HIV Dermatology: Basic Facts

Transcription

1 HIV Dermatology

2 Module Instructions The following module contains hyperlinked information which serves to offer more information on topics you may or may not be familiar with. We encourage that you read all the hyperlinked information.

3 HIV Dermatology: Basic Facts 90% of patients with HIV have skin findings At times, these skin findings can help in diagnosing HIV in a patient HIV causes the loss of helper T cells and this immunodeficiency increases: Skin infections Inflammatory dermatoses (may seem counterintuitive but HIV INCREASES immune activity of the skin!) Neoplasms Typically, ARV therapy improves skin conditions that result from the loss of T cells

4 HIV Dermatology: Basic Facts The skin serves as an excellent marker for CD4 count and state of the immune system Patients with AIDS often have multiple skin problems at presentation making a fully body examination including the mouth important! Some skin conditions may help diagnose HIV+ in individuals unaware of their HIV status In herpes zoster (shingles) patients <50 yo,, HIV serology should be considered

5 Case 1

6 Case 1: History HPI: 53 yo man presents with generalized lymphadenopathy and diarrhea for the past month. He also noticed that he has had lesions on his elbows and knees. PMH: none All: none Meds: none FH: father with dandruff, mother with psoriasis and atopic dermatitis SH: homeless living in the city, reports IV drug use for the past 5 years

7 Case 1: Exam On exam, pt has scattered erythematous plaques on his chest as well as scattered erythematous plaques with overlying scale on the legs bilaterally most prominent on the anterior knees

8 Case 1: Labs Given the patient s s generalized lymphadenopathy,, a HIV serum antibody was drawn The patient was found to be HIV+

9 Case 1: Question 1 What is the patient s s likely CD4 count? a. >500 b c. <200 d. <50

10 Case 1: Question 1 Answer: b What is the patient s s likely CD4 count? a. >500 b c. <200 d. <50

11 Case 1: Explained The patient has a clinical exam and history consistent with psoriasis which is associated with a CD4 count of He also has dandruff consistent with seborrheic dermatitis

12 Dermatologic Manifestations CD Seborrheic dermatitis Psoriasis Reactive arthritis Atopic dermatitis Herpes zoster Acne Rosacea Oral hairy leukoplakia Onychomycosis Warts S. aureus folliculitis Mucocutaneous candidiasis

13 HIV and CD4 Count The typical skin findings of HIV are often CD4 count related. However it is not a definite marker, many healthy individuals get conditions listed previously. The patient has generalized LA, diarrhea, psoriasis and seborrheic dermatitis which are all consistent with a CD4 count of

14 Case 2

15 Case 2: History HPI: 38 yo man with 5 yr history of HIV presents with bumps behind his ear as well as well as white spots on his tongue and mouth PMH: HIV All: none Meds: none (not on ARV) FH: non-remarkable SH: lives in the city with his girlfriend

16 Case 2: Exam On exam, pt has 5-10 <1cm pearly umbilicated papules behind his right ear. He also has multiple white cheesy papules on the palate coalescing into plaques

17 Case 2: Question 1 What is the patient s s likely diagnosis(es)? a. warts b. molluscum contagiosum c. oral candidiasis d. basal cell carcinoma

18 Case 2: Question 1 Answer: b,c What is the patient s s likely diagnosis(es)? a. warts b. molluscum contagiosum c. oral candidiasis d. basal cell carcinoma

19 Case 2: Question 2 What is the patient s s likely CD4 count? a. >500 b c. <200 d. <50

20 Case 2: Question 2 Answer: c What is the patient s s likely CD4 count? a. >500 b c. <200 d. <50

21 Dermatologic Manifestations CD4 <200 Molluscum contagiosum Bartonellosis (bacillary angiomatosis) Systemic fungal infection Mycobacterial infections Also, skin becomes hyperactive at this stage Eosinophilic folliculitis Granuloma annulare Drug reactions Photodermatitis

22 Case 3

23 Case 3: History 55 yo man is admitted with numerous crusted lesions all over his body and causing him significant pruritus PMH: HIV for the past 9 years All: none Meds: none FH: non-remarkable SH: lives with his brother who has also been itching but has not noticed any lesions ROS: negative

24 Case 3: Exam On exam, patient is noted to have diffuse burrows throughout his body. He also has large hyperkeratotic plaques with erosions and ulcerations most severe on his buttock and feet shown here

25 Case 3: Question 1 What is the most likely diagnosis? a. crusted scabies b. disseminated atopic dermatitis c. disseminated psoriasis d. disseminated herpes simplex

26 Case 3: Question 1 Answer: a What is the most likely diagnosis? a. crusted scabies b. disseminated atopic dermatitis (would not have burrows, unlikely to be as diffuse) c. disseminated psoriasis (would( not have burrows, more typically plaques with scale) d. disseminated herpes simplex (would not have burrows, more vesicular with less scale)

27 Case 3: Question 2 What is the patient s s likely CD4 count? a. >500 b c. <200 d. <50

28 Case 3: Question 2 Answer: d What is the patient s s likely CD4 count? a. >500 b c. <200 d. <50

29 Dermatologic Manifestations CD4 <50 Refractory molluscum contagiosum Chronic HSV Chronic varicella zoster Cutaneous acanthamebiasis Chronic atypical mycobacterial infections Crusted Scabies

30 Scabies Eruption that results in pruritic papules and burrows from the mite sacroptes scabiei Typically spares the face and head except in immunocompromised hosts In immunocompromised or neurologically impaired hosts it may become diffuse crusted scabies Similar but more diffuse papular eruption with hyperkeratosis

31 Scabies Distribution In crusted scabies, the head and face are involved as well as the rest of the body. The diagram to the left is a distribution of typical scabies. Diagnosis can be done by scraping on of the lesions and placing it in a KOH or oil preparation to visualize the mite.

32 Scabies Treatment In non-crusted scabies, permethrin 5% cream is rubbed into the skin and washed off hours later. This is repeated 1 week later Ivermectin 200mg/kg can be used in addition at 2 wk intervals for doses but when used alone it is less effective than topical treatment NOT SAFE IN BABIES OR DURING PREGNANCY For these patients, 6-10% 6 sulfur can be used for 3 nights Close contacts of any scabies patient should be treated particularly in the case of crusted scabies

33 Crusted Scabies Treatment Crusted scabies is far more difficult to treat as there are an incredibly large number of mites. Typically combination therapy is used in in crusted scabies Ivermectin 200mg/kg given every weeks up to 3-43 doses Permethrin once a week for 6 weeks Keratolytics and 40% urea for nail involvement Remember to CLEAN CLOTHING AND BED LINENS to avoid reinfestation!

34 Case 4

35 Case 4: History HPI: 48 year old man presents with purple spots on his body that he had not noticed before. They are not causing him pain or pruritus PMH: HIV+ for 12 years All: none Meds: none FH: non-remarkable SH: non-remarkable ROS: negative

36 Case 4: Exam On exam, the patient has scattered purple macules, plaques, and nodules of varying sizes and shapes, mainly found on the truck and face Nodule Macule Plaque

37 Case 4: Question 1 What is the most likely diagnosis? a. thrombotic thrombocytopenia purpura b. Kaposi s s sarcoma c. melanoma d. urticaria

38 Case 4: Question 1 Answer: b What is the most likely diagnosis? a. thrombotic thrombocytopenia purpura b. Kaposi s s sarcoma c. melanoma d. urticaria

39 Kaposi s s Sarcoma Kaposi s s sarcoma is a cutaneous malignancy which is found far more commonly in HIV+ individuals Manifestation in HIV+ patients is clinically different than in HIV- patients Caused by HHV-8 8 virus Clinically it presents with red or purple macules and progresses into purple plaques, tumors, nodules Most commonly found on the hard palate, trunk, penis, lower legs, soles Edema may be present with lower leg lesions

40 Kaposi s s Sarcoma Diagnosis is confirmed with skin biopsy and is used to differentiate Kaposi s s Sarcoma from other diagnoses

41 Kaposi s s Sarcoma Treatment depends on the stage in HIV related cases Mild to moderate disease with <50 lesions can usually be treated with 6 months of ARV therapy 50% resolution results from this treatment For individual lesions, vinblastine injection or cryotherapy is appropriate For systemic manifestations, systemic chemotherapy becomes necessary

42 Other Malignancy in HIV HIV+ patients have a higher incidence of basal cell carcinoma than non HIV- patients but the BCC behavior is the same Squamous cell carcinoma in sun exposed areas is more aggressive in HIV+ patients making COMPLETE resection important Melanoma prevalence is unknown but may be higher in HIV+ patients and behavior is more aggressive The progression of HPV to neoplasm is accelerated in HIV, including cervical, anal, and penile cancer Extranodal B cell and T cell lymphoma is associated with HIV immunosuppression

43 Case 4: Continued What if a patient instead presented with the following problem:

44 HIV associated Lipodystrophy This syndrome comprises of fat re-distribution with primary loss from the face and limbs and fat gain centrally including the neck and upper back buffalo hump Commonly seen in patients who are taking ARVs but otherwise doing well It is associated with hypertriglyceridemia, hypercholesterolemia, and insulin resistance Metformin mg bid and exercise may help reduce waist circumference Switching ARVs is sometimes helpful although not always practical. There have been associations with the use of D4T(stavudine) so many providers are switching to other medications.

45 HIV associated Lipodystrophy: : Treatment There are surgical treatments available using synthetic fillers, however these are rather expensive Currently there are two FDA approved temporary fillers that are used Poly-L-lactic lactic acid (PLLA or Sculptra) Injected into sites of lipodystrophy where the micropheres expand and stimulate collagen formation Many injections are given, separated by 4 or more weeks Calcium hydroxylapatite (Radiesse) Uses microspheres that act as a scaffolding for collagen growth

46 HIV associated Lipodystrophy This syndrome is very stigmatizing! Many patients are affected Treatment options are limited

47 END OF MODULE