An overview of sexually transmitted diseases. Part III ... - Dermatology

J AM ACAD DERMATOL
VOLUME 43, NUMBER 3
tiple HPV types, including oncogenic types. 146,158-60
Clinically, although HIV patients may have the same
condylomas as normal persons, they may also have
more extensive or even disseminated condylomas
that may be relatively refractory to treatment.
Furthermore, HIV-infected patients’ condylomas are
associated with a significant risk of transformation
into squamous cell carcinoma.
Proper diagnosis is essential in these cases.
Usually, anogenital warts are diagnosed by clinical
acumen, but in HIV-infected patients biopsy should
be considered before therapy so that appropriate
diagnosis of dysplastic changes or squamous cell
cancer can be ascertained early in the disease management
process. 1,158 Treatment options available to
the HIV-infected host do not differ from those available
to the immunocompetent host and are discussed
by Brown, Tyring, and Yen-Moore 161 in part II
of this series on sexually transmitted diseases. Some
clinicians advocate treatment by excision and electrodesiccation
because of the poor response and frequent
recurrences after topical treatments 162 and
the association between HPV and cancer in this population.
158,163
Notwithstanding, some studies have evaluated
nonsurgical treatment modalities for genital warts
in the immunocompromised host. Podophyllotoxin
has been studied for genital warts in HIV-positive
Tanzanian patients, 164 but given the association of
HPV in HIV-infected patients with squamous cell
cancer, this therapy may be inappropriate for this
population. 165 Interferon has been studied in this
population, 166,167 as has imiquimod. 168 Although
both have some efficacy in treating HPV infection in
HIV patients, neither appears to be effective as
monotherapy in completely clearing clinical lesions
from the most severely immunocompromised
patients. Use of imiquimod as adjunctive therapy
after surgical or cytodestructive treatment of
condyloma acuminatum does appear effective in
HIV-seropositive and in other immunocompromised
patients in terms of significant delays or prevention
of recurrences. Cidofovir gel has been
studied in a phase I/II trial of HIV-positive patients
with condylomata acuminata and appears safe and
potentially effective in this population. 169 Finally,
Orlando et al 170 recently reported that relapse
rates of condyloma in HIV-infected patients
decreased with improved treatment of their underlying
HIV infection with antiretroviral medication.
Successful treatment of condylomas thus appears
easier when a person’s underlying HIV infection is
better controlled. Clearly, treatment of HPV infections
in HIV-infected patients is an issue that
deserves further study.
Czelusta, Yen-Moore, and Tyring 419
MOLLUSCUM CONTAGIOSUM
The association between HIV infection and molluscum
contagiosum was first noticed in 1983
through an autopsy study of 10 patients with
AIDS. 171 Many reports of severe and atypical infections
have surfaced, and in AIDS patients, the prevalence
of molluscum contagiosum lesions ranges
from 5% to 18%. 172-176 Dann and Tabibian 177 document
molluscum contagiosum as one of the 3 most
common reasons nondermatologists referred HIVinfected
patients to a university-based immunosuppression
skin clinic.
In HIV-infected patients, molluscum contagiosum
manifests itself most commonly when immune function
has been dramatically reduced. Several studies
document that molluscum contagiosum infection is
a clinical sign of marked HIV progression and very
low CD4 cell counts. 176,178-181 Specifically, when the
CD4 cell count drops below 200/mm 3 , the incidence
of molluscum contagiosum appears to increase dramatically.
182 The unfortunate clinical correlate with
this finding is that AIDS patients in whom molluscum
contagiosum occurs have a poor prognosis,
with a median survival time of 12 months in one
study. 176 The presence of mollusca, however, does
not appear to be an independent prognostic indicator
after accounting for immunosuppression.
Considerable debate remains as to whether the
disease is caused by the reactivation of latent virus or
whether it represents a recently acquired infection
complicating patients’ progressive immunosuppression.
The molluscum contagiosum virus commonly
infects the general population. In an Australian study
incorporating both HIV-positive and HIV-negative
patients, 23% of the studied population had antibodies
consistent with either a current or previous
infection. 183 As the age of the studied population
increased, so did the frequency of molluscum contagiosum
antibodies. 183 These findings were believed
to support the theory that mollusca in AIDS patients
reflect the reactivation of a latent infection. 184
However, other studies contradict this supposition.
Molecular research demonstrates that molluscum
contagiosum viruses can be divided into two
major types (designated MCV-1 and MCV-2) based
upon restriction fragment cleavage patterns of the
viruses’ genome. 185 Although it is not yet clear what
clinical implications these types may have, the ratio
of MCV-1 to MCV-2 in one Japanese population was
found to be 13:1. 186 MCV-1 occurred in highest frequency
in children and adult women, whereas MCV-
2 occurred more frequently in adult men and
patients with HIV. 186 This study was consistent with
an earlier Australian study that showed HIV-positive
patients were significantly more likely to be infected