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

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422 Czelusta, Yen-Moore, and Tyring J AM ACAD DERMATOL SEPTEMBER 2000 suggests that the development or resolution of KS is tightly linked to immune system control of HHV-8. HEPATITIS B VIRUS AND HEPATITIS C VIRUS Both hepatitis B virus and hepatitis C virus (HBV and HCV, respectively) commonly coinfect HIVseropositive persons. Sexual transmission of HBV, however, appears to be more frequent than with HCV. Discussion of the cutaneous manifestations of those viruses as well as their treatment and prophylaxis can be found in part II of this 3-part STD review. 161 The relationship between hepatitis C infection and sporadic porphyria cutanea tarda in the immunocompetent host is well documented. 257,258 Similarly, sporadic porphyria cutanea tarda can occur in the HIV-positive patient in association with HCV infection. 259-262 Some reports evaluate the potential of HIV infection as an independent cofactor in the development of porphyria cutanea tarda. 262-265 One recent report describes a case in which an HCV- and HIV-infected man whose porphyria cutanea tarda subsided 18 months after starting HAART for HIV infection. 259 Regardless, any patients presenting with porphria cutanea tarda should be evaluated for both HCV and HIV infection. ECTOPARASITIC INFESTATIONS Scabies Scabies occurs commonly in young adults who acquire it through sexual contact. In 1848, Danielssen Fig 10. HIV-positive patient. Kaposi’s sarcoma. and Boeck first described a particularly contagious and fulminant form of scabies in Norwegian patients immunosuppressed as a consequence of Hansen’s disease. These patients’ infestations were characterized by thick, friable plaques. This form of scabies, Norwegian or crusted scabies, has emerged as yet another harbinger of HIV infection. Published reports of atypical and crusted scabies infestations in association with HIV infection have become increasingly frequent since the first such report in 1986. 266-298 The defining clinical features of scabies in the HIV-positive patient are often determined by the degree of immunocompromise. 299 The typical presentation of a person infested with scabies (papules and burrows in the axillae, groin, or digital web spaces associated with complaints of nocturnal pruritus) occurs in HIV-infected patients with relatively normal immune function. However, as patients become progressively more immunosuppressed, the more contagious and fulminant forms of scabies become apparent. 267-269,271,272,282 This conversion from ordinary scabies to more severe and unusual infestations has been documented in individual patients who experience declines in their CD4 cell counts to below 200/mm 3 . 266,272,274,285 Still, as noted by Portu et al, 295 although low CD4 cell counts may be more commonly associated with the severe and unusual forms of scabies, these fulminant infections can occur in early stages of HIV disease. These severe and unusual forms of scabies can be divided into two overlapping and broad categories:
J AM ACAD DERMATOL VOLUME 43, NUMBER 3 papular (also known as atypical or exaggerated) scabies and crusted (also known as Norwegian or hyperkeratotic) scabies. 285,299,300 The papular forms are characterized by generalized papules, each of which is topped by a scabietic burrow, which may be scaly. Patients complain of severe pruritus with this form. 266,273,277,285 The crusted forms are characterized by thick, friable, white-gray plaques, which may also be diffuse, but are commonly localized to individual body regions including the scalp, face, back, buttocks, nails, and feet (Fig 11). The plaques are often associated with fissuring that may be mild to severe. 267-272 Furthermore, as a patient’s lesions become crusted, they tend to become less pruritic. The distinction between papular and crusted scabies is not mutually exclusive, and some reports document patients with lesions characteristic of both forms. 270,284 Infestations may be mistaken for eczema, psoriasis, contact dermatitis, drug reactions, seborrheic dermatitis, Darier’s disease, or dermatophytosis. Scabies must be suspected in any HIV-infected person with an atypical or pruritic rash. Similarly, young patients with HIV risk factors in whom papular or crusted scabies develops without an apparent underlying cause should be suspected of having HIV infection. Skin scrapings are often diagnostic in crusted or papular scabies and may be taken from any nonexcoriated region or from underneath the nails; however, if scrapings are negative and clinical suspicion remains, a skin biopsy can be very helpful. 285,299,300 It must be noted that a key feature of crusted scabies infestations in the HIV-infected patient is an exceptionally high mite burden. Whereas an immunocompetent host is estimated to have 10 to 15 live female mites during an infestation, 301 individual crusts in crusted scabies may harbor thousands of mites. Furthermore, although the scabies mite has a limited life span (
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An overview of sexually transmitted diseases. Part III ... - Dermatology

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