A Guide To Lower Extremity Cutaneous Manifestations In Patients With HIV Infections
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.
The development of HIV-related disease has changed dramatically since the introduction of highly active antiretroviral therapy (HAART) into clinical practice. Since the use of protease inhibitors became widespread, physicians have seen a 30 to 50 percent reduction in Kaposi's sarcoma. The results of recent studies indicate that HAART may be a useful alternative both to immune response modifiers during less aggressive stages of Kaposi’s sarcoma and to systemic cytotoxic drugs in the long-term maintenance therapy of advanced Kaposi’s sarcoma.
Bower and colleagues recently published a prospective cohort study that evaluated the clinical outcomes of patients with histologically confirmed AIDS-related Kaposi’s sarcoma who have been diagnosed since the introduction of HARRT.20 With this prospective investigation, researchers found a high success rate of HAART in a large cohort of AIDS-related Kaposi’s sarcoma patients over a prolonged period of follow-up.
The use of HARRT therapy for Kaposi’s sarcoma is geared to help control symptoms, reduce edema, eliminate pain and clear lesions. However, the prevailing sentiment is these therapies are not curative. If treatment is necessary, treating physicians commonly use radiation and systemic alpha-interferon or chemotherapy.