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 ability to differentiate between drug reactions that are serious and even life-threateningand those that may be tolerated in order to continue a necessary medication.It has26beenpicaswidely recognized since the early 1980s that patients with AIDS suffer from anincreased incidence of cutaneous eruptions directly attributable to trimethoprimsulfamethoxazole17 and that the incidence of drug eruptions from all sources was likely to beapproximately ten times higher than in the general population. 18Clinical PresentationUnfortunately, the cutaneous manifestations of adverse drug reaction are manifold. Whilea morbilliform eruption with widespread erythematous macules and overlying papules isone of the more common manifestations, urticaria, bullous eruptions, pityriasis rosea-likelesions, palpable purpura, erythema multiforme, and others are also not rare.DiagnosisThe goal is to be able to differentiate between a primary cutaneous process in an ill patientand a drug-related cutaneous reaction. Here, the timing of the medication with the developmentof rash is critical because most eruptions begin 7-12 days after initiation of therapy.For unfamiliar lesions, a biopsy is always the safest route, making sure an analysis bydirect immunofluorescence for immunoglobulin or complement deposition in the skin isperformed. This is especially important in the bullous eruptions or eruptions suggestive ofvasculitis.TreatmentTable 9-3 enumerates the most important indications for discontinuing a medication becauseof an adverse cutaneous reaction.Apart from discontinuing medications, lesions of erythema multiforme that are causingsignificant discomfort may be treated with systemic corticosteroids. It should be notedthat their use does not prevent progression to the more severe toxic epidermal necrolysis.Systemic corticosteroid use in toxic epidermal necrolysis is contraindicated and in Stevens-Johnson syndrome is debated. Intravenous immunoglobulin has been reported on a caseby-casebasis to be successful in treating the more severe cutaneous drug eruptions, includingtoxic epidermal necrolysis. 19 However, to date there have been no controlled trialsto prove its efficacy. If the offending medication is absolutely necessary, desensitizationmay be performed in cases of non-life-threatening adverse reactions. 20SKIN PROBLEMS IN THE CHRONIC, BED-RIDDEN PATIENT■ Immobilization during the latter stages of AIDS, especially when in the hospice environment,generates by itself a number of potentially chronic skin disorders. These often chronically bedriddenpatients, who lack any immune function, suffer from not only skin breakdown and infection,but also from disorders uniquely associated with increased body temperature as well asincreased sweating and impedance of the normal sweating mechanisms. The following sectiondeals with the diagnosis and management of intertriginous infections, and with miliaria andGrover’s disease, which are often seen in such patients.198U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau