Transcript Back to Basics-HIV Dermatology 2012

HIV Dermatology 2013
Toby Maurer, MD
University of California, San Francisco
Who are we seeing?
1) The group who starts ARV’s at high CD4
counts
2) The well controlled AGING pt
3) YOUNG pt with low CD4 counts-nonadherent or not yet linked to care
The HIV infected pt who starts ARV’s
at high CD4’s
Immune reconstitution Acne
• Not at low CD4 counts
• In fact, need CD4 cells to mount this response
• Tx with oral antibiotics-doxycycline 100 bid is
great antiinflammatory
• May have to add prednisone for 3 weeks
• Isotretrinoin may be helpful
Eosinophilic Folliculitis
• Used to seeing this with CD4 counts that are
low (under 200) especially when just starting
ARV’s-immune reconstitution
• Also seeing it with CD4 counts that are higher
especially RESTARTING ARV’s and with
underlying fungal or mycobacterial diseases
Genital Warts
• Big burden of disease-not dependent on CD4
count
• The earlier pts enter care, the more genital
warts we will see and possibly treat
• Are we preventing anything by treating
existing warts?
• Quadrivalent vaccine is recommended for
males and females before they are sexually
active
• Australian study demonstrates that prevalence
of warts in females 21-26 greatly decreased, in
heterosexual men decreased substantially
• Evidence of herd immunity
• Women over age 30, not a significant decrease
in warts.
• Not a significant decrease in warts in MSM
over age 30
• Waiting to see if vaccine shows decrease in
warts in MSM when given earlier in patient’s
sexual history-recruiting subjects through Joel
Palefsky studies
Genital Wart Evidence
THESE DATA NOT FROM HIV INFECTED COHORTS
• Imiquimod-easy to use but not as effective as
cryotherapy and still expensive
• Cryotherapy and podopylin 25%- most
effective at clearing warts-partial clearance
noted after 2 session-may take up to 12
sessions
• Recurrence rate is high
What to do?
• Anything at all?
1) Anal pap smears-should be offered to look
for dysplasia
2) Admit that we are not great at clearing
disease and preventing recurrence of warts
3) Our treatment will not get rid of HPV field
effect
• 1 study notes that imiquimod might be helpful
to prevent recurrent warts but no data on how
long to use and what the long term results
are?
Epidermodysplasia verruciformis
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HPV 5 and 8
Often mimics tinea versicolor
Exacerbated by immune reconstitution
In congenital form-associated with SCC
SCC not reported in HIV acquired
epidermodysplasia
• Treatment: low dose acitretin 10 mg qd
HCV treatment in the HIV infected pt
• Telaprevir and Boceprevir-pts are on various
trails with these protease inhibitors directed
against Hep C
• In non-immunosuppressed host-55% pts had
drug reaction-mostly eczematous-does not
require stopping of drug-treat through with
topical steroids but see pt back
• 6% had serious drug reaction-drug
hypersensitivity with fever, eosinophilia,
redness or erythema multiforme like reaction
• Stop drug
• The reaction gets a little worse after stopping
drug-is it the riboviran-NO
• Takes some time for drug reaction to resolve
The Successfully Treated Aging HIV
Infected Patient
Actinic Keratoses
• Ravages of chronic sun exposure showing up
• 3-10% of AK’s turn into SCC’s
• Treatment: cryotherapy
SCC’s
• Higher incidence of SCC’s and BCC’s in 2 HIV
cohorts
• Recurrent SCC’s on skin at UCSF cohort-17%
in HIV infected men compared to 3% in nonHIV infected group
• Appeared in ½ the time and in younger than
expected age group
• Premature aging????
Chren M et al.
Prednisone use
• Aging HIV population need it for joint aches,
backaches, etc
• Where we were hesitant in past, now giving it
to pts who are on ARV’s and seem fully
reconstituted
• Watch the HHV8 virus-seem to turn it on!!!
Kaposis sarcoma
• Seeing a group of HIV infected and non-HIV
infected gay men getting KS temporally related
to receiving systemic steroids
KS –what is new
• Clinical trials-2 new trials
1:maraviroc added to existing regimen-being
used to block CCR5 which we saw increased in a
group of KS patients.
2: lenolidomide through AIDS Malignancy
Consortium
• Lymphedema is a problem
Lymphedema
• Even in pts whose KS is no longer active,
lymphedema seems permanent
• Leads to infection, skin breakdown
• What do we do for lymphedemacompression? Lymphatic massage?
• From literature on filiriasis and podoconiosis
pts-manage the skin-get rid of tinea, get rid of
maceration and protect-2 cm decrease in
edema
Tinea pedis
• Drysol 2 drops to area between toes
• Econazole crème bid
• Treat onychomycosis with oral antifungals –
lamisil 250 qd for 4 months
Verrucous Herpes simplex
• Hypertrophic lesions resembling SCC’s
• ACV resistant-selected mutations ?
• Tx: cidofovir or foscarnet
The CD4 Depleted Patient
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Seb derm
Herpes zoster
Kaposis sarcoma
Tinea
Opportunistic Infections
• ALL IN THE SAME Patient
Herpes zoster
• First episode occurs around CD4 of 315
• Can be very monomorphic umbilicated
pustules
• Can disseminate from zosteriform lesions or in
HIV can present as chickenpox
• Can have multiple episodes in HIV
• Seems to occur when adherence to ARV’s is
less than perfect
• Seems to occur when adherence to ARV’s is
less than perfect and not because CD4 counts
drop or VL increases drastically
• Can also occur as part of IRIS-so pt may
actually be adherent with sudden decrease of
VL
Treatment of Zoster
• High dose antivirals Acyclovir 800 mg 5x/day
or Valcycolivir 1 gm tid
• Post-herpetic neuralgia not usually a problem
unless V1 distribution
KS
• First line therapy still ARV’s unless visceral
involvement then
• Doxil therapy
• NO PREDNISONE (even if pt develops KS IRIS)
Bacillary Angiomatosis
• Bartonella /ricketsial disease
• Biopsy and blood cultures
• Tx: at least 6 weeks of doxycyline or
erythromycin
Tinea
• Look for the red well dermarcated rim
especially around the neck or face
• Pts will usually have onychomycosis and tinea
pedis as well
• If on neck, going down hair follicles or
inflamed-treat with oral antifungals-lamisil
250 qd for 1 month