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

Chapter 9.26 picasDermatologic ProblemsDavid J Kouba, MD, PhD, and Ciro R Martins, MDINTRODUCTION■ The prevalence of skin disorders in AIDS patients treated in the palliative care setting isexceptionally high. Unfortunately, accurate diagnosis and proper treatment of skin diseases inboth HIV and AIDS can be an especially challenging and often frustrating task, because thepresentation of common dermatoses is often exaggerated into florid cutaneous eruptions. Thepractitioner also has to be cognizant of more unusual cutaneous disorders that would otherwisebe virtually nonexistent in his or her daily practice. Furthermore, because of the severe immunosuppressionseen in end-stage AIDS patients, treatment and eradication of these disorders isalmost always difficult, and often not possible. In these instances, appropriate palliative careneeds to be administered in a timely fashion to assure a better quality of life for these patients.The health care provider will need to be aware of the following in caring for AIDS patients in thepalliative care setting who develop skin disorders.• Many common dermatoses may have unusual or unusually severe presentationsin HIV disease, and especially in advanced and end-stage AIDS.• The hospice environment predisposes patients with AIDS to certain skinconditions. This is attributable not only to severe immunosuppression, butalso to immobilization, bed confinement, and close quarters.• It is important to recognize primary skin lesions, and to differentiate thosefrom cutaneous changes associated with manipulation and trauma to the skin,such as scratching, picking, and rubbing. These are seen in most patientswith advanced HIV disease, as a consequence of severe, chronic, andintractable pruritus.• A thorough skin examination must be done whenever possible and should beperformed under good lighting, with the patient completely undressed.Examine the whole body including scalp, hair, oral mucosa, and nails. It is ofutmost importance to note the pattern of distribution of the lesions and areasof sparing and to determine the predominant type of lesion.• Simple auxiliary tests done on scrapings of the skin can be diagnostic and areextremely helpful in narrowing down the differential diagnosis. They should beperformed as often as possible and whenever a microscope is available. Thesetests include KOH prep of every scaly lesion, Tzanck smear of any ulcerated orbullous lesion, and mineral oil prep of generalized pruritic papules orwhenever the clinical morphology or epidemiology are suggestive of scabies.Cultures for bacteria, fungi, mycobacteria, and viruses should always beobtained whenever clinical findings suggest an infection.IXU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 177