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HIV Dermatology

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Slide 1. From TA Maurer, MD, at 11th RW Program Clinical Update, IAS USA. HIV Dermatology: ... Call dermatology-consider toxic epidermal necrolysis. Slide 23 ... – PowerPoint PPT presentation

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Title: HIV Dermatology


1
HIV Dermatology Case-based Presentation
Toby A. Maurer, MD Associate Professor University
of California San Francisco
The International AIDS SocietyUSA
2
  • 38 y.o. male has been on and off ARVs for 2 yrs,
    secondary to substance abuse
  • New lesions on legs
  • CD4 80, VL 80,000
  • Restart Antiretrovirals (ARVs)
  • Special clinical features
  • edema lower legs/ groin region
  • woody feeling to upper legs

3
  • If lymphedema, ARVs may not be enough
  • For those who need chemotherapy, liposomal
    doxorubicin is first line chemotherapy in this
    country

4
  • Pt does not have swelling-so you convince him to
    get back on ARVs
  • He is anxious-how long will it take to get rid of
    these?
  • Ave 9 months
  • Doesnt want to live with lesion on his face
  • intralesional vinblastine
  • radiation therapy

5
  • He tolerates his ARVs and is adherent to regimen
  • Notes abdominal pain and bloody stools
  • Old cutaneous lesions popping out/enlarging
  • Still no swelling in ankles

6
  • You suspect KS immune reconstitution (IRIS)-just
    skin and tolerable
  • Continue ARVs will stabilize in 16 weeks
  • Systemic involvement-GI, pulmonary-start
    liposomal doxorubicin
  • Do we have labs that indicate IRIS?
  • Do we have a way to work up pts with KS to
    predict systemic involvement?

7
Did you biopsy?
  • Biopsy of KS is always useful
  • Early detection is the name of the game- if you
    dont start ARVs within a year of KS
    presentation, mortality is the same as in the
    pre-ARV era
  • Several skin conditions mimic KS. A real
    diagnosis is useful
  • Pt may fail ARVs or need adjunctive therapy with
    chemotherapy or radiation therapy-need tissue

8
  • Abolulafia DM et al. Regression of AIDS KS after
    HAART. Mayo Clin Proc. 1998 May.
  • Udharain A et al. Pegyalted liposomal doxorubicin
    in treatment of AIDS. KS Int J Nonomed. 2008.
  • Nguyen HQ et al. Persistent KS in HAART era.
    AIDS. 2008 May.
  • El Amari EB et al. Predicting evolution of KS in
    HAART era. AIDS. 2008 May.

9
Kaposis Sarcoma
  • Majority of KS seen with CD4 lt200 and VLs that
    are mounting
  • Your pt has CD4 of 450, VL 8000-do you start
    ARVs?
  • Yes-we have found that within months CD4 declines
    and VL starts mounting

10
Kaposis Sarcoma-new group
  • 17 patients with CD4 over 300 and VLlt75 for more
    than 2 years with new or persistent KS
  • All on ARVs and doing well
  • Ave age 51 (range 41-74 yrs)
  • Ave duration of HIV 18 years
  • Ave length of time on ARVs 7years (1- 19 yrs)

11
What is going on?
  • HHV8 virus-unusual type or unusual behavior
  • Functionally abnormal T cell response to HHV8
  • Immunosenescence-the aging immune system of
    HIV-infected, treated individuals

12
  • How do you manage these individuals?
  • To date, they have not had systemic involvement
    or eruptive KS-reassure
  • Local therapy to include radiotherapy and
    intralesional therapy
  • Monitor closely re HIV status (no change to
    date) and other co-morbidities of the aging
    immune system
  • Let us know- maurert_at_derm.ucsf.edu or
    415-206-8680

13
  • Maurer T et al. NEJM. May 2007, Sept 2007.
  • Dittmer DP et al. NEJM. Sept 2007.

14
The skin as a window to the immune system
  • Pt known to you to have psoriasis. Walks into ER
    with thick, oozing plaques
  • Could this really be psoriasis?
  • Is this infected psoriasis?
  • Suspect change in pts CD4 count, VL
  • Look for resistance

15
  • First line therapy ARVs
  • ARVs turn off psoriaisis before CD4 count
    increases or VL declines
  • ? Anti-inflammatory mechanism??

16
  • Pt also has pulmonary TB-cant start ARVs yet
    until his TB is treated
  • What about his psoriasis? Start acitretin 25 mg
    qd-this is a retinoid designed specifically for
    psoriasis
  • TB under control-start protease inhibitor
    regimen-acitretin still on board-watch for
    retinoid toxicity-monitor cholesterol, TG,
    painful red skin-can probably discontinue
    acitretin
  • Tx with topical steroids

17
Other Markers of Poor Immune Status
  • Prurigo nodularis
  • Pruritic papular eruption of HIV
  • Molluscum

18
  • Prurigo nodularis-pts consumed by itch
  • CD4 under 100 with VL
  • You start new ARV regimen in this patient-cant
    get the CD4 count above 60 but VL is low
  • Topicals include clobetasol oint (class 1
    steroid) and doxepin 50 mg qhs
  • Thinking about adding thalidomide
  • Is pt a candidate for raltegravir?

19
Pruritic Papular Eruption
  • 86/102 biopsies showed evidence for arthropod
    assault in Ugandan study (Resneck J. JAMA. 2004)
  • The more severe the eruption, the lower the CD4
    count (plt 0.001)
  • Persons on ARVs improve with 16 wks of therapy
    (Castelnuovo B. AIDS. 2008 Jan)
  • Hypersensitivity to bug bites may be secondary to
    T cell dysregulation
  • Resneck J, et al. JAMA. DEC 1, 2004

20
Molluscum
  • 1st line therapy is ARVs
  • Liquid nitrogen only temporary
  • Curretage of large molluscum
  • Cryptococcus can mimic molluscum but lesions
    develop quickly over days

21
New Directions
  • Can we use these skin diseases as markers for
    virologic response?
  • If these recur on treatment, does it indicate
    drug resistance or non-adherence?
  • Particular importance in resource poor
    settings/children with HIV/as a clue to look for
    resistance-obtain CD4 count, VL

22
  • CD4 250, VL lt 50, admitted for IV vancomycin for
    cellulitis
  • Blister on back-is this a new area of methicillin
    resistant staphylococcus?
  • Call dermatology-consider toxic epidermal
    necrolysis

23
Toxic epidermal necrolysis
  • Complete separation of epidermis
  • Watch for triangular blisters
  • Higher incidence in HIV
  • Higher mortalitiy in HIV
  • TMP-SMX/vancomycin
  • Intravenous immunoglobulin (IVIG)???

24
Drug Reactions
  • NNRTIs-redness-treat through
  • NNRTIs- erythema mutiforme-discontinue drug and
    dont rechallenge change class of drug
  • Abacavir-5-8 develop hypersensitivity rxns-HLA
    B5701 higher risk

25
  • 2 cases of erythema multiforme to raltegravir
  • Fixed drug reactions to darunavir
  • Do not give prednisone unless hypersensitivity
    marked by transaminase or creatinine elevation
  • Syphilis-widespread erythematous maculopapular
    eruption-check RPR-usually does not itch

26
  • Pt with CD4 140, VL 100,000-starts ARVs
  • New pruritic bumps on face, scalp, chest, back
    (within 3 weeks of starting ARVs)
  • He felt it was a drug eruption and so
    discontinued his ARVs

27
Eosinophilic folliculitis
  • CD4 counts under 200
  • Develops within 3-6 months of initiating
    ARVs-immune reconstitution
  • Itraconazole 200-400 mg /day
  • Permethrin from waist up
  • UVB
  • Wait for immune reconstitution to settle (3-6
    months after starting ARVs)

28
  • Differential diagnosis
  • Acne-seeing lots of it as a result of normalized
    immune systems and drug induced acne
    (testosterone, INH, lithium)
  • Doesnt itch and not on scalp
  • Staphyloccocal folliculitis-increased incidence
    in HIV infection-easily denuded pustules (not on
    scalp)

29
  • Pt admitted with painful leg with
    erythema-admitting diagnosis cellulitis
  • Developed pustules
  • Discharged on antibiotics-now pustules all over
    body

30
Herpes zoster
  • CD4 between 200-400, VL 70-100,000
  • Disseminated zoster-seeing it more often in pts
    on and off ARVs
  • Recurrent zoster with high CD4 counts-would that
    lead you to place pts on ARVs?
  • Glesby MJ et al. JAIDS. 2004 Dec.
  • Abbas V et al. Am J Med Sci. 2001.

31
Herpes simplex
  • Have never seen disseminated herpes simplex in
    HIV
  • Pt presents with large hypertrophic and painful
    lesion perianally
  • Must rule out squamous cell carcinoma

32
  • Diagnosis-herpes simplex
  • Send for acyclovir resistance testing
  • Pt will need foscarnet/cidofovir /- topical
    cidofovir
  • Levin et al. Clin Inf Dis. 2004.

33
Squamous Cell Carcinoma
  • Several cohort studies have now documented that
    there is a higher incidence of SCC and BCC in HIV
  • Risk factors being white, increasing age, longer
    duration of HIV infection
  • Low CD4 counts not a significant variable for
    tumor initiation
  • Sun and smoking

34
Melanoma
  • Melanoma in HIV may be more aggressive when
    compared by tumor thickness
  • Sentinel node biopsy recommended at shallower
    thickness-usually do sentinel node if melanoma is
    1mm or more in thickness
  • Recurrent melanoma more frequent
  • Max out the immune system-start ARVs
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