HIV

Question 1

please, list examples of HIV-associated inflammatory dermatoses?

Answer 1

• acute exanthem of primary HIV infection: seen in ~50% of newly diagnosed patients with mono-like syndrome +/- ill defined, ASYMPTOMATIC erythematous maculopapules. usually occurs within 6 weeks of transmission.
• eosinophilic folliculitis: pruritic, erythematous, follicular-based papules on face, neck, trunk, and scalp
• aphthous stomatitis: may be seen on oral mucosal surface>esophageal surface>anogenital surface
• erythema elevated diutinum (EED): necrotizing vasculitis which may be a/w beta hemolytic strep. Tx: Dapsone. May also be a/w heme disease, HIV, Hep B, etc
• pruritic papular eruption: extensive, skin colored or hyperpigmented excoriated papules, often seen in patients with HIV in developing countries
• HIV photodermatitis: photodistributed rash, may be related to drugs, difficult to treat, Tx topical steroids and strict sun avoidance. Thalidomide in refractory cases!!

+/- seb derm, psoriasis, type 6 PRP

Question 2

please, list examples of HIV-associated infectious dermatoses?

Answer 2

• oral hairy leukoplakia: a/w EBV
• HSV: may be refractory to treatment if CD4 count is super low; may be verrucous known as “herpes vegetans” (Tx intralesional cidofovir)
• Herpes zoster: may present in atypical manner (think disseminated or multidermatomal)
• HPV: may see EV epidermodysplasia verruciformis-like lesions
• bacillary angiomatosis: opportunistic infx caused by bartonella hensae/quintana. Tx doxycycline, erythromycin
• molluscum contagiosum: tend to be on face and larger than normal. If tx resistant, use cidofovir
• CMV:often secondary to co-infection with HSV. If you treat HSV, then CMV should clear up, can colonize areas of HSV ulceration if CD4<50
• proximal white subungual onychomycosis **
• disseminated mycoses: cryptococcus neoformans, coccidiodes immitus, histoplasmosis capsulatum, penicillium marneffei

+/- crusted scabies, vaginal/oropharyngeal candidiasis

Question 3

please, list examples of HIV-associated skin cancers?

Answer 3

• BCC
• SCC: increased risk of recurrence even after treatment. increased risk if patient has HIV and HPV
• melanoma
• kaposi sarcoma: usually involves the oral mucosa or genitalia in HIV+ patients, may even occur in well controlled patients. Tx: resume antiretrovirals, intralesional chemo, radiation, LN2, excision, topical retinoids

Question 4

please, list examples of ART-associated dermatoses?

Answer 4

• IRIS immune reconstitution inflammatory syndrome: inflammatory response to pre-existing antigen that develops soon after initiation of ART in the setting of decreasing viral load +/- increase in CD4 counts. usually occurs 2 weeks-3 months after initiation of ART therapy. do NOT stop ART therapy due to IRIS, symptoms resolve within a few months
• antiretroviral associated lipodystrophy: seen < 2 years of start therapy. caused by PI (-vir) and NRTI (-vudine, abacavir, didanosine, emtricitabine). Tx fillers, poly-L-lactic acid (sculptra) and calcium hydroxylapatite (radiesse)
• pigmentary alteration: caused by zidovudine (NRTI) which leads to nail discoloration
• morbilliform exanthem: caused by NRTI. Tends to be self-limiting so don’t need to d/c med
• DIHS/DRESS: caused by abacavir***(PI), Bactrim, and dapsone. abacavir caused by HLAB5701
• retinoid like effects: caused by PI (indinavir). presents with xerosis, alopecia, cheilitis, periungual pyogenic granulomas
• injection site reactions: caused by enfuvirtide*** (fusion inhibitor)

note: Protease inhibitors (PI) all end in -vir
note: NRTI (-vudine, abacavir, didanosine, emtricitabine).