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 ProblemsSimpleThe usual presentation in both normal children and adults with AIDS is that ofscattered skin-colored, dome-shaped papules, approximately 3 mm in diameter26 picaswith a central dimple, or umbilication. The lesions can be a few in number orbe present in hundreds, covering large areas of the body, commonly the faceand neck, with devastating impact on the patient’s quality of life.ComplicatedLess frequently, in the immunocompromised patient giant molluscum mayensue with larger papules that appear in a cluster and aggregate into largefungating plaques (Color Plate 9-7).Human papillomavirusDifferent serotypes of the human papillomavirus (HPV) dictate where a wart willarise on the body. Verruca vulgaris, or common warts, are frequently seen in boththe general population and in AIDS patients. They are difficult to eradicate inboth groups. Condyloma accuminata, or genital warts, flourish in the immunosuppressedhost and may reach very large sizes, presenting as warty, cauliflower-likegrowths in the perineal region. Flat warts do occur in the normal host, but tend toflourish in the immunocompromised. They appear as groups of hypopigmented,flat-topped, regularly shaped 2 to 4 mm papules that, at times may be so flat as toappear macular. Condyloma accuminata are generally associated with HPVserotypes 6, 11, 16, and 18. There is a significantly increased risk for thedevelopment of squamous cell carcinoma when the lesions are associated withHPV types 16 and 18. Anogenital veruccae are often difficult to visualize withoutanoscopy and, unfortunately, may cause the most significant morbidity, as verylarge growths may partially obstruct the anal canal.IXDiagnosisMost of the aforementioned disorders are diagnosed strictly on clinical grounds; however,viral culture and serotyping can be an important tool for not only confirmation of theclinical suspicion but also for viral sensitivity profiles, because resistance is not uncommon.If the diagnosis is uncertain, then a simple punch biopsy of the lesion in questioncan also aid in diagnosis. A Tzanck smear for HSV can be performed in the office if vesiclesor fresh ulcers are present. Old, previously unroofed blisters or ulcers will not suffice.Using a sterile scalpel blade and a sterile swab, the intact blister roof is removed and thebase of the blister is aggressively scraped. (Extraction of the blister fluid alone is insufficientfor the Tzanck smear.) Once the base is swabbed, the cells are rubbed onto a microscopeslide and the specimen is rapidly fixed and stained in the office prior to microscopicexamination looking for multinucleated giant cells. During the same procedure, a culturemay be taken from the same denuded blister.TreatmentHSVThe approach to treating herpes labialis, genital herpes, and herpetic whitloware very similar. Previous initial therapy utilized acyclovir, a cumbersomeregimen that required five daily doses which, in combination with other AIDSU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 191