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 Problemsantifungal agents. It usually presents as an erythematous/brownish intertriginous patchthat has a characteristic coral red fluorescence under Woods lamp. Prompt attention tothese conditions is important because inflammation and the frequent maceration seen26predisposepicasthese patients to skin breakdown and superinfection with bacterial pathogens.In addition to the overt infectious processes from dermatophytes, Candida, and Corynebacterium,other mimicking conditions may also flourish in the perineal region. Althoughpsoriasis typically affects the extensor surfaces (i.e., knees, elbows) inverse psoriasis oftenappears in intertriginous spaces. Again with an erythematous, well-demarcated patchwith heavy silvery scale, inverse psoriasis may resemble infectious intertrigo. When afriable bleeding base is revealed from gentle removal of scales, this condition should beconsidered. Additionally, as AIDS progresses, seborrheic dermatitis often becomes morewidespread and not uncommonly involves the perineum. Greasy yellow scale on an illdefined,erythematous base differentiates this condition from inverse psoriasis and infectiousintertrigo. Finally, irritant contact dermatitis is a very common problem in the hospicesetting. As patients approach terminal illness, incontinence and/or chronic diarrhea is veryprevalent. This causes tremendous irritation, not dissimilar to diaper dermatitis of infants,accelerating the formation of decubitus ulcers and enhancing bacterial superinfection.TreatmentThe treatment of dermatophyte and Candida infections is covered in Other Common Infections.The treatment for erythrasma is with topical erythromycin and antibacterialsoaps, including benzoyl peroxide washes. In general, it is critical to reduce macerationand predisposing conditions. Appropriate skin care includes washing the affected areasdaily or twice daily followed by the use of drying agents such as aluminum acetate ordiluted acetic acid soaks and lotions. Hydrophobic barrier creams and ointments such aspetroleum jelly or dymethicone- or silicone-containing creams can also be used to preventrecurrence of the problem. One therapy often used for uncomplicated diaper dermatitis isa compound made of 15 g of nystatin cream, 15 g of 2.5% hydrocortisone cream compoundedin a zinc oxide base. Zinc oxide helps to dry the area, nystatin reduces yeastcolonization, and the steroid reduces inflammation.Miliaria and Grover’s DiseaseMiliaria and Grover’s disease are the more common heat-related conditions in bed-riddenpatients. Miliaria, or “prickly heat” is a transient condition usually seen in children during thesummer months and it is related to obstruction of eccrine sweat gland ducts. Grover’s diseasewas originally described as a transient vesiculopapular eruption occurring usually in men over50 years old. Chronic forms are not uncommon.Clinical PresentationMiliaria cristalina presents with small, clear superficial vesicles in bedridden patientswith increased perspiration and inadequate ventilation from tight or excessive clothing.Miliaria rubra, or prickly heat, is a very pruritic papulovesicular eruption that produces aburning or tingling sensation. It is common in the flexural fossae and intertriginous areas.Grover’s disease is generally limited to the trunk and presents with erythematous 2 to3 mm papules and vesicles. There is usually mild pruritus. Grover’s disease is associatedwith increased temperature and sweating.200U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau