HIV Dermatology

HIV Dermatology

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.

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

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

Case 1

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

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

Case 1: Labs

 Given the patient’s generalized
lymphadenopathy, a HIV serum antibody was
drawn

 The patient was found to be HIV+

Case 1: Question 1

 What is the patient’s likely CD4 count?
a. >500
b. 200-500
c. <200
d. <50

Case 1: Question 1

Answer: b
 What is the patient’s likely CD4 count?

a. >500
b. 200-500
c. <200
d. <50

Case 1: Explained

 The patient has a clinical exam and history
consistent with psoriasis which is associated
with a CD4 count of 200-500. He also has
“dandruff” consistent with seborrheic dermatitis

Dermatologic Manifestations CD4 200-500

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

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 200-500.

Case 2

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

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

Case 2: Question 1

 What is the patient’s likely diagnosis(es)?
a. warts
b. molluscum contagiosum
c. oral candidiasis
d. basal cell carcinoma

Case 2: Question 1

Answer: b,c
 What is the patient’s likely diagnosis(es)?

a. warts
b. molluscum contagiosum
c. oral candidiasis
d. basal cell carcinoma

Case 2: Question 2

 What is the patient’s likely CD4 count?
a. >500
b. 200-500
c. <200
d. <50

Case 2: Question 2

Answer: c
 What is the patient’s likely CD4 count?

a. >500
b. 200-500
c. <200
d. <50

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

Case 3

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

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

Case 3: Question 1

 What is the most likely diagnosis?
a. crusted scabies
b. disseminated atopic dermatitis
c. disseminated psoriasis
d. disseminated herpes simplex

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)

Case 3: Question 2

 What is the patient’s likely CD4 count?
a. >500
b. 200-500
c. <200
d. <50

Case 3: Question 2

Answer: d
 What is the patient’s likely CD4 count?

a. >500
b. 200-500
c. <200
d. <50

Dermatologic Manifestations CD4 <50

 Refractory molluscum contagiosum
 Chronic HSV
 Chronic varicella zoster
 Cutaneous acanthamebiasis
 Chronic atypical mycobacterial infections
 Crusted Scabies

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

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.

http://www.stanford.edu/class/humbio103/ParaSites2005/Scabies/SCABIES.html

Scabies Treatment

 In non-crusted scabies, permethrin 5% cream is rubbed into
the skin and washed off 8-10 hours later. This is repeated 1
week later

 Ivermectin 200mg/kg can be used in addition at 2 wk
intervals for 2-3 doses but when used alone it is less
effective than topical treatment
 NOT SAFE IN BABIES OR DURING PREGNANCY
 For these patients, 6-10% sulfur can be used for 3 nights

 Close contacts of any scabies patient should be
treated particularly in the case of crusted scabies

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 1-2 weeks up to 3-4
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!

Case 4

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

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

Case 4: Question 1

 What is the most likely diagnosis?
a. thrombotic thrombocytopenia purpura
b. Kaposi’s sarcoma
c. melanoma
d. urticaria

Case 4: Question 1

Answer: b
 What is the most likely diagnosis?

a. thrombotic thrombocytopenia purpura
b. Kaposi’s sarcoma
c. melanoma
d. urticaria

Kaposi’s Sarcoma

 Kaposi’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 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

Kaposi’s Sarcoma

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

Kaposi’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

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

Case 4: Continued

 What if a patient instead presented with the
following problem: