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 ProblemsDifferential DiagnosisClassical scabies: Insect bite reactions, papular urticaria, drug reaction, folliculitis, prurigosimplex, organic causes of pruritus; crusted scabies: psoriasis, various forms of eczemaand lichen planus.26 picasDiagnosisIdentification of the mites, their eggs, or their feces from skin scrapings is necessary fordiagnosis. The region most fruitful for scraping is a nonexcoriated papule, especially inthe burrows. Scrapings can also be performed from under the fingernails because this is aprotected area. Once an adequate sample is scraped onto a microscope slide, a drop ofmineral oil is placed on the specimen and covered with a coverslip before viewing underthe microscope.TreatmentScabetic infestation represents a good example of why topical steroids should not be givento patients until an exact diagnosis has been reached. Suppression of the local immuneresponse around the infection will only help the mite, not the patient. Even though theestimated life span of the mite outside of human hosts is very short, it is important that thepatient’s environment, including bed sheets, towels, and personal clothing that have beenworn and are not freshly laundered should all be washed. Whenever possible, carpetingand upholstery should be cleaned. This should be done after the patient has completedthe recommended treatment. In addition, all intimate contacts and nonintimate householdor roommate contacts should be treated simultaneously. Health care workers whohad direct skin contact with the patient or their bed should also be treated as soon aspossible. Topical antiscabetic preparations include permethrin 5%, crotamiton 10%, andlindane 1%, applied to cover the entire body surface once, washed off 10 to 12 hours laterand repeated 10 to 14 days later when the female mite’s eggs hatch. Ivermectin, althoughnot FDA-approved for this purpose, has shown to be effective as a single-dose oral treatmentfor scabies in both HIV-positive and HIV-negative individuals. 11 The dose is 200 micrograms(µg) per kilogram of body weight once and repeated 10 days later if necessary.This is a good option when compliance is questionable and in epidemics affecting hospitalsand hospices. Case reports have noted that for the thick plaques of crusted scabies, acombination of oral and topical antiscabetic regimens is likely most effective. For cases ofcrusted scabies, a keratolytic agent such as salicylic acid 3–5% or urea 20% should also beused to facilitate removal of the crusts that harbor thousands of mites and penetration ofthe antiscabetic medication. Side effects of ivermectin include eosinophilia and constitutionalsymptoms. It should not be given to young children, pregnant women, or breastfeedingmothers.Kaposi’s SarcomaKaposi’s sarcoma (KS) is the most common tumor seen in patients infected with HIV and isan AIDS-defining illness. More common in homosexual or bisexual men, KS is also 300 timesmore common in AIDS patients than in patients immunosuppressed for transplants. The etiologyis clearly multifactorial; however, there have been significant strides made in the past decadein understanding the pathogenesis of this tumor. At the heart of the pathology is angiogen-196U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau