Generalized cutaneous conditions, such as xerosis (dry skin), seborrheic eczema, and pruritus, are common and may be manifested prior to development of opportunistic infections. Treatment is with emollients and, if necessary, mild topical steroids. Pruritus may respond to oatmeal baths and antihistamines. Other infections, including S. aureus (manifested as bullous impetigo, ecthyma, or folliculitis), Pseudomonas aeruginosa (which may present with chronic ulcerations and macerations), and syphilis are frequently seen and should be treated with standard therapies. Several specific dermatologic conditions are discussed in more detail below.
Kaposi's sarcoma appears more often in homosexual men than in other risk groups. Clinically, it consists of painless, raised brown-black or purple papules and nodules that do not blanch. Common sites are the face, chest, genitals, and oral cavity; however, widespread dissemination involving internal organs may occur. Since cutaneous Kaposi's sarcoma is not generally associated with significant rates of morbidity or mortality, therapy is indicated only for extensive, painful, or cosmetically disfiguring lesions. Cryotherapy or radiation can be used for localized disease; widespread disease may be responsive to chemotherapy with vincristine, vinblastine, or doxyrubicin.
Herpes simplex infections are common and may be localized or systemic. In patients with significant immunosuppression, infection may become progressive, manifested as chronic ulcerative mucocutaneous lesions. Diagnosis and treatment are the same as for other patients with herpes simplex (see Chap 150, "Common
Viral Infections"). Intravenous acyclovir therapy 5 to 10 mg/kg/day is needed for extensive disease.
Reactivation of varicella zoster virus is more common in patients with HIV infection and AIDS than in the general population. 18 The clinical course is prolonged, and complications are more frequent. In HIV-positive patients with oral acyclovir 800 mg five times a day or oral famciclovir 500 mg tid for 7 days is usually sufficient.
However, in patients with disseminated disease or ophthalmic zoster, admission is indicated for intravenous acyclovir.
Intertriginous infections with either Candida or Trichophyton are often seen in patients with HIV and can be diagnosed by microscopic examination of potassium hydroxide preparations of lesion scrapings. Treatment includes topical imidazole creams, such as clotrimazole, miconazole, or ketoconazole. Scabies occurs in about 20 percent of HIV-infected patients, but classic intertriginous lesions are less common. Any patient with a scaly, persistent pruritic eruption should have lesions scraped and examined histologically for scabies mites. Treatment is with permethrin 5% cream or lindane lotion. Human papillomavirus infections occur with increased frequency in immunocompromised patients. Treatment is cosmetic or symptomatic and may include cryotherapy, topical therapy, or laser therapy. Other dermatologic conditions that occur with increased frequency among HIV-infected patients include psoriasis, atopic dermatitis, and alopecia. Referral for dermatologic consultation is appropriate.
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