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HIV Derm PDF
HIV Derm PDF
UCSF Dermatology
Answer: e
What is your next step in evaluating this
patient?
a. Look inside the patients mouth
b. Order an HIV test (history of IV drug use)
c. Order a baseline lipid panel
d. a & c
e. a & b
Case One: Diagnosis
Answer: c
Which of the following values likely
represents Mr. Mitchels CD4 count?
a. > 500
b. 200-500
c. <200 (although both can be found at any CD4
count, oral candidiasis and psoriasis
commonly occur at CD4 counts < 200)
d. <50
Case Two
Mr. Donald Conrad
Case Two: History
HPI: Mr. Conrad is a 38 year-old, HIV-positive gentleman
(unknown last CD4 count, not on HAART) who presents
with bumps behind his ear as well as well as white spots
on his tongue and mouth
PMH: HIV diagnosed 5 years ago, no hospitalizations
Medications: none
Allergies: none
Family History: no history of major illnesses or cancers
Social History: lives downtown with his girlfriend
Health-related behaviors: remote history of alcohol and IV
drug use
ROS: new odynophagia
Case Two: Exam
Answer: f
What is the patients likely diagnosis(es)?
a. Verruca vulgaris
b. Molluscum contagiosum
c. Oral candidiasis
d. Basal cell carcinoma
e. a&c
f. b&c
Molluscum Contagiosum and HIV
Molluscum contagiosum (MC) is caused by a DNA
poxvirus
More common in HIV-positive patients with CD4
counts < 100
Lesions are spread through direct skin to skin and
sexual contact
Lesions commonly found on the face and genital areas
as firm, pearly skin-colored papules with central
umbilication
In HIV-positive patients, lesions may be more numerous, more
verrucous, larger and much less likely to spontaneously
resolve
See the module on Molluscum Contagiosum for more detail
MC Evaluation and Treatment
Diagnosis is often made clinically
Diagnosis can also be made by extracting the contents of the
lesion and examining microscopically after staining
May also use a skin biopsy if diagnosis is unclear
First-line treatment is antiretroviral therapy
Treatment for MC usually involves destruction of the
lesion by one of the following methods:
Cryotherapy
Electrodessication
Curettage
Cantheridin
Trichloroacetic acid
Candidal Infection and HIV
Answer: a
Which of the following is the best treatment
option for Mr. Conrad?
a. Oral fluconazole (patient likely has oropharyngeal +
esophageal candidiasis, which requires systemic
treatment)
b. Nystatin suspension (used to treat oropharyngeal
candidiasis)
c. Clotrimazole troches (used to treat oropharyngeal
candidiasis)
d. Oral cephalexin (a cephalosporin antibiotic will not
help treat candidiasis)
Mucocutaneous Candidiasis Treatment
Answer: a
What is the most likely diagnosis?
a. crusted scabies
b. widespread atopic dermatitis
c. psoriasis
d. disseminated herpes simplex
Scabies and HIV
See module on Infestations and Bites for more information about Scabies
Treatment of Crusted Scabies
Answer: b
What is the most likely diagnosis?
a. Bacillary angiomatosis (skin lesions appear as small
red papules that may enlarge to become nodules)
b. Kaposi sarcoma
c. Angiosarcoma (angiosarcoma of the skin presents as
singular or multifocal "bruise"-like patches on the skin,
most frequently on the head and neck)
d. Urticaria (pruritic, elevated papules and plaques, often
with erythematous, sharply-defined borders and pale
centers)
Kaposi Sarcoma
Facial lipoatrophy is
characterized by loss of
fat throughout the face
leading to temporal
wasting and changes in
the contour of the
cheeks and orbits.
Lipodystrophy
Potential complications of lipodystrophy syndrome
include both psychological and medical aspects
Association between specific antiretroviral exposure and
morphological change is strongest for lipoatrophy.
Management of HIV-associate lipodystrophy includes
both medical and surgical approaches
Lipoatrophy
Changing antiretroviral regimen may benefit
Surgical approaches to facial lipoatrophy include the use of fillers
and injectable medical devices
Lipohypertrophy
Surgical procedures, including liposuction
Weight loss through diet and exercise
Take Home Points
A high percentage of HIV-positive patients have dermatologic
disease
Skin lesions may the 1st sign of HIV infection
Dermatologic disease common to the general population may
have an increased prevalence or severity in HIV positive
individuals
Various skin manifestations of HIV infection can be correlated with
levels of immune suppression
A thorough skin exam includes looking inside the mouth
HIV-associated psoriasis may be refractory to conventional
therapy
The lesions of molluscum contagiosum are often more numerous,
more verrucous, larger and much less likely to spontaneously
resolve in HIV-positive patients
Oral candidiasis is the most common fungal disease in HIV-
positive individuals
Take Home Points
Oropharyngeal candidiasis may be treated with topical antifungals
Esophageal candidiasis requires systemic treatment
HIV-positive patients are at increased risk for crusted scabies,
which is far more difficult to treat, requiring both topical and oral
therapy
AIDS-associated or epidemic Kaposi sarcoma is one of four types
of KS
KS most often affects the skin, but mucous membranes,
gastrointestinal treat, lymph nodes and lungs may be involved
HIV-positive individuals are at an increased risk of skin cancers
Institution of HAART often results in the improvement of HIV-
associated skin disease
HIV-associated lipodystrophy is characterized by an abnormal
distribution of body fat that is often accompanied by metabolic
abnormalities such as insulin resistance and dyslipidemia
End of the Module
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Dezube B, Groopman J. AIDS-related Kaposis sarcoma: clinical features and
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Garnan ME, Tyring SK. The cutaneous manifestations of HIV infection. Dermatol
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Kaufmann C. Treatment of oropharyngeal and esophageal candidiasis.
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Lopez FA, Sanders CV. Fever and rash in HIV-infected patients. Uptodate.com.
10/2009.
Luther J, Glesby MJ. Dermatologic Adverse Effects of Antiretroviral Therapy.
Recognition and Management. Am J Clin Dermatol. 2007;8(4):221-233.
Mauer T. Dermatologic Manifestations of HIV Infection. Top HIV Med
2005;13(5):149-154.
Menon K, et al. Psoriasis in patients with HIV infection: From the Medical Board
of the National Psoriasis Foundation. J Am Acad Dermatol 2010;62:291-9.
End of the Module