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Skin Disorders With Advanced Disease (CD4+ COUNT < 200 cells/mm3)
Oral candidiasis
More than 90% of patients will have oral candidiasis at some stage of their disease, most commonly at low CD4+ counts. The most typical appearance is as a white thick exudate on the oral mucosa (pseudomembranous thrush). However, it may also present as diffuse oropharyngeal hyperaemia (erythematous thrush) or as depapillation of the tongue and angular cheilitis (Fig.3). Most patients respond to oral nystatin suspensions. If thrush is severe or if oesophageal or vaginal candidiasis is also present an oral azole like fluconazole can be used. In advanced HIV disease, low gastric acidity is often present and reduces the absorption of imidazole antifungal therapies such as ketoconazole and itraconazole.
Oral hairy leukoplakia
More than 90% of patients will have oral candidiasis at some stage of their disease, most commonly at low CD4+ counts. The most typical appearance is as a white thick exudate on the oral mucosa (pseudomembranous thrush). However, it may also present as diffuse oropharyngeal hyperaemia (erythematous thrush) or as depapillation of the tongue and angular cheilitis (Fig.3). Most patients respond to oral nystatin suspensions. If thrush is severe or if oesophageal or vaginal candidiasis is also present an oral azole like fluconazole can be used. In advanced HIV disease, low gastric acidity is often present and reduces the absorption of imidazole antifungal therapies such as ketoconazole and itraconazole.
Eosinophilic folliculitis
This dermatological entity presents as a follicular erythematous urticaria and paular rash that usually involves the face and central trunk, with sparing of acral sites. The lesions are pruritic and chronic but may display periods of improvement. Accurate diagnosis requires a skin biopsy. Therapy for eosinophilic folliculitis is varied and includes ultraviolet B light, natural sunlight, potent topical steroids, antihistamines, and dapsone. Despite treatment, most patients will suffer from persistent and severe pruritus.
Herpes simplex virus
Low CD4+ cell counts can be associated with persistent, AIDS-defining herpes simplex lesions which present as painful facial, genital or perianal ulcerations (Fig. 4). Proper management includes oral or intravenous acyclovir until the lesions have cleared, followed by prophylactic acyclovir, given orally. If the disease is clinically resistant to acyclovir, intravenous foscarnet may be effective.
Cytomegalovirus
Cytomegalovirus (CMV) infections can present with lesions similar to the previously described perianal and genital ulcerations of herpes simplex. Patients may also have other systemic features of CMV infection such as chorioretinitis, oesophagitis, or enterocolitis. If these systemic features are absent, skin biopsy may be necessary for diagnosis. Treatment consists of intravenous gancyclovir or foscarnet.
Molluscum contagiosum
Typically, this pox virus presents with flesh-coloured, dome-shaped papules with central umbilication. In advanced HIV disease the lesions tend to be more wide-spread, with genitalia and face, especially the beard area, mostly involved (Fig. 5). Lesions are often much larger in HIV-infected patients compared with uninfected subjects, and may even resemble a basal cell carcinoma. Dermatological features must be differentiated from those seen in cutaneous cryptococcosis which can present with molluscum-like lesions. Treatment tends to be difficult. Cryotherapy (using liquid nitrogen) and topical retinoic acid can be tried. Antiretroviral therapy, as with all skin manifestations of HIV, is the best therapy.
Bacillary angiomatosis
Bacillary angiomatosis is caused by the Gram-negative, rickettsia-like organisms, Bartonella henselae and Bartonella quintana. Acquisition of infection is often related to contact with cats, either through a bite or scratch. Clinically there are small erythematous vascular-appearing papules which can enlarge to form friable, exophytic nodules, often with a purplish hue. Any site except the palms and soles can be involved. Accurate diagnosis requires a skin biopsy in order to differentiate bacillary angiomatosis from Kaposi's sarcoma. Treatment with erythromycin or doxycycline for 8-12 weeks is generally curative. If relapse occurs treatment should be re-initiated.