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 ProblemsPsoriasisPsoriasis occurs in approximately 1% of the population worldwide. Its prevalence in HIVinfected26individualspicasis not significantly greater than this, but its presentation is often atypicaland more widespread. Not uncommonly, the abrupt development of widespread psoriasis as anadult without prior history of the disease is the first manifestation of HIV infection.Clinical PresentationPsoriasis can develop in one of two forms, namely localized lesions or generalized disease.The typical lesion is a well-circumscribed, erythematous plaque with thick, “silvery” scalesthat are easily detached, leaving a bright pinkish/red base (Color Plate 9-5). The mostcommon location is on the areas of pressure and trauma such as the extensor surfaces ofthe extremities, sacral area, hands, feet, and scalp. In patients with AIDS, however, psoriasisusually presents as a generalized eruption. Most commonly generalized plaques, butmore atypical forms such as erythrodermic and pustular psoriasis, as well as psoriasisassociated with severe arthropathy are frequently seen.Differential DiagnosisLocalized disease: atypical pityriasis rosea, nummular eczema, tinea corporis; widespreaddisease: seborrheic dermatitis, disorders causing erythroderma including dermatomyositisand lymphoproliferative disease.TreatmentTreatment of generalized disease usually requires some form of systemic therapy, but itoften becomes a difficult issue because of the immunosuppression and/or liver or renaltoxicity that can be associated with most of the systemic drugs available. Examples ofthese therapeutic modalities are the immunosuppressive agents methotrexate andcyclosporine as well as oral retinoids such as acitretin, and biologic response modifierssuch as specific monoclonal antibody therapy. Phototherapy using ultraviolet B alone orPUVA are both associated with very good response rates. Unfortunately, these are notpractical options for patients in the hospice setting because these treatments requiretransportation to a facility that has the appropriate equipment, three times a week, for aprolonged length of time.Topical therapy therefore is the therapeutic modality of choice for most of these patients.Mid to high-potency (Classes I, II, or III) topical corticosteroid preparations, coal tar products,vitamin D derivatives such as calcipotriol, and vitamin A derivatives such as tazarotenecan all be tried. Again, regular emollient use is a very helpful adjuvant measure.FolliculitisInflammation of the hair follicle usually indicates an infection of the pilosebaceous unit. InAIDS, infections with Staphylococcus aureus are very common but additionally organisms thatare part of the normal flora in the hair follicle such as Pityrosporum yeasts (P. ovale) or Demodexmites (D. folliculorum) can induce a very pruritic process characterized by eosinophilic inflammation.In many instances, an infectious agent cannot be identified and biopsy of the skin lesionreveals destruction of the hair follicle by a dense eosinophilic infiltrate, known as eosinophilicfolliculitis. It has been estimated that 25% of the pruritic conditions of advanced HIV disease186U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau