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 Problemscommon fungal infections are the “tineas,” caused by dermatophyte fungi, followed by Candidainfections. As the disease progresses, patients are more susceptible to acquiring deep fungalinfections such as blastomycosis and sporotricosis and also to developing cutaneous lesions ofgeneralized26systemicpicasfungal infections, such as cryptococcosis and histoplasmosis. There is alsoa poorer response to standard therapies and higher recurrence rates. Additionally, the resultingskin breakdown may also predispose these patients to bacterial superinfection and bacteremia,which they are ill equipped to handle.Clinical PresentationDermatophytosesSuperficial fungal infections in AIDS patients may be extensive, especially inthe groin and feet. Tinea pedis (“Athlete’s foot”), tinea cruris (“jock itch”),and tinea corporis (“ringworm”) all occur with a similar frequency in thegeneral population, but tinea pedis is the most common dermatophytosis seenin AIDS. 8 With all three infections, the lesions may become more widespread,larger, and more resistant to traditional therapies. They may also present withatypical clinical features resembling other noninfectious dermatologicproblems (Color Plate 9-8).ThrushOral candidiasis, or thrush, occurs in almost all HIV patients and is oftendifficult to cure. In addition to immunosuppression, complicating factorsinclude a high rate of oral carriage in even healthy patients as well as frequentand long-term antibiotic use. Classically, there are white plaques on thepalate, tongue, and gingival area, which can be scraped off to leave anerythematous, often slightly bleeding base. In the case of long-standinginfection, it may be difficult to scrape them off. Dysphagia and sore throat areall commonly associated complaints. Candida intertrigo occurs commonlyin patients with warm, macerated, moist skin and very commonly in AIDSpatients (covered in Skin Problems in the Chronic, Bedridden Patient on page198). Candida paronychia is a frequently misdiagnosed condition that is oftenseen in patients who wash their hands frequently, do dishes frequently, or havetheir hands in cleaning solutions. Periungual erythema, swelling, and theextrusion of pus is a common presentation, and is often misdiagnosed asbacterial infection. Here, the patient’s history should guide diagnostic andtreatment options.Deep Fungal InfectionsPresentation varies from fungating nodules and tumors to ulcers and diffusepapulonodular disease. Cryptococcosis and histoplasmosis, when affectingthe skin, may present with multiple, widespread, translucent, dome-shapedpapules with a slight central dimple resembling molluscum contagiosum, butthe morphologic variation can be broad.IXDiagnosisDermatophytesTinea can have atypical presentations in these patients, often resembling oneof the eczemas or even psoriasis. As a rule of thumb, every lesion that is scalyU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 193