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.

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.

Dermatologic Conditions according to Clinical Status

Seborrheic Dermatitis

Etiology	Findings/ Distribution	Diagnostic Clues	Management
See photo in DermAtlas.
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

Etiology	Findings/ Distribution	Diagnostic Clues	Management
*See Potential ARV Interactions, below.
Eosinophilic folliculitis (see photo in DermAtlas)	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 DermAtlas)	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 folliculitis	Erythematous 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 folliculitis	Papular lesions appear within 8-48 hours after exposure	Associated 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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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%).

Type	Findings/ Distribution	Diagnostic Clues	Management
* See Potential ARV Interactions, below, and Common Medications.
Distal subungual onychomycosis (see photo in DermAtlas) 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 distally	Same as above	Same as above
White superficial onychomycosis Trichophytonmentagrophytes most common	Starts as dull white spots, then spreads centrifugally	White areas are soft and can be scraped with a curette for culture or KOH slide	Same 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 yeast	Oral 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 infection	Consider when dermatophyte infection is ruled out	Oral 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)

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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 DermAtlas)

HPV-Associated Warts

(see photo in DermAtlas)

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

• Maurer TA. Dermatologic manifestations of HIV infection. Top HIV Med. 2005 Dec-2006 Jan;13(5):149-54.
• Maurer T, Leslie K. Common Skin Diseases in HIV-Infected Patients in the Antiretroviral Era. International AIDS Society - USA Resource Card 2007. Accessed November 20, 2008.
• Muñoz-Pérez MA, Rodriguez-Pichardo A, Camacho F, et al. Dermatological findings correlated with CD4 lymphocyte counts in a prospective 3 year study of 1161 patients with human immunodeficiency virus disease predominantly acquired through intravenous drug abuse. Br J Dermatol. 1998 Jul;139(1):33-9.