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Dermatology and HIV

Dermatology and HIV. HAIVN Harvard Medical School AIDS Initiative in Vietnam. Learning Objectives. By the end of this session, participants should be able to: Describe the most common skin diseases among PLHIV in Vietnam Explain how to treat these skin conditions.

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Dermatology and HIV

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  1. Dermatology and HIV HAIVN Harvard Medical School AIDS Initiative in Vietnam

  2. Learning Objectives By the end of this session, participants should be able to: • Describe the most common skin diseases among PLHIV in Vietnam • Explain how to treat these skin conditions

  3. What are Common Skin Conditions Among PLHIV in Vietnam? • Pruritis • Drug allergy rash • Varicella-Zoster • Herpes Simplex • Seborrheic dermatitis • Scabies • Molluscum contagiosum • Penicillium Marneffei • PPE (Papulo-Pruritic Eruption)

  4. Pruritis - Itchy Skin (1) Causes: • Dry scaly skin: • Seborrheic dermatitis • Fungal infection • Eczema • Xerosis • Papules: • Scabies • Insect bites • Eosinophilic folliculitis • Papulopruritic eruption • Infections

  5. Pruritis - Itchy Skin (2) Treatment: • Oral antihistamines • Topical moisturizers • Topical steroids • Avoid excessive bathing, soap, or hot water

  6. Topical Steroid Use for Pruritis • Use the lowest potency that is effective for the least amount of time needed Topical Steroids by Potency:

  7. What is the Diagnosis? • This patient presented with a painful rash on the back of the neck for 2-3 days • On exam, there were multiple vesicles with surrounding erythema

  8. Varicella Zoster Virus (VZV)Shingles – Zona (1) • Vesicular rash in one dermatome • Treatment: • Acyclovir 800 mg 5x/d x 7d • Most effective if started within 72 hours of onset of rash • For >1 dermatome or disseminated infection: • Acyclovir IV 10 mg/kg q8hr x 7-14 days

  9. Varicella Zoster Virus (VZV)Shingles – “Zona” (2)

  10. What is the Diagnosis? • This patient presented with a recurrent painful ulcer on the penis

  11. Herpes Simplex Virus (HSV) (1) • Most common cause of chronic or recurrent ulcers in the genital area • Ulcers are more likely to be chronic in PLHIV • Primary or recurrent episodic treatment: • Acyclovir 400 mg TID or 200 mg 5x per day x 7-10 days • Severe case: 5 mg/kg IV every 8 hours • Chronic suppressive treatment: • Acyclovir 200 mg TID or 400 mg BID

  12. Herpes Simplex Virus (HSV) (2) Chronic ulcer on scrotum Chronic ulcer on hand

  13. What is the Diagnosis? This patient presented with a chronic red scaly rash on the forehead and face

  14. Seborrheic Dermatitis (1) • Cause: Dermatophyte (fungal) • Erythematous, papular to scaly rash • CD4 < 500 • Nasolabial fold, beard, hairlines

  15. Seborrheic Dermatitis (2) Treatment: • Ketoconazole cream or shampoo • Shampoos (tar, selenium sulfide) • Low potency steroid cream (hydrocortisone or antifungal) • Antiretroviral Therapy

  16. What is the Diagnosis? • This patient presented with a very itchy rash on the hands, ankles and abdomen • Lesions were red and 1-2 mm in size • There were no pustules or vesicles

  17. Scabies (1) • Cause: SarcoptesScabiei(mites) • Symptoms: • Itchy, red, papular lesions • Linear “burrows”, often between fingers • Commonly located on hands, wrists and ankles, and groin • Norwegian Scabies • Severe form in PLHIV • Hyperkeratotic lesions

  18. Scabies (2)

  19. Scabies (3) Treatment: • Benzyl benzoate, DEP • Permethrin 5%- safe for children >2 months • Lindane 1%- not safe in young children or pregnancy • Ivermectin

  20. What is the Diagnosis? • This patient presented with many small nodules on the face and neck. • No pain or itching • No fever or wasting

  21. Molluscum Contagiosum (MC) (1) • Caused by a viral infection (MC virus) • Spread by direct skin-to-skin contact • Lesions: • Chronic, dome shaped papules (2 to 5 mm) • Shiny surface and central umbilication • Must differentiate from Penicillium and Cryptococcus • Lesions can be found anywhere on the body except the palms and soles

  22. Molluscum Contagiosum (2)

  23. Molluscum Contagiosum (3) Molluscum lesions on neck Treatment: • Responds to ARV • Cryotherapy: liquid nitrogen

  24. What is the Diagnosis? • This patient presented with erythematous papules with central umbilication on the face and torso • He also had fever, wasting and enlarged liver and spleen

  25. Penicillium marneffei (1) • Common OI in Vietnam • Occurs in advanced AIDS; CD4 < 100 • Skin lesions: papules with central necrotic umblication

  26. Penicillium marneffei (2) • Lesions occur most commonly on the face • Usually accompanied by systemic symptoms such as : • Prolonged fever • Fatigue • Weight loss • Hepatosplenomegaly • Diagnosis: • Scraping skin lesions for staining and culture • Blood culture

  27. What is the Diagnosis? • This patient presented with a very itchy papular rash on the legs • No fever or other symptoms

  28. Pruritic Papular Eruption (PPE) • Itchy red papules 1-5 cm • Etiology is unclear • Differential diagnosis: • Bacterial infection (staphylococcus) • Fungal infection • TB • Scabies • Eosinophilicfolliculitis • Responds well to ARV

  29. A B Identify the Skin Condition (1) C D

  30. Oral Mucosal Lesions

  31. Oropharyngeal Candidiasis (Thrush) • Common OI in Vietnam • Diagnosis: clinical appearance • Treatment: • Fluconazole 100-150 mg/day x 7 days • Ketoconazole 200 mg bid x 7 days

  32. Aphthous Ulcers • Can be very large and painful in PLHIV • Topical anesthetics for pain • Topical steroids may decrease pain and swelling

  33. Oral Hairy Leukoplakia • Caused by Ebstein-Barr Virus (EBV) • WHO Clinical stage 3 • No treatment necessary

  34. Less Common Skin Conditions • Eosinophilic Folliculitis • Cryptococcal Infection • Bacillary Angiomatosis • Kaposi’s Sarcoma

  35. Eosinophilic Folliculitis • Chronic pruritic skin eruption • Occurs with low CD4 counts (< 200) • Etiology is unknown • Clinical findings: • Pruritus: moderate-to-severe • Follicular papules on face, neck, upper trunk

  36. Disseminated Cryptococcus • Skin lesions occur in up to 15% of patients • Lesions may present as: • small nodules or papules that subsequently ulcerate, or • abscesses, erythematous nodules, or cellulitis • Treatment: • Amphotericin B • Fluconazole

  37. Bacillary Angiomatosis • Vascular lesions in skin and other organs • Caused by infection with Bartonellaspecies • Lesions are red to purple papules or nodules • Treatment: • Doxycycline, erythromycin or azithromycin x > 2 months

  38. Kaposi’s Sarcoma • Vascular tumor associated with infection with human herpes virus 8 (HHV-8) • Typically involves skin, but can involve any organ • Skin lesions are red to purple dermal papules, nodules, tumors, or plaques • Treatment: • Most respond to ART • Chemotherapy for severe cases

  39. E F Identify the Skin Condition (2) H G

  40. Key Points • Skin conditions are very common in PLHIV, but can be difficult to diagnose • If treatment is not effective, biopsy may be necessary to make a diagnosis • Most skin conditions will improve with ART

  41. Thank you! Questions?

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