SKIN MANIFESTATIONS IN AIDS
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Transcript SKIN MANIFESTATIONS IN AIDS
SKIN MANIFESTATIONS IN
AIDS
Pornchai Chirachanakul M.D.
Bamrasnaradura Institute
Classification
Infection
Non-specific dermatitis
Neoplasm
Bacterial infection
Pyogenic diseases
Mycobacterial diseases
Nocardiosis
Bacillary angiomatosis
Pyogenic disease
Impetigo
Hemorrhagic ecthyma
Ecthyma gangrenosum
Folliculitis
Furuncle
Pyogenic disease
Abscess
Carbuncle
Cellulitis
Pyomyositis
Pyoderma
Secondary infection of scabies, eczematous
dermatitis & intravenous catheter site
Pyogenic diseases
-staphylococcus aureus*
-pseudomonas aeruginosa
Pathogenesis: -B-cell defect
-neutropenia
-defective chemotaxis of
neutrophil
Pathogen:
Pyogenic disease
Diagnosis:
clinical
features
Gram stain & culture
blood culture
skin biopsy
Treatment of pyogenic disease
(Staphylococcus aureus)
Semisynthetic penicillin
dicloxacillin,cloxacillin,oxacillin
First-generation cephalosporin
*Rifampicin 450-600 mg/d for 5-10 days
or topical mupirocin ointment
Treatment of pyogenic disease
(Pseudomonas aeruginosa)
debridement
compress with 5% acetic acid
oral ciprofloxacin
i.v.imipenem
Mycobacterium tuberculosis
Clinical features:
Neck
mass (necrotic enlarged lymph node)
Folliculitis-like lesion
Necrotic papules
Diagnosis:
Acid
fast staining of pus,skin,lymph node
skin biopsy
Culture & sensitivity test
Treatment of M. tuberculosis
Standard short course regimen:
2HRZE/4HR
for 6 months
Nocardiosis
Low incidence (0.2-1.8%)
Pathogen: Nocardia species
Nocardiosis
Clinical features:
fever
productive
hemoptysis
chest
pain
dyspnea
weight loss
cough
Nocardiosis
Clinical features:
subcutaneous
cellulitis
pustules
pyoderma
paronychia
ulcer
abscess
Nocardiosis
Diagnosis:
clinical
features
Gram stain
modified acid fast stain
culture
Nocardiosis
Treatment:
TMP-SMZ
(2.5-10 mg/kg of TMP) twice a day
Sulfadiazine 4-6 g/d
Ceftriaxone 2 g/d
Amikacin 1 g/d
Minocycline 200 mg/d
>6-12 months duration
Bacillary angiomatosis
Clinical features:
Elevated
friable bright red granulation tissue
like papules 1-1,000 lesions
Subcutaneous
nodules
Ulcerating tumor
Cellulitic plaque
Pathogen:
Bartonella
quintana (or B. henselae)
Bacillary angiomatosis
Diagnosis:
Histopathology:
-Warthin-Starry stain or
-modified Brown-Hopp’s stain
Culture: -brain heart infusion agar or
-trypticase soy agar with 5% sheep
blood
Treatment of Bacillary
angiomatosis
Erythromycin 250-500 mg qid for 6 weeks
or until lesions cleared
Doxycycline, minocycline, tetracycline
Co-trimoxazole
Rifampicin, isoniazid
Azithromycin, roxithromycin
Norfloxacin, ciprofloxacin
Viral infection
Herpes simplex virus infection
Varicella-Zoster virus infection
Cytomegalovirus infection
Epstein-Barr virus infection
Human papillomavirus infection
Poxvirus infection
Herpes simplex virus infection
Clinical features:
Deep seated (hemorrhagic) vesicles
Chronic ulcerative mucocutaneous lesion
Exophytic lesion
Ulcerated tumor like lesion
Herpes simplex virus infection
Diagnosis:
Clinical feature
Tzanck smear
Histopathology
Viral culture
Herpes simplex virus infection
Diagnosis:
Direct fluorescent Ab staining
Polymerase chain reaction
Electron microscopy
Treatment of HSV infection
Oral acyclovir 200-800 mg five times daily
I.V. acyclovir 5mg/kg/dose three times daily
I.V. trisodium phosphonoformate
(Foscarnet) 40mg/kg/dose two-three times
daily or cidofovir (ACV resistant mutant)
Treatment of HSV infection
Oral valaciclovir 1,000 mg two times daily
for 7-10 days
Oral famciclovir 250 mg three times daily
for 7-10 days
Varicella-Zoster virus infection
Varicella:
Clinical
features (Monomorphism)
# hemorrhagic infarcted vesicles
# clear vesicles
Herpes zoster:
Clinical
features
# groups of vesicles in dermatomal distribution
# ecthymatous crusted punch out ulcer
Varicella-Zoster virus infection
8-13% of HIV- infected patients had
previous history of herpes zoster
incidence is more than normal population 7
times
common in young adult (<60 years)
Varicella-Zoster virus infection
post-herpetic neuralgia is uncommon
may be disseminated infection
more skin necrosis
high risk cases have 73% positive anti-HIV
Ab
Varicella-Zoster virus infection
Diagnosis:
clinical features
Tzanck smears
Histopathology
Viral culture
Varicella-Zoster virus infection
Diagnosis:
Direct fluorescent Ab staining
Polymerase chain reaction
Electron microscopy
Varicella-Zoster virus infection
Treatment
Oral
acyclovir 800 mg five times daily for 7-10
days
Oral famciclovir 500 mg three times daily for 710 days
Oral valaciclovir 1,000 mg three times daily for
7-10 days
I.V. acyclovir 10 mg/kg/dose three times daily
Foscarnet (resistance to ACV)
Molluscum contagiosum
Incidence 10-20%
common at genitalia, face(periorbital
area),axilla,groin & buttock
่ may be larger than 1 cm.
CD4+ count <250 cells/cu.mm.
Diagnosis:
clinical
feature
Histopathology
Treatment of molluscum
contagiosum
Curettage
Electrocoaggulation
Cryosurgery
Carbon dioxide LASER vaporization
Treatment of molluscum
contagiosum
Topical wart agents
Topical retinoic acid
Highly active antiretroviral therapy
Cidofovir
5% Imiquimod cream
Systemic fungal infection
Penicilliosis
Cryptococcosis
Histoplasmosis
Penicilliosis
Pathogen: - Penicillium marneffei, a
dimorphic fungi
- endemic in Southeast Asia
Reservoirs: - bamboo rat
Penicilliosis
Clinical features: skin lesions ~ 71.2%
Molluscum-like
Crusted
papulonecrotic lesions
plaque
Pustulo-nodular lesions
Ulcer (oral or extraoral lesion)
Penicilliosis
Clinical features:
Erythema
nodosum-like lesions
Subcutaneous nodule (lymphadenopathy)
Illusion of vesiculation
Penicilliosis
Diagnosis:
Skin
scraping
Skin biopsy touch smear
Skin biopsy (histopathology)
Culture:-blood
sensitivity ~ 76%
-skin
sensitivity ~90%
-bone marrow sensitivity ~100%
Treatment of penicilliosis
Initial therapy:
Amphotericin-B
0.6-1.0 mg/kg/d (~2 weeks) &
follow with itraconazole 400 mg/d (~10 weeks)
Suppressive therapy:
Itraconazole
200 mg/d
HAART-induced penicilliosis
Pathogenesis:
restoration
of CD4+ and CD8+ T lymphocyte
may be cytokine-mediated reaction
HAART-induced penicilliosis
Clinical feature:
shiny
erythematous papulo-nodular plaques
non pruritic lesions
occur within the first 2 months after HAART
HAART-induced penicilliosis
Diagnosis:
history
of previous treated penicilliosis
history of HAART
skin biopsy (granulomatous dermatitis with
yeast cells)
skin culture for fungus
HAART-indued penicilliosis
Treatment:
Amphotericin
B or itraconazole
Short course systemic corticosteroid
Cryptococcosis
Pathogen: Cryptococcus neoformans
Clinical features: skin lesions ~ 10-20%
Molluscum-like
papulonecrotic lesion
Subcutaneous nodule
Oral nodule
Oral ulcer
Verrucous tumor
Localized cellulitis
Cryptococcosis
Diagnosis:
Skin
scraping
Skin biopsy touch smear
Histopathology
Culture: -skin
-CSF
-blood
Treatment of cryptococcosis
Initial therapy:
Amphotericin-B
0.6-1.0 mg/kg/d (~2 weeks) &
follow with fluconazole 400 mg/d (~10 weeks)
Suppressive therapy:
Fluconazole
200 mg/d
Itraconazole 200 mg/d
Histoplasmosis
Pathogen: Histoplasma capsulatum
Clinical features: skin lesions ~ 10-20%
exanthema-like
maculopapular eruption
molluscum-like papulonecrotic lesion
oral ulcer or oral mass
vegetative plaque
diffuse purpura
panniculitis
Histoplasmosis
Diagnosis:
Skin
scraping
Skin biopsy touch smear
Histopathology
Culture: -skin
-blood
-bone marrow
Treatment of histoplasmosis
Initial therapy:
Amphotericin-B
0.6-1.0 mg/kg/d (~ 2 weeks) &
follow with itraconazole 400 mg/d (~ 10 weeks)
or fluconazole 400 mg/d
Suppressive therapy:
Itraconazole
200 mg/d or
Fluconazole 200 mg/d
Crusted (Norwegian) scabies
Pathogen: Sarcoptes scabiei
Clinical features:
generalized
scaly hyperkeratotic nonpruritic
plaque(bark-like appearance)
subungual hyperkeratosis
psoriasiform dermatitis
Diagnosis: skin scraping
Treatment of crusted scabies
1% gamma benzene hexachloride
5% permethrin cream (lotion)
keratolytic agent (5%-6% salicylic acid
oint.)
oral ivermectin 200 microgram/kg as a
single dose (efficacy ~ 91 %)
Non-specific dermatitis
Pruritic papular eruption (PPE)
Seborrheic dermatitis
Psoriasis
Exfoliative dermatitis
Drug eruption
Prurigo nodularis
Miscellaneous skin diseases
Pruritic papular eruption (PPE)
chronic recall reaction to mosquito bite
excoriated hyperkeratotic hyperpigmented
papules at extremities & lower back
severe itch
refractory to treatment
Treatment of pruritic papular
eruption (PPE)
high potent topical corticosteroid
short course systemic corticosteroid
antihistamine (esp.oral doxepin HCl)
antibiotic( esp. excoriation)
UVB phototherapy or natural sunlight
systemic PUVA
Seborrheic dermatitis
greasy scaly erythematous patch
more severe in late stage of disease
refractory to treatment
Treatment of seborrheic
dermatitis
ketoconazole + hydrocortisone cream
clotrimazole cream
ketoconazole shampoo
selenium sulfide shampoo
zinc pyrithione shampoo
ciclopirox olamine shampoo
Psoriasis
Incidence ~ 5-13 % (normal ~ 1-2%)
more severity
multiple types of lesion
often occur with seborrheic dermatitis
secondary infection with candida albicans
or staphyllococcus aureus (esp. psoriatic
erythroderma)
Treatment of psoriasis
Acitretin 50-75mg/d
Low-dose MTX (should prophylaxis OI)
Cyclosporin
High-dose Zidovudine (1,200 mg/d)
Highly active antiretroviral therapy
Treatment of psoriasis
Topical tar & corticosteroid preparation
Topical calcipotriol preparation
UVB phototherapy
Narrow-band UVB phototherapy
Systemic PUVA
Exfoliative dermatitis
Etiology:
psoriasis
drug
reaction
cutaneous T-cell lymphoma
high grade non-Hodgkin’s lymphoma
unknown cause
Exfoliative dermatitis
Diagnosis: - skin biopsy
Treatment:- eliminate the causes
- if no causes, the drugs are
systemic corticosteroid
antihistamine
emollient cream
Drug eruption
Incidence: ~10 times of general population
Etiology:
multiple
drugs treatment
abnormal immune response
metabolic factor
Drug eruption
Common causative drugs:
sulfonamide (TMP-SMZ, sulfadiazine)
dapsone
anti-tuberculous drugs(INH, RFP)
ofloxacin
fluconazole
Drug eruption
Common causative drugs:
pentamidine
carbamazepine
foscarnet
nevirapine
efavirenz
indinavir
Drug eruption
Clinical feature:
Morbiliform
reaction
Fixed drug eruption
Urticaria
Photoallergic reaction
Drug eruption
Clinical feature:
Exfoliative
dermatitis
Hypersensitivity syndrome
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Treatment of drug eruption
Mild form:
offending
drug may be stopped
topical corticosteroid
antihistamine
Treatment of drug eruption
Severe form:
offending
drug must be stopped
short course high dose systemic corticosteroid
antihistamine
antibiotic if necessary
Prurigo nodularis
Etiology:
arthropod reaction (esp. Mosquito)
pre-existing HIV-associated pruritic
dermatosis
circulating pruritogenic factor
emotional stress
Prurigo nodularis
Etiology:
malabsorption & malnutrition
peripheral nerve infection with HIV
immunologic abnormality
Prurigo nodularis
Clinical features:
firm hyperkeratotic nodules & papules
only 1-2 or more than 100 nodules
crusting & excoriation
perilesional pigmentary alteration
symmetrical distribution
Prurigo nodularis
Diagnosis:
clinical features
skin biopsy (to exclude
pseudocarcinomatous inflammation in
cutaneous infection)
Prurigo nodularis
Treatment:
thalidomide 50-300 mg qid
high potent topical corticosteroid
antihistamine (e.g. doxepin, hydroxyzine)
Miscellaneous skin diseases
Recurrent Apthous Ulcer (RAU)
Xerostomia & exfoliative cheilitis
Pigmentary skin change
Patchy depapillation of the tongue
Xerosis
Miscellaneous skin disease
Chronic actinic dermatitis
Vitiligo
Alopecia areata
Necrotizing vasculitis
Recurrent apthous ulcer
CD4+ cell count: <50 cells/cu.mm.
Etiology:
- unknown
Diagnosis:
clinical
feature
ulcer smear
ulcer biopsy
Recurrent apthous ulcer
Differential diagnosis:
histoplasmosis
cryptococcosis
herpes
simplex virus
cytomegalovirus
mycobacterium avium complex
klebsiella pneumoniae
enterobacter cloacae
Recurrent apthous ulcer
Treatment:
thalidomide
50 -300 mg/d
topical steroid in orabase
intralesional injection of triamcinolone
colchicine 1.5 mg/d
prednisolone 30 -70 mg/d
G-CSF (neutropenic patient)
Xerostomia & exfoliative
cheilitis
Etiology: - salivary gland disease (parotid
gland
- pathology look like Sjogren’s
syndrome
Xerostomia & exfoliative
cheilitis
Treatment:
topical fluoride
topical glycerine
topical white petrolatum
HIV-related vasculitis
Incidence: low
Etiology:
drug-induced
hypersensitivity
infectious process (HIV,HBV,HCV & systemic
fungus)
immunological disorder
HIV-related vasculitis
Clinical features:
palpable
purpura
digital necrotic ulcers
swelling of hands & feet
arthralgia
fever
HIV-related vasculitis
Diagnosis:
clinical
features
histopathology
HIV-related vasculitis
Treatment:
bed
rest
antihistamine
NSAID
colchicine
avoid immunosuppressive agent
eliminate the etiologic agent
Chronic actinic dermatitis
Prevalence:
common
in men
younger than 60 years old
CD4+ cell count <200 cells/cu.mm.
Chronic actinic dermatitis
Pathogenesis:
reactive
photoproduct + endogenous carrier
protein
photohapten
photosensitivity
Chronic actinic dermatitis
Clinical features:
hypo
& hyperpigmented patches
lichenified plaques
fissures & erosions
confine to sun exposed areas
Chronic actinic dermatitis
Diagnosis:
clinical
features
phototest
decreased
MED of UVA & UVB
Chronic actinic dermatitis
Treatment:
avoid
sunlight
sunscreen
topical corticosteroid preparation
systemic antihistamine
HIV-associated eosinophilic
folliculitis
Pathogenesis:
follicular
hypersensitivity reaction to
Pityrosporum yeast,Demodex folliculorum or
Leptotricia bucalis
change in cellular immune homeostasis
HIV-associated eosinophilic
folliculitis
Clinical features:
common
in male patients
advanced stage of HIV infection
groups of edematous erythematous pruritic
follicular papules at face, upper trunk, arms &
(thighs)
HIV-associated eosinophilic
folliculitis
Diagnosis:
clinical
features
histopathology
peripheral blood eosinophilia (~ 35%)
elevated serum IgE
CD4+ cell count < 200 cells/cu.mm.
HIV-associated eosinophilic
folliculitis
Treatment:
metronidazole
250 mg t.i.d. for 3-4 weeks
itraconazole 200-300 mg/d for 4 weeks
isotretinoin 0.5-1.2 mg/kg/d
5% permethrin cream apply once a day for 4
weeks
HIV-associated eosinophilic
folliculitis
Treatment:
Prednisolone
60mg/d (tapered over1-2week)
or 60mg/d (one day/week)
UVB phototherapy
Systemic PUVA
Kaposi’s sarcoma (KS)
Classic KS
Endemic KS
KS in iatrogenically immunocompromised
patients
HIV-associated KS
HIV-associated KS
Epidemiology:
95%
in homosexual or bisexual men
low incidence in thailand
Etiology:
genetic
marker
immune dysregulation
retrovirus
HHV-8 (Human Herpes Virus-8)
HIV-associated KS
Clinical features:
common
at nose,eyelids & pinna
skin lesions may be numerous & disseminated
bleeding ulcers
symptom & sign of respiratory &
gastrointestinal tract
Diagnosis:
histopathology
& immunopathology
HIV-associated KS
Treatment:
simple
excision
Cryotherapy,
Radiotherapy
Carbondioxide or Argon LASER
Photodynamic therapy,Chemotherpy
Interferon alpha & beta
Highly active antiretroviral therapy
Merkel cell carcinoma
originate from cutaneous Merkel cell
(neuroendocrine cell)
no reported case until now
clinical features: - raised reddish blue
nodule
- occur at any site
Merkel cell carcinoma
Diagnosis:
histopathology
electron
microscopy (specific dense core
granule)
special stain
Treatment: - surgical excision
Prognosis: - poor
Lymphoma
Non-Hodgkin Lymphoma
Hodgkin’s disease
Cutaneous T-Cell Lymphoma (CTCL)
Cause of HIV-related Lymphoma
Polyclonal proliferation & lymph node
follicular hyperplasia
Chromosomal abnormalities
Epstein-Barr Virus (EBV) infection
Treatment of lymphoma
chemotherapy
immunostimulator
antiviral agent