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 Problemsesis, and various mechanisms are known to be responsible, namely sexual transmission of humanherpesvirus 8 (HHV8), an altered cytokine environment and the HIV trans-activating protein,Tat.26 12 It is thought that in the presence of a dysregulated cytokine milieu, Tat inducesHHV8, whichpicasalso encodes on its genome, viral IL-6. This IL-6 leads to increased expression of13, 14endothelial growth factor which, in turn, promotes angiogenesis.Clinical AppearanceThe skin is the most commonly affected organ, where this disorder may present with eithera few localized lesions or diffusely (Color Plate 9-10). Any body area may be involvedwith red or purple, hyperpigmented, indurated patches, papules, nodules, plaques, or tumors,but there appears to be a higher predilection for the lower extremities. The lesionstend to be oval shaped, be symmetrically distributed, and to follow skin tension lines. Inthe oral cavity, the palate and gingiva are usually involved. Chronic lesions may show superficialchanges such as scaling and crusting and they may even ulcerate.IXDifferential DiagnosisBacillary angiomatosis, pyogenic granulomas, traumatic ecchymoses and hematomas, cutaneousB-cell lymphoma, angiosarcoma. If the clinical diagnosis is in question, simplepunch biopsy of the lesion should be diagnostic.TreatmentOptions for treatment vary according to the extent of the disease, rate of progression, thedevelopment of new lesions, and presence of systemic involvement. Therapeutic optionsfor localized cutaneous disease are very different from widespread, symptomatic, systemicinvolvement (reviewed in Dezube, 2000 15 ). Local disease can be treated by any number ofmodalities, including cryotherapy with liquid nitrogen, CO 2laser ablation, infrared photocoagulation,intralesional chemotherapy, surgical excision, electrofulguration, radiationtherapy, and alitretinoin 0.1% gel applied topically.Chemotherapeutic options include paclitaxel or the liposomal anthracyclines doxorubicinand daunorubicin. These modalities are useful for disseminated, symptomatic KS. Paclitaxelis very effective but has a higher incidence of myelosuppression, alopecia, and arthralgiasthan the liposomal anthracyclines, which are widely considered first-line chemotherapeuticagents in these patients. Radiation therapy is also very effective for palliation in advanced,symptomatic, and extensive disease. A radiation schedule of 3.5Gy/fraction at 3fractions per week for a total cumulative dose of 21 Gy has shown to reduce visible tumorburden as soon as 2 weeks after completion of therapy.The importance of successful antiretroviral therapy cannot be overstated. Studies haveshown that HAART dramatically reduces the incidence of new KS lesions and can decreasethe size of or even clear existing lesions. 16Drug EruptionsAIDS patients are at high risk for the development of adverse drug reactions because of thesheer number of medications they require as well as their body’s dramatically altered immunologicmilieu. The most critical knowledge for the health care worker caring for these patients isU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 197