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Dermatologic Conditions and HIV

for Health Care Providers

Dermatologic Conditions

This chapter will focus on the diagnosis and treatment of some of the most common dermatological diseases in HIV-infected adults: seborrheic dermatitis, folliculitis, onychomycosis, psoriasis, and HPV-associated warts.

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Key Points

  • Immunologic status strongly influences the incidence and clinical presentation of many dermatologic conditions.
  • At CD4 counts of <50 cells/µL, patterns in skin findings can become atypical and bizarre.
  • In the absence of effective ART, up to 40% of HIV-infected patients and 80% of those with AIDS have seborrheic dermatitis; this condition usually improves with ART.
  • Eosinophilic folliculitis is seen more commonly in patients with CD4 counts of <200 cells/µL, and during immune reconstitution. It usually improves after 6 months on ART.
  • Staphylococcal folliculitis is seen more commonly in patients with CD4 counts of <200 cells/µL. Presumptive treatment should include coverage for MRSA.
  • Onychomycosis should be confirmed by KOH preparations of nail clippings before treatment. Oral antifungals interact with many ARVs; consult dosing information before prescribing.
  • Psoriasis can be severe (>50% of the body surface area) in patients with CD4 counts of <200 cells/µL, particularly those not on effective ART.
  • HPV-associated warts are difficult to treat, require multiple treatments, and may recur despite immune reconstitution with ARVs.

Background

Epidemiology

  • Dermatological diseases are common among HIV-infected persons.
  • In one large population study, 69% of HIV-infected patients had cutaneous disease.
  • Seborrheic dermatitis is the most common dermatologic diagnosis.
  • At CD4 counts of <50 cells/µL, patterns in skin findings can be atypical and bizarre.
  • Skin findings may represent opportunistic infections or other illnesses.

Veterans with HIV*

Number of visits to dermatology clinic: 7,098

*Veterans in the VA HIV Clinical Case Registry in care in 2007

Dermatologic Conditions according to Clinical Status

Clinical StatusAssociated Dermatological Diseases

(Print table)

Most common at CD4 counts of <200 cells/µL in patients who are not on effective ART
  • Severe psoriasis (>50% body)
  • Extreme photodermatitis
  • Prurigo nodularis
  • Molluscum contagiosum (see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)
  • Adverse drug reactions
  • Mycobacteria: tuberculosis, kansasii, MAC
  • Fungal infections (eg, cryptococcus, aspergillosis)
  • Herpes zoster
  • Eosinophilic folliculitis
  • Bacillary angiomatosis (Bartonella)
  • Kaposi sarcoma
  • Lichenification
  • Diffuse seborrheic dermatitis
May occur at any CD4 count despite ART
  • Eczema
  • Xerosis
  • HPV-associated warts
  • Kaposi sarcoma (less common at higher CD4 count and with ART)
  • Staphylococcal and streptococcal skin infections
  • Drug reactions
May emerge or worsen with immune reconstitution on ART
  • Acne
  • Erythema nodosum
Associated with HIV/HCV coinfection
  • Lichen planus
  • Xerosis
  • Leukocytoclastic vasculitis
  • Pruritus without apparent rash

Seborrheic Dermatitis

EtiologyFindings/ DistributionDiagnostic CluesManagement
See photo in DermAtlas.Link will take you outside the VA website. VA is not responsible for the content of the linked site.
May be related to skin-surface yeasts (Malassezia furfur) and environmental factors Erythematous scaly plaques on the central face, scalp, behind ears

Can be pruritic

Can affect sternum, axillae, and genital region
More severe, atypical, and diffuse in patients with low CD4 count nadirs

Common in patients who are not on ART: up to 40% of HIV-infected patients and 80% of AIDS patients have seborrheic dermatitis

Should improve with immune reconstitution on ART
Hydrocortisone 1% ointment mixed with ketoconazole or econazole applied BID to affected area

If very itchy: triamcinolone 0.5% ointment in nonfacial areas

Scalp: ketoconazole, tar (T-Gel), selenium sulfide (Selsun), or zinc pyrithione (eg, Head & Shoulders) shampoo twice weekly; leave lather on for 5 minutes before rinsing

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Folliculitis

EtiologyFindings/ DistributionDiagnostic CluesManagement
*See Potential ARV Interactions, below.
Eosinophilic folliculitis (see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)Numerous, extremely itchy pustules on the face, neck, scalp, and trunk Mainly seen in patients with CD4 counts of <200 cells/µL

Can be seen during immune reconstitution in the first 3-6 months on ART

Very pruritic, especially on face
Itraconazole* 200-400 mg daily (for anti-eosinophilic effect)

Permethrin 5% can be used every other day from the waist up (for drying effect)

Should resolve after 6 months on ART
Pityrosporum folliculitis (see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)Erythematous papules and tiny pustules along hair follicles Looks like a milder version of bacterial folliculitis with much smaller lesions

Lesions are smaller and less pruritic than eosinophilic folliculitis

Commonly excoriated

Less likely to form large pustules

Overgrowth of tinea

Ketoconazole* 200 mg PO QD for 3 weeks

Follow with maintenance therapy using ketoconazole 2% shampoo twice weekly
Staphylococcus folliculitisErythematous papules and pustules along hair follicles Often excoriated

Often draining pus

Presents as an erythematous flare

MRSA common; consider culture to guide treatment
Presumptive treatment for MRSA:

  • TMP-SMX DS BID, or doxycycline 100 mg BID, treat for 10-14 days
  • If severe, IV antibiotics. Consider vancomycin or clindamycin
  • Nares should be treated with intranasal mupirocin QHS for 5 days
If confirmed MSSA:

  • dicloxacillin or cephalexin
Pseudomonal folliculitisPapular lesions appear within 8-48 hours after exposureAssociated with use of hot tub and wet suit/swimwear (lesions may be concentrated in areas covered by swimwear)

In immunocompetent persons, self-limited to 7-14 days
For immunosuppressed persons or those with prolonged or severe cases, consider treating with ciprofloxation for 10 days

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Be sure to differentiate folliculitis and acne.
  • Acne presents with red papules and pustules on face, neck, arms, and back.
  • It is associated with exogenous testosterone and other systemic steroids, isoniazid, lithium, and antiseizure medications.
  • Management: Stop the offending drug, if possible.
  • Treat cystic acne with tetracycline, doxycycline, or minocycline. If severe and unresponsive to these antibiotics, consider isotretinoin. Because of its toxicity and teratogenicity, isotretinoin use is restricted in the United States; see VA Criteria for Use.

Onychomycosis

  • Refers to invasion of nails by dermatophytes (tinea unguium; with 3 subtypes), yeast, or molds.
  • Dermatophytes cause more toenail infections, yeast cause more fingernail infections, and molds cause <10% of toenail infections.
  • Prevalence in the general population is approximately 8%.
  • Increased prevalence among patients with HIV infection, with more severe disease if CD4 count is <400 cells/µL.
  • Thought to be the cause of 50-60% of abnormal-looking nails.
  • Differential diagnosis includes psoriasis, eczematous conditions, senile ischemia, trauma, and lichen planus.
  • Poor response to treatment: Before starting treatment, inform patients about high rates of treatment failure (25-50%) and recurrence (20-50%).
TypeFindings/ DistributionDiagnostic CluesManagement
* See Potential ARV Interactions, below, and Common Medications.
Distal subungual onychomycosis (see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)

Infection with Trichophyton rubrum in vast majority of cases

Affects great toe first; can affect all toes

Begins with discoloration of distal corner of nail, spreads across nail, then extends toward cuticle

Distal nail plate can break off, becoming heaped and irregular

Culture: most sensitive and specific

KOH preparation: clip or file nail-plate and collect scales from most proximal area

Look for hyphae and arthrospores

Low sensitivity and specificity, but up to 100% sensitive if >2 preparations examined

If negative, consider biopsy for histopathology

Indications for treatment: cellulitis, pain, patient desire for treatment

Oral therapies* (in order of decreasing efficacy), pulse dosing:

  • Terbinafine 250 mg QD for 1 week each month
  • Itraconazole 200 mg QD for 1 week each month
  • Fluconazole 150 mg once weekly
Treat 2 months (fingernails), 3-4 months (toenails)

Fluconazole 400 mg once weekly for 6 months has shown efficacy in immunocompromised patients; fluconazole has fewer drug interactions than itraconazole

Cure rates range from 76% with terbinafine to 48% with fluconazole

Topical therapies generally ineffective; ciclopirox topical nail lacquer can be used with patients who cannot safely take oral therapy; trials show 7% cure rate

Surgery: removal of nail in isolated nail infection or dermatophytoma

See Potential ARV Interactions, below, and Common Medications.

Proximal subungual onychomycosis

Trichophyton rubrum most common

Marker of HIV infection, immunocompromised state

Discoloration begins at cuticle and extends distallySame as aboveSame as above
White superficial onychomycosis

Trichophytonmentagrophytes most common

Starts as dull white spots, then spreads centrifugallyWhite areas are soft and can be scraped with a curette for culture or KOH slideSame as above
Candida onychomycosis

Candida albicans

More common in patients with HIV infection

Common cause of fingernail infection

Often in previously damaged nails

Rarely in toenails

Nail thickening and discoloration

Can lead to onycholysis

Fingernail scraping should be sent for culture of yeastOral therapies (in order of decreasing efficacy), pulse dosing:

  • Itraconazole 200 mg QD for 1 week each month
  • Terbinafine 250 mg QD for 1 week each month
Treat 2 months (fingernails), 3 months (toenails)

Mold (eg, Aspergillus, Scopulariopsis)Rare cause of toenail infectionConsider when dermatophyte infection is ruled outOral therapies (in order of decreasing efficacy), pulse dosing:

  • Itraconazole 200 mg QD for 1 week each month
  • Terbinafine 250 mg QD for 1 week each month
Treat 2 months (fingernails), 3 months (toenails)

Print table

Antifungal safety monitoring:

Terbinafine, itraconazole, and fluconazole can cause hepatotoxicity.

  • Obtain pretreatment liver function values.
  • Monitor the development of hepatic symptoms.
  • Monitor liver function in patients with underlying liver disease.

Potential ARV Interactions

Pharmacokinetic interactions between many ARVs (PIs, NNRTIs, and maraviroc) and antifungal medications may significantly affect serum levels of the ARV or the antifungal medication. Some of these require dosage adjustment or careful monitoring, and some combinations are contraindicated. See Common Medications for further information.

Psoriasis

(see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)

EtiologyFindings/ DistributionDiagnostic CluesManagement
Activation of lymphocytes causes shortened epidermal life cycle (10 times shorter than normal), leading to epidermal hyperproliferationSilvery scales on red plaques

More common on extensor surfaces

In HIV infection, can have unusual distribution, such as inverse psoriasis on palms and on soles of feet

More severe and more difficult to treat in patients with low CD4 cell counts

Patients with CD4 counts of <200 cells/µL not on ART can have lesions on >50% of body

May see unusual presentations of inverse and diffuse psoriasis

Biopsy shows epidermal hyperplasia, parakeratosis, neutrophils, diminished granulosum layer

Clobetasol 0.05% ointment BID

OR

Calcipotriene topical 0.005% ointment BID

Ultraviolet light; narrowband UVB

Narrowband UVB and acitretin is more effective than acitretin monotherapy

Acitretin 10-25 mg daily; avoid during pregnancy; can cause dyslipidemia

Interactions: acitretin + tetracycline carries risk of pseudotumor cerebri; avoid combination

In cases of extensive psoriasis, consider initiating ART (or maximizing efficacy of ART)

Severe life-threatening psoriasis (pustular psoriasis or erythrodermic disease) requires expert consultation

Topical steroid relative potency (1 = least potent; 10 = most potent)

14710
Hydrocortisone 1% cream/lotion/ointmentTriamcinolone (TAC) 0.1% cream/ointment

Alclometasone 0.05% cream/ointment

Desonide 0.05% cream/lotion/ ointment

Fluocinonide (Lidex) 0.05% cream/gel/lotion/ ointmentClobetasol 0.05% cream/gel/ointment/ solution

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HPV-Associated Warts

(see photo in DermAtlasLink will take you outside the VA website. VA is not responsible for the content of the linked site.)

EtiologyFindings/ DistributionDiagnostic CluesManagement
Human papillomavirus; most common subtypes 6, 11; also associated with dysplastic subtypes 16, 18, 31, 33, 35

Worse and more difficult to treat in patients with low CD4 nadirs

Condyloma acuminata: soft, skin-colored fleshy warts

Perianal lesions can be rough and cauliflower-like

In and around genitalia and anus, around mouth, palmar surface of hands, on feet

Can recur despite effective ARTCan recede on their own in 3 months with or without ART

Start with liquid nitrogen (10-second bursts with 30-second thaw), podophyllin (for genital warts), or paring (for large lesions) every 3 weeks for 12 sessions

Patients can be instructed to use duct tape and other exfoliative techniques at home between office treatment sessions (eg, for lesions on the extremities, apply duct tape nightly and pull off during the day; use pumice stone daily to sand down lesions)

For genital warts, may add imiquimod if initial treatment is not effective

Consider laser treatment, surgical excision (and send for pathology)

Repeat treatments are usually required

Can recur after any of the treatment modalities; none is 100% effective

For anal lesions, see Anal Dysplasia

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Glossary of Dermatologic Descriptors

Primary Lesions

Macule: circumscribed area of skin, up to 1 cm in diameter, with a change from normal skin color, which is neither raised above nor depressed below the surrounding skin. Many use the term for lesions much larger than 1 cm. Term does not include purpura.

Patch: a flat, circumscribed, discoloration of skin or mucous membrane >1 cm in diameter.

Papule: discrete solid area of skin that is elevated by palpation above the surrounding skin and<1 cm in diameter. Variations include accuminate, keratotic, flat-topped, follicular, umbilicated, pedunculated, and necrotic.

Plaque: similar to a papule but >1 cm in diameter. Often formed by the confluence or coalescence of papules. Secondary features may include, among others, atrophy, lichenification, and hyperkeratosis.

Nodule: discrete, solid, palpable, round or oval (ellipsoidal) lesion of the skin measuring ≤1 cm in diameter (or long axis). Applies to processes involving any or all levels of the skin, and is a general term for any mass, benign or malignant.

Tumor: a term used by some for a "nodule" >1 cm in diameter. Applies to processes involving any or all levels of the skin, and is a general term for any mass, benign or malignant.

Vesicle: a circumscribed fluid-filled lesion <1 cm in diameter that usually is elevated above the surrounding skin. May be described as solitary, grouped, umbilicated, dyshidrotic, spongiotic, multilocular, or unilocular.

Bulla: a circumscribed fluid-filled lesion >1 cm in diameter that usually is elevated above the surrounding skin. May attain diameters of several cm and are described as tense or flaccid.

Pustule: discrete elevated vesicle or bulla of skin, usually small, containing purulent exudate composed of inflammatory leukocytes (pus), with or without cellular debris. May be superficial, deep-seated, follicular, grouped, etc, and may arise secondarily from a vesicle.

Wheal: an evanescent, round or irregular, often flat-topped elevation of skin with a pale red color, arising from edema in the superficial dermis. May vary from 2-3 mm to 10 or more cm in diameter, with round or arcuate configurations. Should be distinguished from angioedema, a massive edema involving the entire dermis and subcutaneous tissues.

Secondary Lesions

Scar: a hard plaque of dense fibrotic tissue covered by a thin epidermis. A mark of injury from any sort of process (physical or pathologic).

Atrophy: usually refers to thinning of the epidermis leaving an easily wrinkled or shiny surface. Atrophy also may apply to thinning of dermal or subcutaneous tissue, with or without changes in the epidermis.

Ulcer: loss of skin tissue or substance from the surface downward, leaving an uncovered or denuded wound that is slow to heal.

Erosion: a superficial denudation of the skin, usually implying the loss of the epidermis.

Fissure: a vertical splitting or separation of the skin.

Crust: dried surface fluid, often serous (inspissated serum), with or without tissue debris; includes the term "scab."

Excoriation: a scratch mark, often with denudation of the skin to form a small ulcer. Exposure of the corium by mechanical removal of the epidermis.

Scale: a thin flake of epithelium (mostly composed of corneocytes) that is separated from the underlying intact skin proper.

Lichenification: a thickening of the skin surface and an increase of skin markings, usually seen with chronic coalescence of papular lesions, especially atopic eczema.

Vegetating: a lushly growing, proliferating process, usually with elevated or exophytic features.

Linear/Figurate: technically not secondary features, but included here for convenience. These are configurations that skin lesions may assume, and the descriptors aid in their diagnostic identification. Figurate includes geometrical shapes (eg, annular, arciform, cyclic).

References