Common Cutaneous Complications of HIV Disease Jeffrey S. Roth, MD, PhD Instructor, Department of , Columbia University College of Physicians and Surgeons Clinical Instructor, Department of Dermatology, Mount Sinai School of Medicine Summary by Theo Smart; Robert Warner, MD; and James Braun, DO

rom to scabies to malignan- Warts cies, skin disorders “are more The most common skin com- common and more aggressive in plaint of HIV-positive patients is F HIV-positive patients than others,” warts. These dull-colored pa- Dr. Jeffrey Roth told members of PRN. Dr. pules erupt anywhere on the Roth presented a slide-show overview on skin, including the anal mucous the clinical manifestation and diagnosis of membrane, vagina, , pe- the cutaneous complications of HIV dis- nis and mouth. Their appear- ease (several of these slides are reproduced ance, size and number vary with over the next few pages). At the same meet- the site. Warts can range in size ing, Dr. Charles Farthing reviewed the der- from less than 1 mm to 1-2 cm matologic procedures most useful for pri- “cauliflower lesions.” mary-care providers working with HIV-pos- The smaller lesions often itive patients (see page 11). can be treated locally with podophillum resin of varying Warts are dull-colored that erupt anywhere on the skin, including the anal mucous strengths, trichlorocetic acid, membrane, vagina, scrotum, penis and mouth and/or liquid nitrogen. Larger le- sions generally require surgical debridement or excision, at least as a first pillomavirus (HPV), warts are grouped by step. Lasers have been used, even though it is subtype: strains 6 and 11; 16 and 18; or 31, unclear whether they represent an advance 33, and 35. The three groups differ from over other physically destructive modalities. one another in oncogenic potential. The Two other treatments, Condylox topical so- oncogenic strains, particularly 16 and 18, are lution (podofilox 0.5%) and Aldara cream probably the major cause of cervical carci- (imiquimod 5%) can be used at home, as noma in women and rectal carcinoma in can 5FU. The success with these modalities both men and women. “Biopsying provides appears to be more limited, especially in pa- useful information in terms of patient man- tients with more advanced immunosuppres- agement and assessing the danger for the pa- sion. “Warts can be difficult to eradicate in tient’s sex partner,” said Dr. Roth. Above HIV-positive people, and the larger and more all, a biopsy is necessary to make certain that multiple the warts, the worse the prognosis what looks like a is a wart—and not a for ultimate eradication. This seems to be a squamous cell carcinoma with metastatic special defect in immune competence.” potential. Such carcinomas are sometimes Dr. Roth recommends biopsying most mislabeled as multiply resistant, or recalci- Warts are the most common skin warts—particularly when multiple or very trant, warts, and in a worst-case scenario if complaint of HIV-positive patients large—on initial presentation to determine untreated on the penis, amputation may their cancer risk. Caused by the human pa- eventually be required.

THE PRN NOTEBOOK™ • VOLUME 2, NUMBER 4 • AUGUST 1997 7 actually cryptococcus,” he said. he said. Though its effects are only tempo- “Cryptococcus is much, much more rary, ultraviolet B radiation has proved use- unusual.” Cases of severely resistant ful, as has Accutane, an anti- retinoid molluscum, unusual lesions or cases that makes the chemical environment of in which systemic signs are present the sebaceous gland less hospitable to the should be biopsied with appropriate microorganism. stains to rule out cryptococcosis.

Seborrheic , and Tinea The “itchy, red bumps” HIV-positive Seborrheic dermatitis, psoriasis and tinea patients bewail are likely the swollen are often confused with one another. Seb- papules of folliculitis, which can ap- orrheic dermatitis is another condition that pear anywhere on the skin. Dr. Roth appears to occur more frequently in HIV may be very widely considers the condition’s usual disease. Characterized by and distributed, especially on the face and neck. name—eosinophilic folliculitis—in- rounded, itchy, scaly plaques on the scalp, Papules tend to be dome-shaped and to accurate; he prefers atypical folli- the face and occasionally the chest and have a certain translucence culitis, since it can have a variety of groin, seborrheic dermatitis is thought to be causes. “If you biopsy the folliculitis, caused by a reaction to you may find no distinguishing features fungi in hair follicles. It is usually a chron- Molluscum Contagiosum whatsoever,” he explained. “On occasion ic condition that can be controlled with hy- Molluscum contagiosum is almost as preva- you will find an overgrowth of pityrospo- drocortisone or ketoconazole cream. lent as warts. In people with AIDS, mol- rum-type yeasts, Demodex or other Psoriasis also produces erythema and luscum may be very widely distributed, es- microorganisms. I suspect that many cases plaques that can occur in any location. pecially on the face and neck, and much of atypical folliculitis represent a hyper- These plaques, which tend to be covered more difficult to control. Molluscum can sensitivity reaction to normal microscopic with silvery scales, typically do not be distinguished from warts by several fea- residents of .” Accordingly, he and may, in fact, bleed when scratched. tures. Molluscum papules tend to be dome- recommends that therapy target the prob- But beware: Psoriasis is not exclusively a shaped and to have a certain translucence. In lem-causing microorganism. “Eurax (cro- cosmetic problem. It can cause arthritis in better-developed lesions, there is often an tamiton) works well in some cases, anti- the joints and extremely debilitating lesions umbilication. Histologically, the papules fungals or Flagyl (metronidazole) in others,” on the hand or foot. Traditional therapies do contain protein and viral particles known not work very well in HIV-positive patients, as molluscum bodies. Unlike warts, mol- and topical steroids lose their effectiveness luscum, which are caused by a pox , do quickly. Some success has been reported not occur in the mouth or anorectal mucosa with etretinate (Tegison), a relative of Ac- and have no known oncogenic potential. cutane, or PUVA (ultraviolet A light after Like warts, molluscum may spread and pretreatment with psoralen). Dovonex can be transmitted to other people through cream (calcipotriene 0.005%) has had suc- direct contact. Dr. Roth reported seeing cess, especially in intretriginous and geni- “many cases of multiple warts and mollus- tal psoriasis. Tazarotene gel, a new retinoid, cum spread through razor blades. I tell pa- is another potential treatment for HIV-as- tients that if they are going to shave their sociated psoriasis. bodies, use a different razor from the one Tinea tend to have an advancing edge, or they use for their face. I advise a patient to “active border,” with central clearing. Scrap- use an electric razor or to change his razor ings are positive on KOH examination. every time he shaves, or if he can’t do that, Tinea may be treated with topical antifun- to clean the razor in alcohol, hydrogen per- gals, but in more severe cases oral antifun- oxide or some other disinfectant solution, or gals may be needed as well. under hot water. Otherwise, this practice problems—particularly psoriasis can quickly lead to a carpet of molluscum or and fungal infections—trouble many pa- warts in the pubic area or on the face.” He tients with HIV. Psoriasis may cause pits further cautioned that a condition called cu- in, or complete dystrophy of, the nail—a taneous cryptococcus may be mistaken for notable diagnostic characteristic when the molluscum. Early cryptococcus lesions may skin findings are equivocal on KOH exam. present as dome-shaped papules with um- Atypical folliculitis may represent a Fungal-infection scrapings from these nails bilication, although as they advance, more hypersensitivity reaction to normal would be positive. However, because a trau- necrotizing features become evident. “Don’t microscopic residents of human skin matized nail is more vulnerable to fungi be afraid that every molluscum you see is than one intact, psoriatic nails are often co-

8 THE PRN NOTEBOOK™ • VOLUME 2, NUMBER 4 • AUGUST 1997 infected with tinea, yeasts or aspergillus. HSV antibodies do not reliably distinguish This may be demonstrated by culture. between types 1 and 2. Since HSV-1 in- fection is endemic in the North American population, this is likely to contribute little. Scabies HSV IgM levels may help in culture-nega- The can erupt on the tive, otherwise confusing cases. Dr. Roth wrists, folds of the skin, webs between the said that a Tzanck smear is usually reli- fingers and even, in people with HIV, on the able in experienced hands. face or scalp. Its itchy, red papules are some- In contrast to , zoster is times mistaken for folliculitis, but the pa- dermatomal. Although it is widely believed tient’s foremost complaint will be itchiness. that the vesicles of zoster are larger than Visual cues that can help the clinician iden- herpes,’ Dr. Roth contends that is not al- tify scabies are the linear furrows interspersed ways the case. Zoster’s dermatomal pattern with papules (see photo on page 14). There may be so vague as to make diagnosis dif- can also be a vesicular component secondary ficult, but this, too, he says, is unusual. Pro- to a hypersensitivity reaction. A more severe dermal pain following a dermatomal pat- variant, Norwegian scabies, properly termed tern can be an important diagnostic clue hyperkeratotic scabies, forms large crusted before or during the earliest stages of vesic- plaques that may resemble psoriasis. Large crusted plaques caused by ulation. Chronic zoster may present as hy- An immune-competent individual hosts, Norwegian scabies can be confused perkeratotic dermatomal nodules. on average, ten to 20 scabies-causing mites. with psoriasis. A zoster infection is considered “dissem- “The two live in a sort of immunologically inated” when it contains more than 20 non- mediated harmony,” Dr. Roth said. “But in dermatomal lesions or involves the eye. A a person with HIV, the number of mites can patient with zoster-involving V1, the oph- jump to the hundreds, thousands or even thalmic division of the trigeminal nerve, tens of thousands. This in turn introduces should be immediatedly referred to an oph- into a sexually active community a pool of thalmologist due to the risk of corneal ul- mites much larger than it had been before ceration. Signs or symptoms of this condition epidemic .” Clinicians such as painful vesicular lesions on the tip of should take care when touching these le- the nose or lid margins should be consid- sions during diagnosis lest they catch sca- ered an ocular emergency. A significant num- bies. The use of latex gloves and hand - ber of people with HIV disease may also de- ing at the end of examination cannot be velop Herpes meningoencephalitis secondary overemphasized. to disseminated zoster. Neurological symp- (Kwell) is inexpensive, but rela- toms should be sought and a mental status tively ineffective for the treatment of Nor- exam should be included in the neurological wegian scabies. Therefore, the treatment of exam of patients presenting with . choice is Elimite (5% ) — this If present, a neurological consultation with a seems to be ovicidal as well as scabicidal. Fu- lumbar puncture is imperative, and intra- ture developments may include approval of venous acyclovir is indicated. , a single-dose oral agent which has In immune deficiency, the number of Uncomplicated zoster outbreaks should been shown to erradicate epidemic scabies in scabies can jump dramatically and be treated with acyclovir (Zovirax) 800 mg human populations (this product currently cause a therapeutic challenge. five times a day or famciclovir (Famvir) is approved for veterinary use). 500 mg three times a day, both for ten days.

Herpesviruses Other Skin Infections Breakouts of grouped -like lesions Cutaneous Staphylococcus aureus infec- typically caused by the common herpes tions can cause —pustules with a simplex virus are easily recognized. In peo- honey-colored crust— or folliculitis ple with advanced HIV, however, these may on the face or trunk. Neglected infections develop into chronic ulcers and fissures can progress to ecthyma. Like molluscum, with a substantial degree of edema. These staphylococcus can be spread by erosions may occur on the oral and genital shaving and are highly contagious from mucosa as well as perianally; their scal- person to person. Since the foci of staphy- loped edge is the hallmark for diagnosis. A lococcus colonization is in the nares or pe- culture is helpful, but HSV IgG levels are Zoster (shingles) is dermatomal. rianal region, “HIV-positive patients subject generally not, as the commercial tests for to recurrent infections may benefit from

THE PRN NOTEBOOK™ • VOLUME 2, NUMBER 4 • AUGUST 1997 9 Malignancies Farthing CF, Brown SE, Staughton RCD, et Dr. Roth closed by reminding al. Color Atlas of AIDS and HIV Disease. PRN members that in addition to Chicago, Year Book Medical Publishers, KS (see Dr. Krown’s review on 1988. page 2) they should be cautious not to overlook non-AIDS-related Friedman-Kien AE, Color Atlas of AIDS. skin malignancies in people with Philadelphia, W.B. Saunders, 1989. HIV. The most common include basal cell carcinomas, which have Grossman ME, Roth J. Cutaneous Mani- a pearly, rolled border; squamous festations of Infection in the Immunocom- cell carcinomas that occur peri- promised Host. Baltimore, Wilkins & anally following oncogenic wart Wilkins, 1995. infection; and malignant mela- Bacillary angiomatosis, a vascular nomas, pigmented lesions char- Lipman MCI, Gluck TA, Johnson MA. An proliferation that resembles KS acterized by their large size, Atlas of in HIV Dis- asymmetry and irregular colors ease. New York, London, Parthenon Pub- an antibiotic ointment such as Bactroban or borders. “It’s important to avoid tunnel lishing, 1995. (mupirocin) twice a day in the nose and vision in just looking for infectious com- around the anus to keep the staph carriage plications of HIV,” he said, emphasizing Ray MC and Gately LE. Dermatologic to a minimum,” Dr. Roth recommended. that a may kill a patient much manifestations of HIV infection and Patients alarmed at a lesion that resembles faster than HIV disease. AIDS. Infectious Disease Clinics of North Kaposi’s sarcoma may instead have bacil- • America September 1994;8:583-605. lary angiomatosis, a vascular proliferation that resembles KS. The causative agent, Bar- Bibliography Zalla MJ, Su WPD, Fransway AF. Derma- tonella henslae, can be observed upon biop- Ansary MA, Hira SK, Bayley AC, et al. A tologic manifestations of human immun- sy. Nodular melanoma may also need to be Colour Atlas of AIDS in the Tropics. Lon- odeficiency virus infection. Mayo Clin considered in the differential diagnosis. don, Wolfe Medical Publications, 1989. Proc November 1992;67:1089-1108.

NOTES

10 THE PRN NOTEBOOK™ • VOLUME 2, NUMBER 4 • AUGUST 1997