The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 8: Oral ProblemsRecurrent aphthous lesions are generally shallow, cratered lesions with a raised, erythematousborder and a gray, central pseudomembrane. HIV-positive patients can have these lesions onkeratinized tissue, whereas HIV-negative patients generally do not.26 picasThese lesions are left to heal on their own in a patient with a competent immune system. However,the lesions do cause pain and can become quite large, particularly if a patient has a compromisedimmune system. If the lesions become secondarily infected, treatment should beimplemented immediately. Accordingly, HIV-positive patients require palliative care for any lesion,irrespective of its size, to prevent it from expanding, creating potentially serious problems.Palliative care consists of a steroid medication, most frequently topical, to prevent the possibilityof an extended problem or progression to recurrent aphthous stomatitis major. Options fortreating aphthous ulcers include dexamethasone solution (“swish and spit”), local steroid ointment(such as Kenalog, sometimes compounded together with an adherent paste such asOrabase), or even systemic steroids such as prednisone for patients with large lesions or suspectedinvolvement of the esophagus or lower gastrointestinal tract. Treatment with thalidomidehas recently been approved for aphthous ulcers in patients with AIDS.Patients with advanced disease, particularly if they have wasting syndrome or are generallydebilitated, have great difficulty when this lesion causes pain and decreases their ability toconsume food comfortably. Early treatment is key, and palliative care should be implementedright away.These lesions can be mistaken for recurrent herpes. Patients with either lesion have had ahistory of this condition and usually do not suffer from both, so a reliable history is a goodmethod to determine the condition; viral cultures for herpes simplex can also be helpful.VIIIRECURRENT HERPES SIMPLEX■ Herpes simplex lesions, like aphthous ulcers, occur frequently irrespective of a patient’s HIVstatus. (Color Plate 8-6) Just as aphthous ulcers can be more problematic for HIV-positive patients,the same is true for herpetic lesions. Herpes simplex lesions can be more painful, larger,and more prone to secondary infections in HIV-positive patients. Again, like aphthous ulcers,these can accelerate problems for patients with wasting syndrome by causing pain and decreasingthe ability to eat comfortably.Herpes simplex lesions start with a prodromal feeling of malaise, fever and general debilitation.This can be masked in patients who are already debilitated. There may be an itching or tinglingsensation. Vesicles form, usually within 24 hours, with rupture shortly after, forming a scab. Thelesion usually is not treated in an immune-competent patient, and ordinarily resolves within twoweeks.However, in immune-compromised patients treatment should be provided, and usually involvesthe use of a systemic antiviral medication for herpes. Topical medications do not usually work aswell as systemic medications in this situation. However, if the condition is at an early stage, priorto the rupture of the vesicles, topical antiviral medication may be effective. Once the vesiclesrupture or are well established, systemic treatment with antivirals is warranted, most commonlyacyclovir or famciclovir.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 171