Transcript Session 9 - Teaching Slides

Dermatology and HIV
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
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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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What are Common Skin Conditions
Among PLHIV in Vietnam?
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Pruritis
Drug allergy rash
Varicella-Zoster
Herpes Simplex
Seborrheic
dermatitis
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Scabies
Molluscum
contagiosum
Penicillium
Marneffei
PPE (PapuloPruritic Eruption)
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Pruritis - Itchy Skin (1)
Causes:
 Dry scaly skin:
• Seborrheic
dermatitis
• Fungal infection
• Eczema
• Xerosis
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Papules:
• Scabies
• Insect bites
• Eosinophilic
folliculitis
• Papulopruritic
eruption
• Infections
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Pruritis - Itchy Skin (2)
Treatment:
 Oral antihistamines
 Topical moisturizers
 Topical steroids
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Avoid excessive bathing, soap, or hot
water
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Topical Steroid Use for Pruritis
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Use the lowest potency that is effective for
the least amount of time needed
Topical Steroids by Potency:
Potency Steroid
Low
Medium
High
• Hydrocortisone (Hytone, Synacort)
• Fluocinolone (Flucinar, Synalar)
• Triamcinolone (Kenalog)
• Clobetasol (Cloderm, Dermovate,
Eumovate, Powercort)
• Betamethasone (Diprolene,
Diprosalic, Beprosalic)
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What is the Diagnosis?
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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
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Varicella Zoster Virus (VZV)
Shingles – Zona (1)
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Vesicular rash in one dermatome
Treatment:
• Acyclovir 800 mg 5x/d x 7d
• Most effective if started within 72 hours
of onset of rash
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For >1 dermatome or disseminated
infection:
• Acyclovir IV 10 mg/kg q8hr x 7-14 days
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Varicella Zoster Virus (VZV)
Shingles – “Zona” (2)
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What is the Diagnosis?
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This patient
presented with a
recurrent painful
ulcer on the penis
Herpes Simplex Virus (HSV) (1)
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Most common cause
of chronic or
recurrent ulcers in
the genital area
Ulcers are more
likely to be chronic
in PLHIV
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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
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Chronic suppressive
treatment:
• Acyclovir 200 mg TID
or 400 mg BID
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Herpes Simplex Virus (HSV) (2)
Chronic ulcer on scrotum
Chronic ulcer on hand
What is the
Diagnosis?
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This patient
presented with a
chronic red scaly
rash on the
forehead and
face
Seborrheic
Dermatitis (1)
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Cause:
Dermatophyte
(fungal)
Erythematous,
papular to scaly
rash
CD4 < 500
Nasolabial fold,
beard, hairlines
Seborrheic Dermatitis (2)
Treatment:
 Ketoconazole cream or shampoo
 Shampoos (tar, selenium sulfide)
 Low potency steroid cream
(hydrocortisone or antifungal)
 Antiretroviral Therapy
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What is the Diagnosis?
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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
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Scabies (1)
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Cause: Sarcoptes Scabiei (mites)
Symptoms:
• Itchy, red, papular lesions
• Linear “burrows”, often between fingers
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Commonly located on hands, wrists and
ankles, and groin
Norwegian Scabies
• Severe form in PLHIV
• Hyperkeratotic lesions
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Scabies (2)
Scabies (3)
Treatment:
 Benzyl benzoate, DEP
 Permethrin 5%- safe for children >2
months
 Lindane 1%- not safe in young
children or pregnancy
 Ivermectin
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What is the Diagnosis?
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This patient
presented with
many small
nodules on the
face and neck.
No pain or
itching
No fever or
wasting
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Molluscum Contagiosum (MC) (1)
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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
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Lesions can be found anywhere on the
body except the palms and soles
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Molluscum Contagiosum (2)
Molluscum Contagiosum (3)
Molluscum lesions on neck
Treatment:
 Responds to
ARV
 Cryotherapy:
liquid
nitrogen
What is the Diagnosis?
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This patient
presented with
erythematous
papules with central
umbilication on the
face and torso
He also had fever,
wasting and
enlarged liver and
spleen
Penicillium marneffei (1)
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Common OI in
Vietnam
Occurs in advanced
AIDS; CD4 < 100
Skin lesions:
papules with
central necrotic
umblication
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Penicillium marneffei (2)
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Lesions occur most commonly on the face
Usually accompanied by systemic symptoms
such as :
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Prolonged fever
Fatigue
Weight loss
Hepatosplenomegaly
Diagnosis:
• Scraping skin lesions for staining and culture
• Blood culture
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What is the
Diagnosis?
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This patient
presented with a
very itchy
papular rash on
the legs
No fever or
other symptoms
Pruritic Papular Eruption (PPE)
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Itchy red papules 1-5 cm
Etiology is unclear
Differential diagnosis:
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Bacterial infection (staphylococcus)
Fungal infection
TB
Scabies
Eosinophilic folliculitis
Responds well to ARV
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A
B
Identify the Skin Condition (1)
C
D
Oral Mucosal Lesions
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Oropharyngeal Candidiasis
(Thrush)
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Common OI in
Vietnam
Diagnosis: clinical
appearance
Treatment:
• Fluconazole 100150 mg/day x 7
days
• Ketoconazole 200
mg bid x 7 days
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Aphthous Ulcers
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Can be very
large and
painful in PLHIV
Topical
anesthetics for
pain
Topical steroids
may decrease
pain and
swelling
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Oral Hairy
Leukoplakia
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Caused by
Ebstein-Barr
Virus (EBV)
WHO Clinical
stage 3
No treatment
necessary
Less Common Skin Conditions
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Eosinophilic Folliculitis
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Cryptococcal Infection
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Bacillary Angiomatosis
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Kaposi’s Sarcoma
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Eosinophilic
Folliculitis
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Chronic pruritic skin
eruption
Occurs with low CD4
counts (< 200)
Etiology is unknown
Clinical findings:
• Pruritus: moderate-tosevere
• Follicular papules on
face, neck, upper
trunk
Disseminated Cryptococcus
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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
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Treatment:
• Amphotericin B
• Fluconazole
Bacillary
Angiomatosis
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Vascular lesions in skin
and other organs
Caused by infection
with Bartonella species
Lesions are red to
purple papules or
nodules
Treatment:
• Doxycycline,
erythromycin or
azithromycin x > 2
months
Kaposi’s
Sarcoma
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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
E
F
Identify the Skin
Condition (2)
G
H
Key Points
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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
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Thank you!
Questions?
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