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Skin Disorders At Early And Intermediate Stages Of Disease(CD4+ COUNT 200-500 cells/mm3)
Seborrhoeic dermatitis
This type of eczema, seen in up to 85% of HIV-infected patients, initially affects the scalp, face, neck, axillae and groin. As the CD4 count declines the extent and severity of seborrhea increase and the response to therapy decreases. Lesions may also be psoriaform in morphology, leading to diagnostic confusion. Treatment of seborrhoeic dermatitis involves the topical application of low-to-midpotency corticosteroids. Topical preparations with ketoconazole or sulfacetamide may also benefit some patients. Shampoos containing selenium sulfide may be used daily, whereas ketoconazole shampoo is used twice weekly. A topical corticosteroid lotion or gel may be massaged into the scalp following shampooing.
Scabies
Scabies presents in a typical form when the CD4+ lymphocyte counts are greater than 200 cells/mm3. Small pruritic papules and burrows are found in warm, moist areas such as the axillae, interdigital web spaces, and buttocks (Fig. 1). Therapy includes topical benzyl benzoate emulsion and gamma benzene hexachloride.
Xerosis and acquired ichthyosis
About 25-30% of HIV-infected patients have dry, pruritic, scaling skin (xerosis). Occasionally, the scaling can be more severe resembling 'fish scales' (ichthyosis). Treatment of these conditions includes emollients and occasionally combination topical preparations including 10% urea or 10-20% salicylic acid.
Herpes zoster
Herpes zoster in HIV-infected persons usually displays its typical clinical appearance with groups of painful vesicles on an erythematous base, located in dermatomal distribution. The CD4+ count is usually 300-400 cells/mm3. At lower CD4+ cell counts, however, there is greater risk of complicated zoster in which the lesions may be haemorrhagic, multidermatomal, disseminated, or ulcerated (Fig. 2). Recurrent herpes zoster appearing in different dermatomes may also occur. Herpes may affect multiple dermatomes in HIV-infected persons. Oral antiviral agents such as acyclovir are of benefit if given within the first 72 hours of infection. The patient may consult an ophthalmologist if there is suspicion of ocular involvement.
Human papilloma viral infections
In HIV-infected patients there is an increased incidence of warts on the hands and face and within the oropharynx. Shaving may cause disease spread in male patients. Condyloma acuminata, or venereal warts, are also common and such patients should be monitored for rectal carcinoma, cervical intraepithelial neoplasia (CIN), and cervical carcinoma. Warts and condylomata are difficult to treat in patients with HIV infection and tend to recur. For condyloma acuminata in males and non-pregnant females, topical podophyllin at 1-2-weekly intervals can be used. Cryotherapy is a treatment alternative and is used for warts elsewhere.
Papulopruritic eruption
Studies from Africa have indicated that this skin disorder tends to occur at higher CD4+ lymphocyte counts than in Europe and North America. This HIV-specific rash consists of sterile pruritic papules and pustules located mainly on the extensor surfaces of the arms, dorsa of the hands, and trunk; there is sparing of the palms and soles. The condition is chronic and tends to wax and wane. Varying therapeutic success has been achieved with ultraviolet light, antihistamines, and potent topical corticosteroids.