A Guide To Lower Extremity Cutaneous Manifestations In Patients With HIV Infections

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Robert G. Smith, DPM, MSc, RPh, CPed

Warts And HIV: What You Should Know

   Verrucae vulgaris are common, benign, painless growths that are caused by the papillomavirus. When warts occur in individuals with HIV infection, they tend to be bigger, more numerous and widespread. These warts may be resistant to standard treatments and recurrence after treatment is common. De Socio and colleagues describe a 42-year-old man with AIDS and Hodgkin's lymphoma who presented with severe, recalcitrant cutaneous warts, which resolved following treatment with local 1% cidofovir.16

When Scabies Occurs In People With HIV

   If scabies occurs in people with HIV infection, it will usually present with the typical pattern of pruritic papules with accentuation in the intertriginous areas, genitalia and finger webs. The infestation may exaggerate and become more widespread and refactory to treatment with advance immunosuppression.

   Applying Lindane® (gamma benzene hexachloride) from the neck down for eight to 24 hours is therapeutic. For those patients who do not respond to Lindane therapy, they may benefit from topical application of permethrin 5% cream (Elimite®) from the neck down for eight to 24 hours. Elimite is safe for patients over two months of age as well as pediatric patients with HIV infection.

   True crusted atypical or Norwegian scabies, which appear as widespread hyperkeratotic, scaly maculopapular eruptions or crushed plaques, can occur in patients with advanced HIV infection. These crusts teem with mites and are highly contagious. Therefore, patients with Norwegian scabies should be isolated until therapy is complete. Despite the treatment being difficult, it is recommended to apply permethrin 5% cream weekly until cutaneous manifestations clear.

   Marchell and co-workers describe the atypical presentation and difficulty in treating painful plaques on soles of the feet of a patient who was HIV-positive and had scabies infestation.17

A Closer Look At Reiter’s Syndrome In Patients With HIV

   Reiter’s syndrome consists of the triad of arthritis, conjunctivitis, and urethritis. It occurs predominantly in genetically predisposed “HLA-B27 positive” men although researchers have reported cases in children and women occurring commonly after genitourinary or gastrointestinal infections. Dermatologic manifestations are common. They include keratoderma blennorrhagicum, circinate balanitis, ulcerative vulvitis, nail changes and oral lesions.18 Treatment is difficult, especially in HIV-positive patients. The prognosis varies. Fifteen to 20 percent of patients may develop severe chronic sequelae.18

   Typically, the palms and soles of the feet develop superficial pustules that are dry and form keratotic papules. Over time, these papules coalesce until the soles are diffusely thickened and scaled, evolving into the condition known as keratoderma blennorrhagicum. The nails are commonly affected. Extensive subungual debris may be present along with horizontally ridged nail plates.

   Florell and colleagues present an interesting case report of a 34 year-old man who presented with keratoderma blennorrhagicum.19 Success and resolution of the skin lesions occurred when the authors treated the patient with the combination of clobetasol propionate ointment (applied to the skin lesions twice a day) with 25 mg of oral acitretin daily, and the initiation of antiretroviral therapy.19

Pertinent Insights On Kaposi’s Sarcoma And HAART

   Kaposi’s sarcoma is a neoplasm of endothelial cells involving any portion of the cutaneous surface and some times other internal organs. This tumor varies in color from pink to dark red to purple to brown. They may be flat macules, raised papules or nodules, and vary greatly in size. Lesions may tend to arise along the lines of cleavage and form oval papules. The lesions of Kaposi’s sarcoma do not hurt or itch unless they become large.

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Anonymoussays: December 5, 2009 at 8:05 pm

Great Job by Podiatry Today :)

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Anonymoussays: December 10, 2009 at 4:46 pm

This article is a great reference. It would be nice to see more from this author. I noticed this author is not on your editorial board. Why Not ?

Nice job

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