles. • Prolonged treatment with repeated course of scabicides is needed
  48. 48. Ecto.parasities…….  Crusted scabies, in particular, is extremely contagious.  In any itchy HIV-infected patient, there should be a high index of suspicion for scabies.  HIV-infected individuals with scabies are usually treated initially with standard therapies but they may require multiple courses.
  49. 49. Treatment. Permethrin 5% cream Ivermectin 250to 400microgram/kg single dose.
  50. 50. Hypersensitivity Reactions • The immune dysregulation associated with AIDS has made these patients to react abnormally for any exogenous stimuli like arthropod bite, drugs, and UV radiation
  51. 51. Hair and Nail Disorders • Diffuse alopecia or alopecia areata • Elongation of the eyelashes and softening and straightening of the scalp hair • Yellow or white • Blue nails • Proximal subungal onychomycosis
  52. 52. Drug reaction.  Adverse Cutaneous Drug Eruptions  Adverse cutaneous drug eruptions can range from extremely mild to life-threatening and may be caused by either a single drug or drug combinations.  They are quite common in HIV-infectcd Individuals.  Mechnisms underlying these reactions are unknown likely related to:  immune dysregulation.  Glutathion deficiency.
  53. 53. Drug eruptions •Increased 100 times in patients with HIV •12-16% skin rash is due to Bactrim •Commonest type is maculopapular(morbiliform) rash •8-10 days within Bactrim intake. •Resolves with discontinuation of the drug
  54. 54. Common Drug reaction • Steven Johnson Syndrome (SJS) •Toxic epidermal necrolysis(TEN) •Erythroderma •Fixed drug eruption • targetoid lesions and mucosal lesions
  55. 55. Drug reaction  Patients may also present with: urticaria, pruritus, vasculitis, photodermatitis  An adverse drug reaction should be high on the differential diagnosis list when a patient taking several medications develops cutaneous eruption.
  56. 56. Fixed drug eruption
  57. 57. Targetoid lesions
  58. 58. SJS
  60. 60. Drug reactions • ASK Recent drug intake within 4 week. • Anti TB therapy • Sulpha drugs • •Ampicillin • •Nevirapine • •NVP rashes occur in 20%
  61. 61. Management • •Stop offending drug • •Antihistamines • •If severe, short course prednisolone