BEING ALIVE; April 1995
Margaret E. Muldrow, MD and Kees Rietmeijer, MD

Almost everyone knows that opportunistic infections in people infected with HIV become more prevalent as CD4 counts fall. This is also true of skin problems in patients with HIV. In fact, almost 100% of all patients with CD4 counts less than 200 will have some sort of dermatologic condition. Although dermatologic conditions like dry skin, seborrheic dermatitis and scabies are not life-threatening diseases (like pneumocystis pneumonia or cryptococcal meningitis), these disorders impact greatly on the quality of life of someone with HIV. It is not uncommon for a dermatologist to be referred a patient who is taking ten different kinds of medications, who has disseminated MAC and is going blind from CMV, who tells us that they can live with all of that, but the thing that is driving them "crazy" is this terrible itch.

This tells us something about the patient's quality of life. And the good news is that dermatologists can have a positive impact on a person's quality of life by alleviating some of their symptoms and possibly even curing some of their skin problems.

The following is a quick review of a wide range of dermatologic manifestations seen in patients with HIV infections along with the standard treatment. As with all medical treatments, working with your physician is essential because not all people or viruses, bacteria or fungi respond exactly the same every time.

Rash of Seroconversion

Individuals who are in the process of seroconverting to being HIV+ may develop a fever, malaise, muscle and bone pain, a sore throat, enlarged lymph nodes and even a rash. This rash, which can be described as faint background redness that is distributed primarily over the trunk, is easily missed and lasts only a short period of time.

Herpes Simplex

The most common skin problems associated with HIV infection are viral in nature. As people become sicker, herpes infections tend to become recurrent, persistent and even widely disseminated. In clinic, dermatologists often see many individuals with perianal herpes. Acyclovir usually clears up the problem in seven to ten days. If the lesions persist, it is often a sign that there is associated infection with bacteria, fungus or even another type of virus. Foscarnet, although a toxic and poorly tolerated medication, can be used for acyclovir resistant strains of herpes.

Herpes Zoster

In 1982, Dr. Rietmeijer began working at one of the sexually transmitted disease clinics in Amsterdam. At that time, AIDS was perceived as something that was very far away from Amsterdam. It was across the ocean. Nobody thought they would ever have a problem with it there, but by the middle of that year, they began to see more and more gay men with herpes zoster or "shingles." In retrospect, 12 years later, it is obvious that these individuals were infected with HIV and that "shingles" was the first manifestation of their illness.

"Shingles" is produced by the same virus that causes chicken pox. Although the chicken pox rash may go away, the individual remains infected with the virus which hides out in the nervous system. As people become sicker and their immune systems become more compromised, the virus is reactivated producing painful blisters along the distribution of a nerve. "Shingles" is treated with acyclovir, but in doses four times that used for the treatment of herpes simplex.

Human Papilloma Virus (HPV)

This virus produces warts which can occur anywhere on the body including the genitals, anus, mouth, hands, arms and feet. The lesions are often extensive and very hard to treat. Liquid nitrogen and podophylline are the main forms of therapy.

Molluscum Contagiosum

This is an infection produced by a pox virus. Lesions are described as firm, flesh colored bumps with a central depression which tend to occur on the scalp, face and genital area. They can be very extensive and disfiguring. Treatment is similar to that used for warts.

Fungal Infections

"Ringworm" and "athlete's foot" are common in patients infected with HIV and can be treated with topical or oral antifungal therapy. Although rare, cryptococcus can involve the skin. Lesions are often mistaken for molluscum. This infection can be life threatening and is more difficult to treat.

Bacterial Infections

Impetigo, recurrent "boils" and microbacterial infections are also seen. Basilary angiomatosis, which is caused by the "cat scratch" organism, has been described only in HIV+ patients. We have not seen a case of this in Denver. These infections are all treated with antibiotics.

Scabies

Infection is caused by a mite which burrows into the upper layers of the skin where it lives and lays its eggs. The body's immune response to the mite produces a very itchy rash. Treatment involves the use of Kwell or Permethrim lotion and close followup.

Seborrheic Dermatitis

More commonly known as "dandruff," this disorder is characterized by yellow to white scale on the scalp. In people infected with HIV, the lesions can also become more extensive (also involving the central face and chest) and more severe. It may also be an initial sign of HIV infection. Treatment includes the use of an anti-dandruff shampoo, topical steroid ointments and antifungals.

Psoriasis

One to three percent of people with AIDS develop psoriasis. This is a disorder characterized by red bumps and plaques with thick silvery white scale that are most commonly found on the scalp, trunk, elbows, knees and buttocks. It is not an infectious process, but all kinds of infections can make it much worse. Unfortunately, the disorder can become severe (even requiring hospitalization) and is often very difficult to treat.

Eosinophilic Folliculitis

Nearly all individuals with CD4 counts below 100 will at some time in the course of their illness suffer from severe itching. One disorder that often causes this symptom is eosinophilic folliculitis (commonly called "itchy bump syndrome"). Patients develop very itchy red bumps around the hair follicles on their neck, upper trunk and arms. Since the cause of the disorder is unknown, treatment is empiric with the use of itraconazole and indocin along with good basic skin care.

Dry Skin

This is a problem for people living in Colorado where the climate is dry, but in particular, for people infected with HIV. Treatment involves taking fewer showers or baths and the use of lots of moisturizers and topical steroids.

Drug Reactions

Reactions to medications are more common in people who are HIV+ than in the general population and reactions become more frequent as the disease progresses. Bactrim and penicillin cause the most reactions, but people with central nervous system toxoplasmosis who are taking anti-seizure medications appear to be at high risk for the most serious kinds of drug reactions.

(This article was excerpted from the presentation given by Margaret F. Muldrow, MD and Kees Rietmeijer, MD at the 10th Annual Rocky Mountain Regional Conference on HIV Disease held February 2-4, 1995 in Denver, CO and is reprinted from the April 1995 issue of Resolute!)

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