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 Problemsostium (“pore”) at the center of each individual lesion. Another way ofassessing if they are follicular is to see if the lesions are roughly equally spacedon the affected areas, since hair follicles do have a homogeneous distribution26on anypicasgiven skin area.Yes, Lesions Are FollicularOnce it is determined that the lesions are associated with hair follicles, a shortdifferential diagnosis is available and includes folliculitis, acne, and rosacea.No, Lesions Are Found on Sites Other than Hair FolliclesThe remaining primary nonfollicular, pruritic lesions should then be groupedinto two main groups: papular/nodular lesions and the scaly/papulosquamouseruptions. Diagnosis of papular nonfollicular primary lesions most commonlyincludes scabies, insect bites and papular urticaria, drug eruptions, miliaria,and Grover’s disease (discussed in section on Skin Problems in the Chronic,Bedridden Patient on page 198). The most frequently encountered scaly/papulosquamouseruptions are xerosis cutis, asteatotic eczema, seborrheic dermatitis,dermatophyte infections, and psoriasis, which are differentiated by the extent ofdisease, the quality of the scale, location, and degree of associated inflammation(discussed in section on Eczemas and Papulosquamous Disease on page 183).IXObjective DataIn patients with HIV, a thorough skin examination will reveal, in most cases, at least onepossible dermatologic cause for the pruritus. In these cases, the skin condition should be treatedbefore an expensive workup for possible systemic causes of pruritus is done, because clearingthe skin problem very often clears the pruritus as well.The laboratory investigation for internal causes of pruritus in the absence of primary skin pathologyand neurologic disease is the same for AIDS patients as it is for the immunocompetentindividual. A complete blood count with manual differential can exclude anemia, polycythemiavera, or lymphoproliferative disorders. Liver function tests can rule out obstructive biliary processes.An electrolyte screen that includes blood urea nitrogen, creatinine, and glucose levelsexcludes renal insufficiency, uremia, and diabetes. Thyroid-stimulating hormone and parathyroidhormone are good primary screens for thyroid and parathyroid disorders.TreatmentAs previously mentioned, the first step is to treat any primary dermatologic process. In casesassociated with a systemic disease, cure of the underlying systemic process is frequently impossible,therefore therapy is aimed at achieving and maintaining symptomatic relief only. Some generalguidelines should be followed, keeping in mind that the main goal is to break the itching/scratching cycle, because scratching induces more pruritus, thus perpetuating and intensifyingthe problem. Some measures that may help most patients with pruritus are discussed below.• Modification of showering and bathing habits, advocating the importance of taking no morethan one shower a day, avoiding hot showers, using soap very sparingly, preferably on the intertriginousareas only, and not using any abrasive material such as washcloths, sponges, etc.• Adequate moisturization of the skin with daily or twice-daily applications of emollient lotionsor creams to prevent or correct xerosis cutis, one of the most common causes of pruritus inpatients with advanced HIV disease.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 181