Chapter 39 Cutaneous manifestations of AIDS*
1. How significant is the occurrence of skin disease in the setting of HIV infection?
Dermatologic diseases are frequently encountered in HIV-infected patients. In one study of 100 serial outpatients, a 92% prevalence of skin disease was noted. Skin disease may also be the first manifestation of HIV disease and may suggest HIV infection because of increased severity of presentation, atypical clinical appearance, or increased resistance to treatment. In addition, mucocutaneous disease, such as an infection or neoplasm, may be the initial sign of a systemic process in an HIV-infected patient. Highly active antiretroviral therapy (HAART) was introduced in 1997 and has significantly decreased the occurrence and severity of many skin conditions associated with HIV infection, such as Kaposi’s sarcoma, eosinophilic folliculitis, oral hairy leukoplakia, and molluscum contagiosum.
3. What are the most common dermatoses associated with HIV infection?
Papulosquamous dermatoses are among the most commonly seen cutaneous manifestations of HIV infection, and these include seborrheic dermatitis (Fig. 39-1) and xerosis. Other common dermatologic conditions include bacterial infections, such as Staphylococcus aureus skin infections. Fungal infections, such as mucocutaneous candidiasis (oropharyngeal and vulvovaginal) and dermatophytosis (tinea pedis, tinea cruris, tinea manuum, and onychomycosis), are also commonly encountered. Frequently seen viral infections include human papilloma virus infections (condyloma acuminata, common and plantar warts), as well as infections with herpes simplex virus, varicella-zoster virus, molluscum contagiosum, and Epstein-Barr virus (oral hairy leukoplakia).
4. Can mucocutaneous changes occur as a result of primary HIV infection?
Yes. The earliest cutaneous sign of HIV infection is an exanthem consisting of discrete, erythematous macules and papules that usually measure 10 mm or less. They are located primarily over the trunk but also are seen on the palms and soles. These lesions may become hemorrhagic. The exanthem of acute HIV infection is not clinically or histologically specific. Mucosal changes described include oral, genital, and anal ulcers. These changes are associated with an acute febrile illness.
5. What is the most common bacterial pathogen in HIV disease? How does it manifest itself?
Staphylococcus aureus is the most common cutaneous bacterial pathogen in HIV disease. Cutaneous infections due to S. aureus most commonly present as a superficial folliculitis. Less common manifestations include impetigo, ecthyma, furunculosis, cellulitis, abscesses, and botryomycosis. In addition, S. aureus can secondarily infect underlying primary dermatoses such as eczema, scabies, herpetic ulcers, and Kaposi’s sarcoma, or can colonize intravenous catheter sites. Staphylococcal colonization (carriage) of the nose and flexures (perineal, toe webspaces) is known to increase in HIV disease and may account for the increased incidence of cutaneous infections. As in the general population, infections with community-acquired methicillin-resistant S. aureus (MRSA) are becoming increasingly common.
| Neoplastic Diseases | Infectious Diseases |
|---|---|
| Kaposi’s sarcoma Lymphoma Squamous cell carcinoma Basal cell carcinoma |
Bacterial Staphylococcus aureus infections Syphilis Bacillary angiomatosis Fungal Candida, Penicillium marneffei Dermatophytosis Cryptococcosis Histoplasmosis Viral Human papillomavirus (HPV) Molluscum contagiosum Herpes simplex virus (HSV) Varicella-zoster virus (VZV) Cytomegalovirus (CMV) Epstein-Barr virus Arthropods Scabies |
| PAPULOSQUAMOUS DISEASES | |
| Seborrheic dermatitis Xerosis/acquired ichthyosis Psoriasis Reiter’s syndrome |
|
| MISCELLANEOUS DISEASES | |
| Eosinophilic folliculitis Drug eruptions Hyperpigmentations Photoeruptions Pruritus Lipodystrophy Granuloma annulare Aphthosis |
Dover JS, Johnson RA: Cutaneous manifestations of human immunodeficiency virus infection: parts 1 and 2, Arch Dermatol 127:1383–1391, 1549–1558, 1991.
James W, editor: AIDS: a ten-year perspective, Dermatol Clin 9:391–615, 1991.
* Costner M, Cockerell CJ: The changing spectrum of the cutaneous manifestations of HIV disease, Arch Dermatol 134:1290–1292, 1998.
Ahuja D, Albrecht H: HIV and community-acquired MRSA, AIDS Clin Care 21:21–23, 2009.
6. What is the most common cutaneous malignancy in HIV disease?
Kaposi’s sarcoma (KS) or, more specifically, epidemic Kaposi’s sarcoma. In the Swiss HIV Cohort Study, the risk for KS and non–Hodgkin’s lymphoma continued to be at least 20-fold higher among HAART-treated individuals compared with that of the general population. Most cases occurred in homosexual or bisexual men with HIV disease. However, KS has also been reported in HIV-negative homosexual males. Human herpesvirus–8 is associated with epidemic as well as other types of KS.
7. What are the cutaneous clinical features of epidemic Kaposi’s sarcoma?
Epidemic Kaposi’s sarcoma has a widespread, symmetrical distribution of rapidly progressive macules, patches, nodules, plaques, and tumors. Common areas of involvement include the trunk, extremities, face, and oral cavity. Early lesions consist of erythematous macules, patches, or papules that may have a bruiselike halo. They enlarge at different rates and tend to be oval or elongated in shape, following the lines of skin cleavage. The color varies from pink to red, purple, or brown and can easily mimic purpura, hemangiomas, nevi, sarcoidosis, pityriasis rosea, secondary syphilis, lichen planus, basal cell carcinoma, and melanoma. The surface may become scaly, hyperkeratotic, ulcerated, or hemorrhagic.
Disfigurement and pain secondary to edema can occur, especially on the face, genitals, and lower extremities. Koebnerization, or formation of new lesions at sites of trauma, can be seen. Secondary bacterial infection can also occur. Lesions can be arranged in several known patterns, such as a follicular (clustered) pattern (Fig. 39-2), pityriasis rosea–like pattern, or dermatomal pattern.
8. How is Kaposi’s sarcoma treated?
Therapy of localized disease may be with intralesional vinblastine, radiotherapy, liquid nitrogen cryotherapy, surgical excision, and topical alitretinoin. Treatment of more extensive disease includes α-interferon as well as single- or multiple-agent chemotherapy with vinblastine, vincristine, bleomycin, or liposomal doxorubicin.
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