A Guide To Lower Extremity Cutaneous Manifestations In Patients With HIV Infections
- Volume 22 - Issue 12 - December 2009
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Researchers have also postulated that skin diseases can warn of the progression of HIV disease. Also bear in mind that many skin diseases are more likely to occur as the white blood cells or CD4 count decreases. These two observations were validated clinically in a cross-sectional descriptive study by Rad and colleagues.7 The results of this investigation demonstrated that 66 (94.3 percent) patients had at least one skin problem. The study authors noted that fungal infections were the most common cause of skin manifestations. The eight most common types of muco-cutaneous problems were gingivitis, pallor, itching, photosensitivity, seborrheic dermatitis, candidiasis, folliculitis and tinea versicolor.7 Finally, the mean CD4 cell count (expressed with a P <0.05) was lower in individuals with viral and bacterial skin diseases.7
During the course of the lower extremity examination of patients with HIV infection, podiatrists may notice the increased prevalence of dry skin as a chief complaint. Using the Fat Redistribution and Metabolic Change in HIV infection (FRAM) cohort, Lee and co-workers assessed the prevalence of dry skin in 1,172 patients with HIV infection and 297 control patients between 2000 and 2002.8 Researchers employed self-reporting questionnaires to assess for changes in skin over the past five years with bidirectional scales including the terms: dry, no change and moist. The clinicians performing an overall assessment of skin used a similar scale.8 The study authors determined that self-reported dry skin was more prevalent in HIV-infected patients than control patients. A multivariable analysis revealed that HIV infection was associated with self-reported dry skin.8
Typically, xerosis is most prominent on the anterior lower legs but it may be quite widespread. The xerosis is more severe and may be associated with dermatitis in the winter months. Excessive frequent bathing with deodorant or antibacterial soaps is a frequent precipitating factor and patients should discontinue this practice.
Simple measures can be very helpful when advising the HIV-infected patient with dry itchy skin. These patients should wash quickly with warm water and avoid long, hot showers or baths. Recommend the use of a soap substitute, which preserves the skin’s natural moisturizing factors. One can combine soap substitutes with an emulsifiable bath oil and regular use of a moisturizer.
Patients should apply mild topical steroid ointments (1 to 2.5% hydrocortisone or 0.025% triamcinolone) to areas of dermatitis three times a day and should cover all dry areas of the body with a moisturizing lotion or cream after bathing and at bedtime. Patients in the advanced stage of HIV disease may present with dry and thickened skin of the palms and soles as one would see with acquired ichthyosis. Physicians can recommend or use the same treatment modalities to help achieve symptomatic relief for these patients.
When it comes to resource poor settings, Nnoruka and colleagues suggest that physicians should consider mucocutaneous disorders of HIV among the key clinical indicators for the prediction of underlying immune status and disease progression.9 The objective of their investigation was to identify and correlate mucocutaneous disorders to CD4-positive cell count and total lymphocyte count in HIV/AIDS patients in southwest Nigeria. They found that papulopruritic itch accounted for 32.2 percent (73/227) among patients with CD4+ cell counts of 51-200 cells/mm3 while seborrheic dermatitis occurred most significantly with CD4 cell counts of 201-500 cells/mm3 (43.1% vs. 12%) relative to those with lower CD4+ counts (51-200 cells/mm3). The study authors readily observed mucocutaneous lesion counts of >100 cells/mm3 in the advanced stage of HIV.