News HIV/AIDS News & Information - Part 182

Kaposi’s sarcoma is a neoplasm of endothelial cells within the skin and other organs. Most KS patients are homosexual men. KS may be present in up to 46% of homosexual men with advanced HIV disease at initial diagnosis. The incidence in heterosexual injection drug users is only 3.8%. Herpes virus 8 (HHV-8) has been associated with KS. Most individuals with KS have generalized, slowly progressive disease; others have stable KS.

KS may affect any portion of the cutaneous surface. Initially, it appears as red-to-brown flat macules. Papules, nodules, and tumors may also be present or develop later. Numbering from one to hundreds, they range in size from several millimeters to over 10 cm and may be widespread, grouped, or zosteriform. KS may affect mucosal surfaces and internal organs. Visceral involvement occurs in 72% of patients with advanced HIV disease and KS, most often affecting the gastrointestinal tract (50%), lymph nodes (50%), and lungs (37%). canadian online pharmacy

Biopsy of the skin establishes the diagnosis. A 3.5- to 4.0-mm punch biopsy should be taken from the center of the lesion.

Treatment.

If treatment is necessary, radiation and systemic alpha-interferon or chemotherapy may be used. Cutaneous lesions may improve with local cryotherapy or intralesional injections of vinblastine, 0.2 to 0.6 mg/mL.

Eosinophilic folliculitis

Eosinophilic folliculitis typically occurs in HIV-infected persons with helper T cell counts below 200. Intensely pruritic, edematous, urticarial papules and pustules appear in crops on the trunk or face or both. Cultures and histologic examination for infectious agents are negative, but a relative peripheral eosinophilia may be present.

Astemizole ( Hismanal), 10 mg daily has been used with limited success, but concurrent imidazole or erythromycin therapy is contraindicated with astemizole because of the risk of cardiac arrhythmia. Ultraviolet phototherapy is also beneficial. Itraconazole in a dosage of 200 to 400 mg daily is sometimes beneficial. Permethrin 5% (Elimite) used every other day from the waist up may bring improvement in some patients: Permethrin kills the Demodex mite, which may be the etiologic agent in eosinophilic folliculitis.

Reactions

The incidence of adverse reactions TMP-SMX is very high. Most reactions occur in the second week of therapy, and the rash is a maculopapular/morbilliform reaction, beginning in the groin and pressure areas and quickly generalizing. Cutaneous eruptions occur in 48% of treated patients. Resolution of the skin rash during therapy occurs in 33%, and the remaining patients have progressive toxicity, necessitating discontinuation of the drug.

The use of systemic corticosteroids in treating PCP reduces the rate of drug eruption from TMP-SMX. Other drug-induced hypersensitivity reactions include urticarial reactions, exfoliative erythroderma, fixed-drug eruption, erythema multiforme, and toxic epidermal necrolysis. These reactions are most often due to antibiotics, especially TMP-SMX and the penicillins.

Scabies 

Scabies usually presents with pruritic papules with accentuation in the intertriginous areas, genitalia, and fingerwebs. Gamma-benzene hexachloride (lindane) applied from the neck down for 8 to 24 hours is usually curative; however, that lindane may result in peripheral neuropathies in HIV-infected patients, particularly in those with CD4 < 200. In patients with scabies who have not responded to gamma-benzene hexachloride therapy, 5% permethrin cream (Elimite), used in the same method as lindane, is safe and effective.

True crusted ( Norwegian) scabies may occur in patients with advanced HIV disease. Norwegian scabies is nonpruritic and appears as thick crusts. The crusts are highly contagious. Treatment with Elimite should be repeated at least weekly until cutaneous manifestations clear. Ivermectin, 6% precipitated sulfur ointment, daily should be added to the Elimite therapy.

Cutaneous presentations of primary and secondary syphilis in HIV-infected persons are usually similar to those in non-HIV-infected persons. HIV may delay development of serologic evidence of Treponema pallidum, resulting in negative tests. In the HIV-infected person, a negative serologic test may not be adequate to rule out secondary syphilis.

Treatment.

HIV infected patients with early syphilis should be treated with weekly intramuscular injections of penicillin G benzathine (Bicillin) 2.4 million units for 2 or 3 weeks. CSF examination is required if there are any clinical findings suggesting CNS involvement. Discount Canada Drugs

Quantitative nontreponemal tests are repeated at 1, 2, and 3 months and thereafter at 3-month intervals until a satisfactory serologic response occurs. If an appropriate fall in titer does not occur (two dilutions by 3 months for primary or by 6 months in secondary).

In acute primary HIV infection, a rash may develop along with a mononucleosis-like illness. The rash may be exanthematous or pityriasis rosea-like, usually does not itch, is distributed over the upper trunk and proximal limbs, and may involve palms and soles. An associated enanthem of oral erythema or superficial erosions may be present. The exanthem and enanthem spontaneously resolve within 1 to 2 weeks.

Detection of HIV antigen by enzyme immunoassay may confirm the diagnosis of acute HIV infection in HIV-antibody-negative persons.

Superficial cutaneous infection with human papillomavirus (HPV) occurs with increased frequency in immunosuppressed patients. The warts seldom cause symptoms, except when on the soles of the feet and around the fingernails.

Relapse of warts after treatment is common, especially in advanced HIV disease. Liquid nitrogen cryotherapy can be applied every 2 to 4 weeks. Topical “anti-wart” medications containing salicylic and lactic acids are applied daily under occlusion and may lead to complete disappearance of the lesions. The treatment outlook for warts is poor in immunosuppressed patients.

Topical treatment of genital warts with podophyllin or trichloroacetic acid may be applied weekly for 6 to 10 weeks. Liquid nitrogen freezing has a slightly greater response rate. Recurrence is almost universal. discount pills store

The presence of external genital warts in women and perirectal warts in homosexual or bisexual men is usually associated with internal warts. Pelvic examination, Pap smear, and colposcopy are recommended in women, and anoscopy in men.

Molluscum contagiosum is a superficial cutaneous viral infection manifesting as 2- to 3-mm flesh-colored hemispheric papules. A faint whitish core usually is visible at the center of each papule, some of which may be slightly umbilicated. This eruption is seen commonly in immunocompetent young children (ages 3 to 8 years), whose lesions are scattered widely over the face, arms, and trunk. In adults, this mild infection is usually sexually transmitted and occurs in the pubic area.

Genital molluscum in the non-HIV-infected adult may be chronic, and it occurs in 10 to 20% of HIV-infected persons. Early in the infection, the lesions are usually mild and localized to the groin or face. Lesions tend to proliferate once CD4 counts fall below 200. They often number greater than 100 and may involve the face, trunk, and groin; there is a predilection for the eyelids.

Treatment.

Light cryotherapy using liquid nitrogen can treat individual lesions. If this is not available, pricking the lesion with a large-gauge needle and removing the white core may also be effective. For refractory lesions, removal by curettage without cautery is very effective. Prozac Online

Varicella zoster virus (VZV) infection is commonly seen early in the course of HIV infection.

This dermatomal eruption may be particularly bullous, hemorrhagic, necrotic, and painful in HIV-infected persons. The duration of blisters and crusts is usually 2 or 3 weeks.

Dissemination of VZV in HIV infection is uncommon. The clinical manifestations of disseminated VZV infection include typical blisters with or without an associated dermatomal eruption.

Treatment

If the patient has a reasonably intact immune system and does not have clinical features of disseminated or visceral infection, and if lesions are not near the eye (trigeminal nerve), then oral acyclovir is adequate. A dosage of 800 mg orally 5 times daily for 5 days is recommended.

Famciclovir ( Famvir), 500 mg, and valacyclovir ( Valtrex), 1000 mg, may be given only three times daily but the dosage must be adjusted in renal impairment.

Intravenous acyclovir (10 mg/kg 3 times daily) is indicated when the immunosuppression is significant (CD4 <200), when disseminated or visceral lesions are present, and when VZV affects the ophthalmic branch of the trigeminal nerve (eyelid or tip of the nose). Intravenous treatment should continue until the lesions are well crusted (usually about 7 days), after which full doses of oral acyclovir may complete 10 to 14 days of therapy.

Wet compresses (2 or 3 times daily) will help remove necrotic debris. Silver sulfadiazine (Silvadene) or bacitracin keeps the scabs soft and may also prevent secondary infection. Capsaicin cream ( Zostrix) may reduce the pain of both acute and chronic zoster. It may be applied to the lesions 5 times daily until the pain is controlled. order cheap levitra