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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 9: Dermatologic ProblemsPRURITUS AND ITS CONSEQUENCES■ Pruritus, or the sensation of itching, is the most common dermatologic symptom and it can,at times,26be sopicassevere as to drive patients to developing suicidal thoughts. Unfortunately, but notsurprisingly, it is also the most common dermatologic problem in patients with both HIV andAIDS. With this in mind, accurately diagnosing a pruritic eruption becomes a daunting, yetnecessary task because the pruritus can cause significant morbidity.Pruritus can be localized or generalized and is often associated with a state of hypereosinophilia.It can be caused by skin lesions or rashes or it can indirectly induce the development of skinlesions due to trauma, such as from scratching and rubbing. To establish the etiology of thepruritus, the practitioner should first attempt to identify any primary skin lesions and thenfollow a rather simple diagnostic algorithm. Examples of types of primary lesions that one commonlyencounters with pruritic eruptions are papules or nodules (“bumps”), plaques (slightlyelevated, palpable lesions with large diameter), and exanthems (diffuse or patchy “redness” ofthe skin). Very commonly one sees combinations of different types of lesions that may or may notbe associated with surface changes, such as scaling, crusting, or ulceration.IXClinical PresentationThe clinical presentation of pruritus is widely variable because of its many potential etiologies(Table 9-1). Localized pruritus is usually associated with primary skin lesions, i.e., papulesand burrows of scabies or scaling plaques of tinea corporis. However, generalized pruritus mayor may not be associated with primary lesions. For example, pruritus associated with obstructivebiliary disease may only demonstrate excoriations, but generalized xerosis cutis shows widespreaddrying, cracking, and fissuring of the skin, which is responsible for intense itching. Unfortunately,in the terminal stages of AIDS, patients often suffer from cutaneous disorders representinga combination of multiple pathologies. Often, in addition to xerosis, there may beadverse drug reactions, liver failure, and multiple infections, which all result in potentially unbearablepruritus, making diagnosis and palliative treatment very difficult.Table 9-1:Most Common Skin Conditions Associated withPruritus in Patients with AIDSXerosis cutisEczemas: seborrheic dermatitis, nummular eczema, atopic dermatitis, contact dermatitisFolliculitisDrug eruptionsLichen simplex chronicus / prurigo nodularisPapular urticaria (insect bite hypersensitivity reaction)Dermatophyte (tinea) infectionsIntertrigo (Candida, tinea, herpes simplex)ScabiesU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 179