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Acne Is Not a Stigma of HIV Infection: A Review of 36 Patients

Article in Dermatology · February 2005 DOI: 10.1159/000086439 · Source: PubMed

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Dermatology 2005;211:114–117 Received: August 5, 2004 DOI: 10.1159/000086439 Accepted: November 12, 2004

Acne Is Not a Stigma of HIV Infection: A Review of 36 Patients

M. Almagro J. del Pozo J. García-Silva M. Pérez-García J. Rodríguez-Lozano S. Pértega E. Fonseca

Department of Dermatology, Juan Canalejo Hospital, La Coruña , Spain

Key Words oin. 85% of cases reported the onset of acne during Acne Acquired immunodefi ciency syndrome Human adolescence or before HIV infection and without any re- immunodefi ciency virus infection Follicular occlusion lationship with this disease. No relation between acne intensity and stage of HIV infection was observed. A mul- tivariate analysis showed that the most important vari- Abstract able was age. Discussion: In contrast to previous reports, Introduction: Several diseases with follicular occlusion no greater intensity or modifi cations in acne lesions have been described in HIV-infected patients and can ap- were observed in our HIV-infected patients during the pear isolated or associated with each other in an inde- course of the disease. In the majority of cases, cutaneous pendent disease named ‘HIV-associated follicular syn- lesions started before HIV infection, during adolescence, drome’. Worsening of cutaneous lesions during the and the most important factor for suffering from acne course of infection in patients with previous acne vul- was young age. In contrast to data reported in the litera- garis, late onset or severe forms of acne have been re- ture, no relation of acne lesions to CD4 lymphocyte count ported in HIV-infected patients. Patients and Methods: A or AIDS case criteria was found in our patients. Conclu- prospective study of 335 HIV-infected patients was per- sions: Acne in HIV-infected patients has characteristics formed in our hospital. A meticulous dermatological ex- similar to those in non-HIV-infected patients. The age is ploration in all patients was made, and multiple data the most important factor for the appearance of lesions were stored into a Microsoft Access 97 program. Patients that usually develop during adolescence. Acne lesions diagnosed as having acne were considered separately, are not modifi ed by HIV infection, and no relationship and we studied their characteristics. A statistical analysis with the severity of HIV infection has been observed. with SPSS 9.0 (Statistical Package for the Social Sci- Copyright © 2005 S. Karger AG, Basel ences) was performed. Results: Thirty-six patients (10.8%) were diagnosed as having acne. Papulopustular lesions were the most frequent clinical presentation. Introduction Most lesions were localized on the face or on the back, and 80% of patients had mild to moderate acne; 40% of Several dermatoses with follicular occlusion have been them required no treatment and the remainder was treat- described in HIV-infected patients, including acne vul- ed with topical measures, oral antibiotics and isotretin- garis, drug-induced acneiform eruptions, a special form

© 2005 S. Karger AG, Basel Manuel Almagro, MD 1018–8665/05/2112–0114$22.00/0 Servicio de Dermatología Fax +41 61 306 12 34 Hospital Juan Canalejo, Xubias de Arriba 84 E-Mail [email protected] Accessible online at: ES–15006 La Coruña (Spain) www.karger.com www.karger.com/drm E-Mail [email protected] of , lichen spinulosus and acne in- Table 1. Logistic regression models for the presence of acne in ac- versa ( suppurativa) [1–5]. These entities ap- cordance with different variants pear isolated or associated with each other in an indepen- Variable B SE p OR 95% RI dent disease named ‘HIV-associated follicular syndrome’ [6–8]. Moreover, worsening of cutaneous lesions during Adjusted for AIDS case, drug abusers and age the course of infection in patients with previous acne vul- AIDS case 0.333 0.367 0.363 0.716 0.348–1.470 garis, late onset or severe forms of acne and hidradenitis Drug abuser 1.051 0.518 0.042 2.862 1.036–7.906 suppurativa [9] have been reported in HIV-infected pa- Age 0.097 0.031 0.001 0.907 0.853–0.964 tients [10–13] . Adjusted for drug abusers, age and CD4 Furthermore, cases of lipodystrophy and insulin resis- Drug abuser 1.239 0.579 0.032 3.452 1.109–10.74 tance induced by highly active antiretroviral therapy with Age 0.093 0.033 0.005 0.911 0.853–0.972 CD4 0.000 0.001 0.607 1.000 0.999–1.002 polycystic ovarian syndrome as a cause of acne, and amenorrhea have been described [14] . B = Regression coeffi cient; SE = standard error; OR = odds ra- tio; RI = reliance interval; p = statistical signifi cance.

Patients and Methods

A prospective study of 335 HIV-infected patients was per- formed in our hospital between January 1997 and June 1999. A meticulous dermatological exploration in all patients was made, biotics (20%) and isotretinoin, 120 mg/kg (24%). Two and resulting data were stored into a Microsoft Access 97 program. patients were treated concomitantly with indinavir and Filiation, transmission route of HIV infection, data related to HIV isotretinoin, and they had intense retinoid cutaneous side infection, previous dermatological and general diseases, cutaneous effects like cheilitis or . diseases at the moment of the exploration and current therapies 85% of cases reported the onset of acne during adoles- were recovered. Seven patients were treated with protease inhibi- tors, and those treated with drugs which worsened acne were con- cence or before HIV infection and without any relation- sidered apart. ship with this disease, and only 4 cases (11.1%) had al- Patients diagnosed as having acne were considered separately, teration of cutaneous lesions during the course of HIV and we studied the clinical type, severity, localization, treatments, infection. Three of them had a cause for which acne wors- age onset and modifi cations during HIV infection and the associa- ening could be explained: 1 patient had previous Stevens- tion with other diseases characterized by follicular occlusion. Hi- dradenitis suppurativa was considered as a type of acne (acne in- Johnson syndrome, another presented prurigo-like le- versa), following the actual criteria [15] , although its characteristics sions accompanied with scratching signs and the remain- were evaluated independently. A statistical analysis with SPSS 9.0 ing patient was receiving treatment for pulmonary (Statistical Package for the Social Sciences) was performed. tuberculosis with isoniazide. In 1 case, we were not able to fi nd the cause of impairment of acne produced 15 days after the inclusion in the study. Results No relation between acne intensity and stage of HIV infection was observed. We compared the group of HIV- Thirty-six patients (10.8%) were diagnosed as having infected acne patients with the remaining HIV patients acne, and 8 (2.4%) had . If we of our series, and we observed that patients with acne consider the last disease as acne inversa, cases of acne were younger (p = 0.001), more frequently drug abusers were 42 (12.5%), due to 2 patients who had concomitant- (p = 0.019) and had a higher presence of tattoos (p = ly acne and hidradenitis. Papulopustular lesions were the 0.027). A multivariate analysis showed that the most rel- most frequent clinical presentation (47.2%), followed by evant variable to suffer from acne was age (table 1). nodulocystic (19.4%) and comedonic (13.8%) acne. The remaining 18.6% of patients presented excoriations, scars or acne worsened by drugs and external factors. Most le- Discussion sions (74.2%) were localized on the face or on the back, and 80% of patients had mild to moderate acne, while in In contrast to previous reports, no greater intensity or only 20% was it severe. 40% of cases did not require treat- modifi cations of acne lesions were observed in our HIV- ment, and the remainder were treated with topical mea- infected patients during the course of the disease. In the sures (antibiotics, benzoyl peroxide, retinoids), oral anti- majority of cases, cutaneous lesions started before HIV

Acne and HIV Infection Dermatology 2005;211:114–117 115 infection, during adolescence, and the most important those for the general population [20] . Response to treat- factor to have acne was young age. The elements of the ment was similar to that seen in non-HIV-infected pa- skin immune system have been involved in the develop- tients. Parallels are evident between adverse skin effects ment of acne lesions [15]. In contrast to data reported in in HIV-infected patients undergoing treatment with in- the literature [9–13], no relation of acne lesions to CD4 dinavir and those treated with isotretinoin [17, 18]. In lymphocyte count or AIDS case criteria was found in our patients treated with both drugs, side effects, predomi- patients. nantly mucocutaneous ones, resembled signs of retinoid In the comparative study between HIV-infected pa- toxicity, but plasma retinoid levels were lower after the tients with and without acne, signifi cant differences were onset of antiretroviral treatment than before [21] . only found in the mean age of the patients, the age they Hormonal problems related to HIV infection have had when HIV infection was detected, tattoo presence been reported, such as amenorrhea, dysmenorrhea, in- and the history of intravenous drug use in the greater part creased menstrual cycle intervals in women and hypotes- of the patients with acne. Given that tattoos are frequent- tosteronemia in men [22], but it has not been described ly seen among drug abusers and the age when the diagno- in acne patients with HIV infection; therefore, this factor sis is made depends, in part, on the patient’s age, we elim- has not been studied in our report. inated them from the multivariate study, where we found that age is the most predisposing factor for having acne, in a similar way to the general population [16] . Conclusions Patients with hidradenitis suppurativa could be in- cluded in the acne group, if we accept the actual concept (1) Acne in HIV-infected patients has similar charac- of acne inversa. It has been wrongly thought that the main teristics to that shown in non-HIV-infected patients. disorder in hidradenitis suppurativa was produced in the (2) The age is the most important factor in the appear- apocrine glands, but actually it is included as an acne va- ance of lesions that usually start during adolescence. riety because of the follicular occlusion, and the involve- (3) Acne lesions are not modifi ed by HIV infection, ment of the sweat glands is considered a secondary event. and no relationship with severity of HIV infection has The difference from acne vulgaris is the localization in been observed. the axilla, groin, anal and perigenital areas, on the but- tocks, nape and scalp [17, 18]. Although other entities, such as pityriasis rubra pilaris, lichen spinulosus and HIV-associated occlusion follicular syndrome, have been linked to HIV infection [2–8], we have not observed any such case, so we consider them rare diseases. There are many diseases that can present as itchy in HIV-infected patients and are re- lated to immunosuppression and/or immunorestoration [19]. Clinical manifestations may be heterogeneous rang- ing from eosinophilic folliculitis to bacterial folliculitis, fungal folliculitis and others. These entities can be clini- cally expressed as papular, pustular or urticariform le- sions predominantly on the trunk mimicking acne le- sions; in general, they are different because of the usual presentation of the last entity with polymorphous ele- ments in the way of comedos, , pustules, nodules or cysts. Also we have not found differences in the treatment of acne in HIV-infected patients. A wide range of them (40%) needed no treatment because of presenting low- grade acne, and, like other authors, we think that isotre- tinoin is an option that offers good results and suitable tolerance in these patients, with similar guidelines to

116 Dermatology 2005;211:114–117 Almagro et al.

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