Download Article PDF/SlidesFrom warts to scabies to malignancies, skin disorders “are more common and more aggressive in HIV-positive patients than others,” Dr. Jeffrey Roth told members of PRN. Dr. Roth presented a slide-show overview on the clinical manifestation and diagnosis of the cutaneous complications of HIV disease (several of these slides are reproduced over the next few pages). At the same meeting, Dr. Charles Farthing reviewed the dermatologic procedures most useful for primary-care providers working with HIV-positive patients.
| Warts | Top of page |
The most common skin complaint of HIV-positive patients is warts. These dull-colored papules erupt anywhere on the skin, including the anal mucous membrane, vagina, scrotum, penis and mouth. Their appearance, size and number vary with the site. Warts can range in size from less than 1 mm to 1-2 cm “cauliflower lesions.”
The smaller lesions often can be treated locally with podophillum resin of varying strengths, trichlorocetic acid, and/or liquid nitrogen. Larger lesions generally require surgical debridement or excision, at least as a first step. Lasers have been used, even though it is unclear whether they represent an advance over other physically destructive modalities. Two other treatments, Condylox topical solution (podofilox 0.5%) and Aldara cream (imiquimod 5%) can be used at home, as can 5FU. The success with these modalities appears to be more limited, especially in patients with more advanced immunosuppression. “Warts can be difficult to eradicate in HIV-positive people, and the larger and more multiple the warts, the worse the prognosis for ultimate eradication. This seems to be a special defect in immune competence.”
Dr. Roth recommends biopsying most warts—particularly when multiple or very large—on initial presentation to determine their cancer risk. Caused by the human papillomavirus (HPV), warts are grouped by subtype: strains 6 and 11; 16 and 18; or 31, 33, and 35. The three groups differ from one another in oncogenic potential. The oncogenic strains, particularly 16 and 18, are probably the major cause of cervical carcinoma in women and rectal carcinoma in both men and women. “Biopsying provides useful information in terms of patient management and assessing the danger for the patient’s sex partner,” said Dr. Roth. Above all, a biopsy is necessary to make certain that what looks like a wart is a wart—and not a squamous cell carcinoma with metastatic potential. Such carcinomas are sometimes mislabeled as multiply resistant, or recalcitrant, warts, and in a worst-case scenario if untreated on the penis, amputation may eventually be required.
| Scabies | Top of page |
The mite Sarcoptes scabiei can erupt on the wrists, folds of the skin, webs between the fingers and even, in people with HIV, on the face or scalp. Its itchy, red papules are sometimes mistaken for folliculitis, but the patient’s foremost complaint will be itchiness. Visual cues that can help the clinician identify scabies are the linear furrows interspersed with papules (see photo on page 14). There can also be a vesicular component secondary to a hypersensitivity reaction. A more severe variant, Norwegian scabies, properly termed hyperkeratotic scabies, forms large crusted plaques that may resemble psoriasis.
An immune-competent individual hosts, on average, ten to 20 scabies-causing mites. “The two live in a sort of immunologically mediated harmony,” Dr. Roth said. “But in a person with HIV, the number of mites can jump to the hundreds, thousands or even tens of thousands. This in turn introduces into a sexually active community a pool of mites much larger than it had been before epidemic immunodeficiency.” Clinicians should take care when touching these lesions during diagnosis lest they catch scabies. The use of latex gloves and hand washing at the end of examination cannot be overemphasized.
Lindane (Kwell) is inexpensive, but relatively ineffective for the treatment of Norwegian scabies. Therefore, the treatment of choice is Elimite (5% permethrin) - this seems to be ovicidal as well as scabicidal. Future developments may include approval of ivermectin, a single-dose oral agent which has been shown to erradicate epidemic scabies in human populations (this product currently is approved for veterinary use).
| Herpesviruses | Top of page |
Breakouts of grouped blister-like lesions typically caused by the common herpes simplex virus are easily recognized. In people with advanced HIV, however, these may develop into chronic ulcers and fissures with a substantial degree of edema. These erosions may occur on the oral and genital mucosa as well as perianally; their scalloped edge is the hallmark for diagnosis. A culture is helpful, but HSV IgG levels are generally not, as the commercial tests for HSV antibodies do not reliably distinguish between types 1 and 2. Since HSV-1 infection is endemic in the North American population, this is likely to contribute little. HSV IgM levels may help in culture-negative, otherwise confusing cases. Dr. Roth said that a Tzanck smear is usually reliable in experienced hands.
In contrast to herpes simplex, zoster is dermatomal. Although it is widely believed that the vesicles of zoster are larger than herpes,’ Dr. Roth contends that is not always the case. Zoster’s dermatomal pattern may be so vague as to make diagnosis difficult, but this, too, he says, is unusual. Prodermal pain following a dermatomal pattern can be an important diagnostic clue before or during the earliest stages of vesiculation. Chronic zoster may present as hyperkeratotic dermatomal nodules.
A zoster infection is considered “disseminated” when it contains more than 20 nondermatomal lesions or involves the eye. A patient with zoster-involving V1, the ophthalmic division of the trigeminal nerve, should be immediately referred to an ophthalmologist due to the risk of corneal ulceration. Signs or symptoms of this condition such as painful vesicular lesions on the tip of the nose or lid margins should be considered an ocular emergency. A significant number of people with HIV disease may also develop Herpes meningoencephalitis secondary to disseminated zoster. Neurological symptoms should be sought and a mental status exam should be included in the neurological exam of patients presenting with shingles. If present, a neurological consultation with a lumbar puncture is imperative, and intravenous acyclovir is indicated.
Uncomplicated zoster outbreaks should be treated with acyclovir (Zovirax) 800 mg five times a day or famciclovir (Famvir) 500 mg three times a day, both for ten days.
| Malignancies | Top of page |
Dr. Roth closed by reminding PRN members that in addition to KS (see Dr. Krown’s review on page 2) they should be cautious not to overlook non-AIDS-related skin malignancies in people with HIV. The most common include basal cell carcinomas, which have a pearly, rolled border; squamous cell carcinomas that occur perianally following oncogenic wart infection; and malignant melanomas, pigmented lesions characterized by their large size, asymmetry and irregular colors or borders. “It’s important to avoid tunnel vision in just looking for infectious complications of HIV,” he said, emphasizing that a melanoma may kill a patient much faster than HIV disease.
| References | Top of page |
