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 Problemsthe best current therapies, Candida albicans relapse rate is high, and thefailure rate is even higher. There is a high incidence of resistant Candidaspecies among patients with HIV, and prolonged treatment failures necessitate26culturepicasfor sensitivity profiling.Deep Fungal InfectionsCryptococcal infection is the most common lethal mycosis in AIDS and shouldbe treated with amphotericin B with fluconazole as secondary prophylaxis. 10Histoplasmosis should also be treated with amphotericin 0.5 mg/kg/d IV oritraconazole 200 mg PO bid.ScabiesInfestation with the mite Sarcoptes scabeii var hominis results in an intensely pruritic eruptionin both the normal host and in the AIDS patient. An investigation for scabetic infestationshould always be performed in any patient with a persistent or widespread, pruritic eruption.Keep in mind, however, that there may be significant differences in the clinical presentation ofscabies in the immunocompromised host.IXClinical PresentationTypical ScabiesMultiple small, pinpoint to pinhead sized erythematous papules that can beintact, but usually are excoriated due to the intense pruritus. Areas commonlyaffected are the interdigital spaces of the hands, wrists, antecubital fossae,anterior axillary areas, inframammary folds, periumbilical area, waistline,buttocks, and inner thighs. The male genitalia is usually affected and nodulescan be seen on the scrotum. The diagnostic clinical finding is the presence ofburrows on the skin. They present as a pink papule at the end of a small lineartract only a few millimeters in length, often in the interdigital spaces of thehand or lateral aspects of the feet. In many cases, the papular lesions arecaused by an immune response to the mites and, even when they are smallin numbers, the affected individuals may still present with widespreadskin lesions.Atypical, Crusted, or “Norwegian” ScabiesThe incidence of this variant is very low in comparison with typical scabies,but higher in AIDS patients than in the healthy population. Varying degreesof hyperkeratotic plaques associated with skin thickening and crusting isobserved (Color Plate 9-9). Fissuring is common, as is bacterial superinfectionand even bacteremia. Burrows may not be evident because of the thickoverlying crust. These patients are infested with millions of mites, andpruritus, if present, is often only minimal. This form of scabies is usuallymisdiagnosed and, because it is an extremely contagious process, it becomes awalking source of infestation for the health care workers and other patientsfor prolonged periods of time before patients are correctly diagnosed andadequately treated. It should be noted that there have been no reported casesof HIV transmission via scabetic mites passed from patient to health careworker.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 195