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 Problemsextensive, often involving not only the lip but part of the cheek as well, makingdiagnosis more difficult.Genital herpesSeen in both the healthy and AIDS populations, genital herpes presents witheither shallow, clean, superficial ulcers on an erythematous base or with a patchof erythema with a cluster of vesicles that later ulcerate. These lesions are alsopainful. In advanced AIDS, the chronic, extensive perianal lesions may provide adiagnostic challenge (Color Plate 9-6). As ulcers become confluent and theassociated patches of erythema larger, they often resemble Candida intertrigoand irritant contact dermatitis from chronic diarrhea. Again, careful examinationis paramount to accurate diagnosis and treatment because antifungalagents will not help and topical steroids will make the infection much worse.Candidal intertrigo usually involves the entire perineum, not simply the perianalregion, characteristically has peripheral satellite lesions, and ulceration is not afeature. In addition, chronic diarrhea and incontinence should cause perianalirritation and maceration, but there should not be large regions of ulcerationunless there is also associated decubitus ulcer. In such cases, it is always best toswab the ulcer base for viral culture.Herpetic whitlowPainful, tender, erythematous patch on the distal phalynx of usually one finger.Whitlow is the result of direct inoculation of the finger from another site andbefore AIDS was more commonly seen in health care workers as a consequenceof direct, ungloved contact with a patient’s herpetic lesion.Varicella zoster virusReactivation of the varicella zoster virus (VZV) from the dorsal root ganglia ofspinal nerves is a painful sequella to AIDS-related immunosuppression.Following a dermatomal distribution, a strikingly erythematous cluster ofpapules forming a plaque with overlying vesicles is often present in a patch- orband-like configuration. The presentation in normal hosts is one in which anysignificant portion of the rash rarely crosses the midline. However, in theAIDS group, zoster may be more inflamed and painful and may be disseminated.Chronic and recurrent forms may also become an issue. Burning painmay either precede the cutaneous eruption or may continue after the acuteepisode as postherpetic neuralgia. The postherpetic neuralgia is a cause ofsignificant morbidity, as the intense burning pain can last for years after thecutaneous lesions have gone and is often very difficult to treat, especially inthis population. Involvement of the tip of the nose signifies involvement of theophthalmic branch of the trigeminal nerve and heralds a potential ophthalmicemergency, termed zoster ophthalmicus. In AIDS patients receiving chronicacyclovir therapy, acyclovir-resistant VZV infection may present with a chronic,disseminated form of Zoster. The lesions are warty, hyperkeratotic papuleswith or without ulceration or eschar formation.Molluscum contagiosumA contagious viral infection previously seen predominantly in children, thispreviously benign condition can occasionally have devastating consequencesin AIDS.26 picas190U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau