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 Problemsrepresent some type of folliculitis and these prevalence rates can increase during the summermonths. In patients receiving chronic antibiotic prophylaxis, a gram-negative folliculitis mayalso develop. Another type of noninfectious folliculitis commonly seen is that associated withhormonal26therapy,picasmainly testosterone and anabolic steroids as well as growth hormone replacementtherapy.Clinical PresentationS. aureus folliculitis is usually caused by cutaneous spread from nasal carriage, which istwice as common in HIV-positive people than in healthy control subjects. The presentationcan be varied, but typically consists of erythematous follicular papules and pustulessomewhat equally spaced on the skin surface, but may be clustered in some areas. Lesionsin different stages present at the same time, with pustules, crusts, and varying degrees ofinflammation and are very suggestive of a bacterial process. Monomorphic superficial pustulesare more typically seen in folliculitis caused by yeasts, whereas significant edema ofindividual papules (“juicy” appearance) with signs of aggressive excoriation are more suggestiveof either a parasitic or an eosinophilic process. In cases of bacterial folliculitis,depending on the degree of inflammation and the depth of penetration into the follicle, apainful, erythematous nodule may develop, called a furuncle or boil.Eosinophilic folliculitis usually presents when CD4 counts drop below 200. It presentswith urticarial papules usually confined to the upper trunk, face, scalp, and neck, and itcan uncommonly also be pustular. The course waxes and wanes and can be characterizedby unpredictable flares. There is usually an associated peripheral eosinophilia and elevatedlevels of IgE.IXDiagnosisClinical diagnosis alone is difficult for the untrained care provider, therefore lesions shouldbe biopsied and sent for culture and histopathology, specifically requesting special stainsfor different infectious organisms.TreatmentIn the absence of available tissue for histopathologic examination, it is acceptable to empiricallytreat based on a “shotgun” type approach. If forced into such a circumstance bythe inaccessibility of a biopsy, coverage for fungal elements, bacterial pathogens andDemodex, in addition to treating the inflammatory component, is required. In such aregimen, ketoconazole 2% lotion applied qd to bid, erythromycin 2% gel applied bid with orwithout 10% benzoyl peroxide and metronidazole 0.75% lotion applied bid cover fungal,bacterial and Demodex, respectively. Any non-fluorinated steroid of choice used bid isappropriate to control inflammation. In the presence of diagnostic biopsy demonstrating apredominance of either fungal or bacterial or Demodex responsible for the eosinophilicinflammation, treatment modalities should reflect the histopathologic diagnosis.However, in the absence of a biopsy, a “shotgun” approach is not always necessary. Inmany situations, the clinical history and appearance of the lesions can guide a more directedapproach to therapy. Clinically obvious bacterial folliculitis should be treated withtopical antibiotics and benzoyl peroxide combinations. Clindamycin/Benzoyl peroxide aswell as Erythromycin/Benzoyl peroxide combinations are very useful for limited areas. Forlarger treatments, a benzoyl peroxide wash is helpful. In addition, antibacterial soapsU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 187