Figure 18-1. Seborheic dermatitis. Annular scaling plaques on the nasolabial fold and cheeks. ( Drs. J. Rico and N. Prose).
Herpes simplex virus (HSV) infections, and in particular chronic perianal herpes, was one of the first noted complications of HIV infection and remains a cause of significant morbidity. These patients may have persistent or recurrent painful ulcers, sometimes in the absence of vesicles, involving the genitalia, groin, perianal area, or other mucocutaneous surfaces. Acyclovir-resistant HSV has been described in HIV-infected patients with chronic, persistent disease. Foscarnet may be helpful in these resistant cases. In children, chronic or recurrent herpetic gingivostomatitis can significantly impede adequate oral intake. Herpes simplex virus ulcers can become a portal of entry or transmission site for HIV.
Infection with varicella-zoster virus may result in several different clinical manifestations. The occurrence of chickenpox in children or adults with HIV infection may result in disseminated cutaneous disease with systemic manifestations. These patients require treatment with systemic antiviral agents such as acyclovir, famciclovir, and valacyclovir. Herpes zoster ("shingles") is not uncommon in adults and children with HIV infection and may be the initial manifestation of HIV infection ( Fig 18-2).
The occurrence of zoster in a patient at risk for HIV infection should prompt the provider to suggest appropriate counseling and testing for HIV. Chronic ecthymatous varicella-zoster virus infection develops either in patients with AIDS and a previous history of varicella-zoster exposure or in children with HIV infection and varicella
(Fig 18-3). Patients may present either with dermatomal vesicles that subsequently ulcerate and disseminate or with frank ulcers. These lesions are often recalcitrant to therapy and may heal with scarring. Dissemination of both herpes simplex and herpes zoster to extracutaneous sites has been reported.
Figure 18-2. Herpes zoster. Umbilicated vesicles in a dermatomal distribution in a man with AIDS. (Drs. J. Rico and N. Prose) (Owen/Galderma)
Figure 18-3. Ecthymatous herpes varicell-zoster. Crusted erosions and blisters on the foot of a patient with AIDS. ( Drs. J. Rico and N. Prose) (Owen/Galderma)
Molluscum contagiosum in patients with HIV infection often occurs in the beard area and may present as disfiguring papules, plaques, or tumors; disseminated cutaneous disease may also be seen (Fig 18-4). Human papillomavirus infection, particularly condyloma acuminata ( Fig 18-5), may present as large, fungating lesions. Widespread flat warts have been observed. Oral hairy leukoplakia ( Fig 18:6), a mixed infection of Epstein-Barr virus and human papillomavirus, is usually asymptomatic and presents as filiform white papules or corrugated plaques on the lateral sides of the tongue. Complex viral and fungal lesions involving the skin may be hyperkeratotic, vegetating, or ulcerative in appearance. Herpes virus, papillomavirus, and fungal elements have been cultured or observed on biopsy.
Figure 18-4. Molluscum contagiosum. Multiple firm white papules scattered over the dorsal hand and forearm in a Haitian man with AIDS. ( Drs. J. Rico and N. Prose) (Owen/Galderma)
Figure 18-5. Condyloma acuminata. Fungating perianal warts in a child infected with HIV. (Drs. J. Rico and N. Prose)
Figure 18-6. Oral hairy leukoplakia. Filamentous white papules on the sides of the tongue. (Drs. J. Rico and N. Prose) (Owen/Galderma)
The most common mucocutaneous eruption in patients infected with HIV is oral candidiasis (Fig 18.-Z) or thrush. A number of these patients may develop esophageal involvement with characteristic ulcerations visible on endoscopy or barium swallow. Moniliasis involving the diaper area is a significant problem in children with AIDS. Candida paronychia has also been reported.
Figure 18-7. Oral candidiasis. White plaques on the tongue of a child with AIDS. ( Drs. J. Rico and N. Prose)
Cutaneous fungal infections may occur as extensive scaling papules and plaques or involve atypical sites. In the adult population, fungal infection of the nails is common; proximal white subungual onychomycosis is seen with particular frequency in patients with HIV infection. Disseminated deep fungal infections, including cryptococcosis, histoplasmosis, coccidiomycosis, and blastomycosis, may present with skin involvement in patients with AIDS. These patients may present with ulcers, plaques, or nodules; biopsy for routine histology and culture, as well as touch preparations are necessary to establish the diagnosis.
Infants and children with AIDS are particularly at risk for bacterial infections; cutaneous bacterial diseases including cellulitis and impetigo are frequent. In adults, acneiform eruptions and extensive folliculitis have been reported. Myco bacteria may involve the skin in patients with AIDS either as a primary cellulitis with Mycobacterium avium-intracellulare or other mycobacterium, or with secondary spread of M. tuberculosis as in scrofula.
Syphilis, like HIV infection, is a sexually transmitted disease that predominately affects young adults. Patients with AIDS who are homosexual or bisexual or are intravenous drug users are at increased risk for syphilis. Rarely, patients coinfected with syphilis and HIV may be serologically negative for syphilis (RPR, FTA) despite active infection. Several patients with early HIV and syphilis have failed to respond to standard antibiotic regimens, and appropriate serologic follow-up is advised for all patients with syphilis. Those caring for patients with HIV infection or syphilis are urged to review the CDC recommendations for diagnosis and treatment.
Bacillary angiomatosis is a unique illness characterized by the development of fever, chills, weight loss, and numerous angiomatous nodules. The etiologic agent is Bartonella, the same organism that causes cat-scratch disease. Treatment with oral erythromycin, or other antibiotics including doxycycline or ciprofloxacin, leads to the rapid resolution of both skin lesions and systemic symptoms.
Atypical forms of scabies have been reported in both adults and children with AIDS. The rash tends to be highly pruritic, and patients may present with widespread, keratotic papules, similar clinically to Norwegian scabies.
A flu-like illness may occur at the time of acute seroconversion. An evanescent morbilliform rash has been associated with this syndrome. Seborrheic dermatitis is seen in up to 50% of patients with HIV infection. Clinically, seborrheic dermatitis in these patients tends to be more florid and less responsive to therapy than in the nonimmunocompromised host. Psoriasis and Reiter's disease have been reported in 1 to 5% of patients infected with HIV. Psoriasis may flare in those with previously stable plaque type disease, or develop de novo. Reiter's disease ( Fig 1.8-8), manifested by psoriasiform dermatitis, keratoderma blennorrhagica, seronegative spondyloarthropathy, urethritis, balanitis, uveitis, or conjunctivitis, is more common in patients with AIDS and is associated with the histocompatibility locus antigen
B-27. Drug eruptions, particularly due to trimethoprim/sulfamethoxazole (Fig 18-9) and other antibiotics, are common in patients with AIDS. Generalized granuloma annulare (Fig 18.-10) may be seen with widespread annular dermal papules. Additional inflammatory skin disorders that may be associated with HIV infection include acute and chronic photoeruptions, porphyria cutanea tarda, vasculitis, pyoderma gangrenosum, calciphylaxis, and erythema elevatum diutinum. Papular eruption of HIV infection was described by James et al. as multiple, 2- to 5-mm, flesh-colored papules on the face, neck, and upper thorax, which are often pruritic. Pruritus may be one of the initial symptoms of HIV infection and is often incapacitating. Patients may present with excoriations, lesions of lichen simplex chronicus, prurigo nodularis, or minimal skin changes. Xerosis, which is not specific for HIV infection and can be seen in a variety of chronic illnesses, has been reported in up to 30% of patients with HIV infection.
Figure 18-8. Reiter's disease. Psoriasiform dermatitis involving the distal fingers. Note the joint changes due to active arthritis. ( Drs. J. Rico and N. Prose)
Figure 18-9. Leukocytoclastic vasculitis. Palpable purpura on the foot. This patient developed vasculitis after receiving trimethoprim-sulfamethoxazole. ( Drs. J. Rico and N. Prose)
Figure 18-10. Disseminated granuloma annulare. Discrete annular pink papules on the dorsal hand. (Drs. J. Rico and N. Prose)
Patients with AIDS and chronic diarrhea or AIDS-wasting syndrome, particularly children, are at risk for cutaneous manifestations of nutritional deficiencies. Scurvy, acrodermatitis enteropathica, and cutaneous manifestations of B vitamin deficiency have been reported.
Disseminated Kaposi's sarcoma was one of the initial manifestations of HIV infection; the first cases were reported in 1980 in previously healthy homosexual and bisexual men. Since then, Kaposi's sarcoma has remained a disease predominately seen in that subgroup of patients and has been infrequently reported in those who acquire the disease through heterosexual contact, intravenous drug users, or children. The incidence of Kaposi's sarcoma among patients with HIV infection has decreased steadily, and currently fewer than 15% of patients with HIV infection develop Kaposi's sarcoma. Kaposi's sarcoma is associated with herpesvirus 8 (HHV-8). In one recent study, approximately 50% of homosexual men coinfected with HIV and HHV-8 developed Kaposi's sarcoma within 10 years.
Disseminated Kaposi's sarcoma associated with AIDS differs from classical Kaposi's sarcaoma in that the majority of patients present with multiple, often widespread, red or violaceous papules, plaques, or tumors involving the integument and mucosa ( Fig 18:1.1). Visceral involvement occurs in 25%, and may result in systemic hemorrhage. The lesions generally are asymptomatic; however, patients may complain of pruritus or pain, and large lesions may ulcerate. The treatment of isolated lesions by excision, cryotherapy, or local radiation may offer palliation or cosmetic improvement. Doxcil (liposomal adinomycin) is a beneficial systemic agent given intravenously for advanced disease.
B-cell lymphoma, which commonly involves the central nervous system in patients with AIDS, has been rarely reported to involve skin. Patients may present with small, ulcerated papules or nodules. Despite anecdotal reports, there is no clear evidence for an increase in other cutaneous malignancies, such as basal cell carcinoma, squamous cell carcinoma or melanoma, among patients with HIV infection.
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