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 Problemshas to be scraped for a KOH prep. When scraping suspected lesions, use adisposable scalpel blade, held perpendicularly to the skin, collecting theobtained scales on a microscope slide. Then add a drop of 10% KOH, cover witha coverslip, and warm the slide up by placing it under a flame for three to fiveseconds. The slide is then examined under the microscope looking for thepresence of septated, branching hyphae. The highest yield is obtained whenthe peripheral scales on the edge of the advancing lesional border are scraped.ThrushAlthough the differential diagnosis for white plaques in the mouth is extensive,thrush is largely a clinical diagnosis. A KOH prep may be helpful when clinicalpresentation is atypical. Most AIDS patients will have asymptomaticcolonization, so the only use of cultures is for speciation and to determinesensitivity. Adherent white plaques on the sides of the tongue in AIDSpatients may represent oral hairy leukoplakia, caused by Epstein- Barr virusinfection. Biopsy can definitively differentiate the former from squamous cellcarcinoma.Deep Fungal InfectionCulture is indicated for deep fungal infection. If cryptococcal infection issuspected, India ink stain or Wrights stain may be performed. Culture ofhistoplasmosis takes several weeks to grow.26 picasTreatmentDermatophytesFor limited disease, topical antifungal preparations should be tried first.Treatment has to be performed for a period of two to three weeks, even aftersymptoms have completely subsided. Oral antifungal agents are needed whenfungal infection is widespread, when it affects a hairy area such as the scalp orbeard, or when nails are affected. Currently available oral drugs are griseofulvin,fluconazole, ketoconazole, itraconazole, and terbinafine. Things to keep inmind when selecting an oral antifungal agent are the potential drug interactionswith antiretroviral drugs and also with the drugs that are metabolized bythe cytochrome P450 system. Many of the oral antifungal agents areassociated with a significant risk of hepatotoxicity when given for a prolongedperiod of time, such as that required for treatment of nail infections.Therefore, in patients with a history of hepatitis or other liver disease, theoptions are limited. Ketoconazole’s absorption is reduced by achlorhydria thatis often seen with AIDS, so it should be taken with a cola soft drink, which canincrease absorption by 50%.ThrushIn our experience, clotrimizole troches are superior to nystatin swish-andswallow,likely because of greater contact time with the oral mucosa. Fordifficult to treat infections, studies have shown that PO fluconazole is equal inefficacy to itraconazole. 9 The practitioner should keep in mind that even with194U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau