A Guide To Lower Extremity Cutaneous Manifestations In Patients With HIV Infections
While non-infectious cutaneous abnormalities are not prognostic of the rapid progression of immunosuppression, they may be specific markers of the stage of HIV disease. Cutaneous abnormalities like seborrheic dermatitis or xerosis may worsen as HIV infection progresses or they may present suddenly, intensely and severely to a point of lethality.
It must be noted that with improvements in antiretroviral treatment of HIV, as demonstrated with good viral control and preservation of the immune system, skin problems associated with opportunistic infections and many other skin problems associated with HIV have become far less common, less severe and are easier to treat.
Podiatric physicians must also remember that cutaneous manifestation of HIV disease may be less responsive to the usual treatment modalities.
What The Literature Reveals About Tinea, Onychomycosis And HIV
Lower extremity cutaneous manifestations of HIV disease include tinea, warts, scabies, Reiter’s syndrome, Kaposi’s sarcoma and allergic contact dermatitis.
Tinea infection of the feet and toenails is common in people with HIV infection. However, it is not a specific marker of HIV infection because it is also common among people without HIV infection. Researchers have reported that the prevalence of onychomycosis in patients with HIV infection ranges between 15-40 percent.11,12
Tinea of the nail primarily involves the nail plate. Nails become opaque and thickened, and may split or crumble. Proximal subungual onychomycosis is usually a sign of HIV disease.13 Common with tinea involvement of the toenails is an associated tinea infection of the soles or toe webs manifested by chronic maceration, scaling, blistering, and or thickening of the skin. The use of topical imidazole cream twice a day can facilitate improvement of tinea infection of the soles of the feet.
Tinea unguium associated with AIDS is clinically more aggressive and therapeutically more difficult to treat than in the general population.14 Tinea unguium in patients with HIV is common, chronic and usually does not require therapy unless the infection causes discomfort.
If the podiatric physician elects to employ oral therapy to treat the toenail infestation/infection, it may be prudent to investigate all the possible theoretical and probable drug-drug interactions that may result from combining antifungal agents and antiretroviral agents. Barber and colleagues present a discussion of onychomycosis treatment in special populations including those infected with HIV.15 Despite a lack of abundant data, these authors state the literature that does exist demonstrates that one can use oral terbinafine, oral itraconazole and ciclopirox 8% nail lacquer safely and effectively in special populations. They do caution clinicians to assess each presentation on a case-by-case basis.
Researchers investigated the use of terbinafine in a series of 21 HIV-positive patients who were diagnosed with tinea unguium for one year in Madrid.14 All patients underwent a subsequent clinical follow-up for six months. The results showed a high percentage of clinical and mycological cures, as well as maintenance of the response after follow-up. The study authors noted no drug interactions or significant adverse effects related to the drug.
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.