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Home , Scabies

Didactic Series

Dermatologic Manifestations Associated with HIV/AIDS

Ankita Kadakia, MD UCSD Owen Clinic 12/11/2014

ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

1 Learning Objectives

1) Recognize common dermatologic manifestations associated with HIV 2) Understand diagnosis of dermatologic manifestations 3) Understand treatment modalities for dermatologic manifestations

2 HIV • Presenting sign of HIV infection is skin manifestations • HIV positive individuals due to defects in cell immunity are predisposed to certain bacterial, fungal, viral, and mycobacterial disease with skin manifestations • Skin diseases which are common in general population are exacerbated in HIV with increased prevalence

3 American Academy of Dermatology HIV Dermatology

• Infectious Dermatoses • Noninfectious Dermatoses • CD4 count

4 HIV Skin Manifestations by CD4

• CD4 < 50: Bacillary angiomatosis, Cryptococcus • CD4 < 150: Histoplasma • CD4 any count: mycobacterium, Kaposi’s sarcoma, HSV, Herpes Zoster, HPV

5 Infectious Dermatosis

6 Infectious Dermatosis

• • HPV • Cryptococcus • S.aureus • Histoplasma • HSV • Herpes Zoster • Tinea • Kaposi’s Sarcoma • • Bacillary Angiomatosis • Scabies •

7 Case 1

• 50 y homeless M, CD4 22, VL 48K, not on ARVS for several years, lives next to a dumpster where a pregnant cat has been living. Presents with weight loss, fever, and skin lesions present for 6 months.

8 What is this disease?

NeovascularBacillary Angiomatosis nodular lesions or Bartonellosiseither single or in clusters with a reddish or violacious color

Left: P. Volberding, MD, UCSF Center for HIV Information 9 Image Library Right: G. Beatty, MD; A. Lukusa, MD, HIV InSite

Bacillary Angiomatosis

• CD4 <50 • Bartonella henselae / Bartonella quintana • B.henselae associated with cats, cat scratch, and • B.quintana associated with crowded low income area and • Systemic lesions in Liver, spleen, bone, lymph nodes

10 Bacillary Angiomatosis

• B.henselae can cause Peliosis hepatica • Tissue biopsy shows lobular proliferation of small blood vessels, Warthrin Starry stain shows clusters of bacilli • Can isolate using PCR, blood culture • Doxycycline 100mg po BID • Erythromycin 500mg po QID( macrolides)

11 Bacillary Angiomatosis

• IV for bacteremia, endocarditis, bone • Four months or longer, may need chronic suppressive therapy • MAI prophlylaxis with Azithromycin appears to be protective against BA

12 Case 2

• 43 y MSM with HIV, CD4 250, not on ART for 1 year because he wanted to take a drug holiday presents with 2 months of R leg edema from thigh to foot and new skin lesions on his R heel.

13 What is this disease?

Similar in appearance to BA, slightly raised to nodular, redKaposi to violeceous’s Sarcoma color, can also be flat and more brown

14 http://visualsonline.cancer.gov Kaposi’s Sarcoma • Occurs at lower CD4 counts but can occur at ANY CD4 count • HHV-8 associated with all 4 forms • Higher prevalence in MSM regardless of HIV status • Cutaneous and systemic lesions including Lymphedema

15 Kaposi’s Sarcoma • Look similar to Bacillary Angiomatosis • Advanced disease lesions coalesce to form large plaques especially on upper thigh • MC visceral site is GI tract • Pulmonary involvement >50 lesions but can happen with little to minimal lesions, ominous sign

16 Kaposi’s Sarcoma

• ART can prevent / regress lesions • More extensive disease Heme/Onc consult for Chemotherapy • Radiation therapy for localized lesions • Avoid steroids

17 Case 3

• 22 y MSM, CD4 18, VL 5000, sexually active with multiple partners presents with diffuse small which initially appeared on his trunk but have spread to his axillae and face.

18 What is this disease?

2-5 mm painless flesh colored or pearly papulesMolluscum with umbilicated Contagiosum center usually in singles but can be grouped near each other

19 www.alphaderm.ca Molluscum Contagiosum

• Any CD4 count but worse with advanced AIDS • Poxvirus infects epidermal keratinocytes • Spread via skin to skin contact, contact with shavers, sex toys, contaminated towels/linens • Can be located in groin, trunk, axilla, face, more widespread in HIV

20 Molluscum Contagiosum

• Improves with ART but can be difficult to eradicate • Cryotherapy with liquid nitrogen • Local excision with curretage • Topical Imiquimod • Tretinoin • Trichloroacetic acid • Laser therapy 21 Case 4

• 55 y homeless M with CD4 11, taking his ART intermittently, has been living in a shelter for 3 weeks c/o of crusty pruritic skin which got worse after using hydrocortisone cream

22 What is this disease?

Scabies Norwegian (Crusted) Scabies

23 webmd.com Scabies • Can occur at any CD4 count • Scaly pruritic papules or hyperkeratotic plaques on palms, soles, trunk, extremities • Infestation with • Burrows between fingers and toes • Occurs in crowded areas, institutionalized, homeless • Skin scraping of burrow, skin biopsy

24 Scabies

• Superinfestation in Norwegian scabies occurs in advanced AIDS, MSM, HTLV co- infection • 5% cream once, can reapply after 14 days • Need to treat household contacts • 200 mcg/kg oral, at least 2 doses taken 7 days apart

25 Non-Infectious Dermatoses

26 Non-infectious Dermatoses

• • Eosinophilic • Seborrheic • • Xerosis • Prurigo nodularis • to bites

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28 Cedeno-Laurent et al. Journal of the International AIDS Society 2011, 14:5

Case 5

• 48 y M newly diagnosed with HIV, CD4 150, VL 76K, presents with 4 months of raised red pruritic lesions often with a pustule.

29 What is this disease?

Raised pruriticEosinophilic nodules with Folliculitis pustular head on erythematous base 30 Courtesy of Dr.Stephen Raffanti Eosinophilic Folliculitis

• Occurs at CD4 counts 250 or lower • Lesions look similar to bacterial folliculitis • Inflammatory condition and often diffuse • Skin biopsy: Intense infiltration of eosinophils around sebaceous glands/hair follicles, no PMNS or organisms • Peripheral eosinophilia

31 Eosinophilic Folliculitis

• Improves with ART • creams,oral for mild disease • Isotretinoin, Itraconazole, Phototherapy, moderate to severe disease

32 Case 6

• 48 y M newly diagnosed with HIV, CD4 275, c/o of stiffness of his knee joints and multiple scaly patches of skin covering his arms and trunk. He noticed a couple of patches 2 years ago when his HIV test was negative.

33 What disease is this?

Well circumscribedPsoriasis erythematous plaques with silver scaling 34 American Academy of Dermatology Psoriasis

• Any CD4 count • Worsening of psoriasis with HIV • Increase prevalence of psoriatic arthritis • Inverse psoriasis occurs in body folds, smooth shiny red lesions • Topical steroids, retinoids, vitamin D replacement not as effective in HIV • Responsive to ART

35 36 Cedeno-Laurent et al. Journal of the International AIDS Society 2011, 14:5

What is this disease?

Pearly flesh colored papules indicate disseminated Cryptococcusdisease 37 Courtesy of Dr.Stephen Raffanti What is this disease?

DermatomalHerpes pattern, Zoster can be multiple dermatomes, CD4 200-500, recurrent outbreaks 38 aidsetc.org What is this disease?

Rash is contagious (spirochetes), CanSecondary be more severe Syphilis in lower CD4 counts 39 hivguidelines.org References

• American Academy of Derm- HIV module • Mandel, Douglas and Bennet’s Principles and Practice of Infectious Disease ed.2011 • aidsetc.org • Cedano et.al, New Insights into HIV-1 Primary Skin Disorders; Journal of the International AIDS Society 2011, 14:5

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