Nursing

RN/Thomson AHC Home Study Program CE CENTER

CE credit is no longer available for this article. (Expired June 2008)

Originally posted June 2006

By Sally Beattie Dulak, RN, MS, CNS, GNP

SALLY BEATTIE DULAK is the principal of CV Health Promotion, a cardiovascular consultancy in Columbia, MO, and a member of the RN editorial board. The author has no financial relationships to disclose.

Skin disorders can be frequent, severe, and difficult to treat for patients with HIV. Your care and counseling can ensure that they get the right therapy without delay.

No organ is more vulnerable to the effects of HIV than the skin: An estimated 90% of HIV patients develop some form of skin disease. Common culprits include infections (viral, bacterial, or fungal); Kaposi's sarcoma; and drug-related reactions.^1,2 Paradoxically, while the antiretroviral therapy patients with HIV take to extend their survival has decreased the incidence of some of these conditions, it's resulted in the flare-up of others.³

Skin disease can occur at any stage of HIV, but cutaneous signs and symptoms are often the first indication that an individual is infected.¹ Your ability to recognize the skin disorders that commonly occur in this patient population could lead to early diagnosis of HIV on one end of the spectrum, or help you to better manage the care of a patient down the road, when vigilance is essential.⁴

The first sign: A measles-like rash

HIV steadily attacks—and destroys—CD4+ T lymphocytes (T cells), white blood cells that control and support the immune system response. Their continued destruction, and the progressive failure of the immune system that results, allows unwanted microbes to take advantage of the weakened host.

The earliest cutaneous manifestation of HIV infection is usually a fine measles-like rash, primarily appearing on the trunk, upper arms, and possibly the palms and soles, two to six weeks after exposure.⁵ It's accompanied by a mononucleosis-type syndrome that lasts about four or five days.⁵ Signs and symptoms include fatigue, fever, headache, pharyngitis, swollen lymph nodes, myalgias, and sometimes weight loss, nausea, and vomiting.⁵

After this initial rash, the plethora of skin diseases that accompany HIV typically begin when the patient's T-cell count falls below 500 per cubic millimeter of blood.¹ (A normal value is 500 – 1,500.)

The viral skin infections you're most likely to see are herpes simplex (HSV), herpes zoster (shingles), molluscum contagiosum, human papilloma virus (HPV), and Epstein-Barr virus (EBV). Here's a look at how each will present and the treatment options available.

HSV. Herpes simplex virus 1 (HSV1) and herpes simplex virus 2 (HSV2) typically lead to orolabial and genital lesions, respectively, although HSV1 can affect the genitals and HSV2 can affect the mucous membranes and mouth. Herpes often presents early on in groups of painful vesicles on a red base that heal two to three weeks after crusting and eroding.⁶ As the patient's T-cell count drops below 400, the lesions often develop into deeper, more painful ulcers that become chronic and necrotic.^1,6,7

The mainstay of treatment is acyclovir (Zovirax), given PO or IV until all lesions have healed.⁷ Patients who have frequent relapses often remain on a continuous course of acyclovir.^6,7 But many patients develop acyclovir resistance and need to switch to foscarnet (Foscavir) or cidofovir (Vistide), a topical agent.^6,7

Herpes zoster. Early in the course of HIV, herpes zoster is common. It usually manifests as a painful rash, first blistering, then crusty, that follows a band-like pattern on one side of the body. Localized itching or tenderness is common.²

As HIV progresses, however, shingles may develop into more widespread ulcerative, warty lesions that resemble chicken pox and may last for months.^1,6

IV acyclovir is the treatment of choice for shingles, along with analgesia.^3,5,7 Those who develop resistance may need to be treated with other agents.^5,6,7

Molluscum contagiosum. Up to 20% of HIV patients whose T-cell count drops below 100 develop this infection, which presents as either a single lesion or multiple lesions, usually on the face and genital area.⁷ They're firm, pearly pink papules, typically 2 – 5 mm in diameter, with a dimple in the center. The papules are filled with a cheese-like material.²

In addition to being rather large, the lesions tend to be warty and difficult to treat.^6,7 To make matters worse, they can spread to other parts of the body in warm water, so patients must be taught to avoid spas and heated swimming pools, to shower in cool water, and to avoid taking baths.²

Treatment options include electrosurgery, cryotherapy, curettage, shave excision, or laser removal. Lesions can also be treated with intralesional interferon or topical tretinoin (Avita, Renova, others).²

HPV. There are more than 100 strains of human papilloma virus, some of which cause both common warts and genital warts. While not painful, these lesions may be large and widespread in patients with HIV, covering the hands, face, mouth, and genital area. In the anal region, they may form large masses that interfere with defecation and coalesce with lesions in other areas to form large, rough plaques.^5,6

Certain types of HPV are known to cause cervical cancer, and some may play a role in some cancers of the anus, vulva, vagina, oropharynx, and penis.⁸ Suspicious lesions should be biopsied, and HIV-positive women with HPV should have Pap smears done every six months.⁵

The lesions can be removed with cryotherapy, electrodessication (the use of electric current to destroy tissue), laser, or cauterization, or treated with topical fluorouracil (Carac, Efudex, others) or intralesional interferon alpha.^6,7 HPV is often difficult to treat, and relapse is common. Explain to your patient that the goal of treatment is to relieve symptoms caused by large, protruding lesions, particularly in the genital/anal region.⁶

EBV. The immunosuppression caused by HIV infection allows the Epstein-Barr virus to replicate, giving rise to oral hairy leukoplakia (OHL).⁵ This condition causes painless, slightly elevated corrugated white plaques with hair-like projections along the lateral aspects of the tongue.⁶ The plaques cannot be scraped off with a tongue blade, and if enlarged can lead to dysphagia.

Treatment is usually reserved for patients who have difficulty swallowing or are particularly bothered by the appearance of their tongue. Options include topical application of tretinoin, podophyllin (Podophylox), vitamin A, or surgical excision. OHL generally clears up when a patient starts highly active antiretroviral therapy (HAART).⁶

Bacterial and fungal manifestations

Skin problems caused by bacteria, such as Staphylococcus aureus and Treponema pallidum, or fungal infections, including candidiasis and tinea, commonly afflict HIV patients, as well. Up to 85% develop S. aureus, for instance.⁷ It may manifest as impetigo, folliculitis, cellulitis, boils, or soft tissue abscesses, often presenting as macules, papules, pustules, or ulcers that can rupture and shed pus.

Two to four weeks of treatment with oral penicillin (Amoxicillin, Ampicillin, others) or a first-generation cephalosporin such as cephalexin (Keflex) is usually effective in treating S. aureus infection. But patients with large, deep lesions may need IV antibiotics and, in some cases, the lesions may require surgical drainage.^5,6 Recurrences are common in this patient population, in part because of nasal colonization of S. aureus.

Syphilis, caused by T. pallidum, affects about a quarter of patients infected with HIV.⁷ In fact, the two are closely related: Syphilis can facilitate the transmission of HIV.⁷ The CDC recommends that all patients diagnosed with either one be tested for the other, and requires that clinicians report cases of syphilis to their local and state health departments.⁵

Along with its characteristic genital chancre, syphilis may present in unusual ways in HIV patients. These include rapidly progressive and widespread ulcerative nodules and papular eruptions that mimic a molluscum contagiosum infection.^5,7 Penicillin is an effective treatment for syphilis, but HIV-positive patients may need to continue treatment for longer than uninfected patients.⁵

As for fungal infections, mucosal candidiasis is the most common form found in patients with HIV. Most develop candidiasis of the oropharynx—thrush.

Thrush is characterized by a burning sensation on the tongue and white plaques on the mucous membrane of the cheeks and around the tongue and tonsils. Although it's possible to scrape off these plaques, avoid doing so, because removing the plaques won't cure the infection but will cause bleeding and leave a tender, friable surface.^5,9

Patients may also develop painful fissures at the corners of the mouth, as well as itchy, red patches with satellite pustules—smaller raised red infected areas—between the fingers and toes, in the axilla, between the buttocks, and in any area with skinfolds. In women, mucosal candidiasis may also present as a vaginal yeast infection.⁵

Oral antifungal drugs such as fluconazole (Diflucan) and topical applications like nystatin (Mycostatin, Nilstat, others) may be effective, but patients with more advanced candidiasis will require IV fluconazole.^7,9 Unfortunately, it's not unusual to see frequent recurrences.³

Tinea, another fungal infection that's common among HIV patients, can affect the toes, nails, groin, perineum, face, and scalp.⁶ It causes red, patchy, scaly areas that can be extremely itchy. While tinea is relatively easy to treat in the general population, it's likely to be more extensive and refractory to treatment among those with HIV. Many patients require long-term oral drug therapy in addition to topical antifungal agents.⁶

No discussion of HIV and skin disease would be complete without mentioning Kaposi's sarcoma (KS), the most common malignant manifestation of HIV.^5,10 Fortunately, the introduction of HAART has drastically reduced the incidence of this deadly disease.^5,10

Although KS is systemic, it usually presents as tumorous purple macules or nodules, which can appear on any part of the body. The lesions may remain unchanged for months or grow and rapidly spread. Eventually patients with KS experience localized pain and surrounding yellow-green discoloration from subdermal hemorrhage. As the tumors enlarge, they become necrotic and ulcerative and are accompanied by massive edema and secondary infection.^10,11

First-line treatment with HAART often stabilizes KS, and may even completely resolve it. Other measures include local cryotherapy and radiation.¹⁰ Systemic chemotherapy and immunotherapy are reserved for patients with aggressive, advanced KS that affects the lungs and GI tract.^5,10

On top of all this, patients with HIV are subject to an almost limitless array of other skin disorders. These include seborrheic dermatitis (dandruff), psoriasis, eosinophilic folliculitis, lichen planus, and pruritic papular eruptions.^3,7

Skin reactions to HIV drugs

Managing allergic reactions to the medications HIV patients take can be a challenge. Adverse cutaneous drug eruptions, or ACDEs, occur frequently, particularly after patients begin HAART. Although HAART and trimethoprim-sulfamethoxazole (Bactrim) are the most common causes, virtually any combination of prescription, over-the-counter, and alternative medications can produce an allergic skin reaction.^5,12

ACDEs typically present as an itchy rash resembling measles or hives.^2,5 Fortunately, the itching can be relieved with oral antihistamines and topical corticosteroids, and many ACDEs resolve spontaneously even if the patient continues to take the offending agent.^5,11

That said, you still can't let your guard down. An ACDE could be an indicator of a potentially life-threatening hypersensitive allergic reaction, such as toxic epidermal necrolysis or Stevens-Johnson syndrome. If a patient develops new blisters, fever, fatigue, sore throat, anorexia, difficulty breathing, or swollen lymph nodes, the drug that triggered the reaction must be stopped immediately.^2,13

To do everything possible to prevent ACDEs, take a careful medication history. And, because hypersensitivity reactions generally occur in the first few weeks after starting a drug, keep a close eye on your HIV patient whenever you administer a new medication—and advise him to immediately report any widespread skin eruption.

Detailed charting is essential. As is the case with any of the skin disorders your HIV patient may experience, you'll need to note the size, dissemination, condition of surrounding tissue, odor, and amount and color of any drainage. You'll also need to note how he responds to any therapeutic interventions.

Review skin care before discharge

Monitor how your patient's skin responds to his treatment regimen, and ensure that his pain is appropriately managed. At discharge, make sure he understands the ongoing treatment plan and steps he can take to care for his skin.

See the Patient Information below and review it with patient and family (a printable .PDF version can be found on our Web site under "Patient Handouts".) Advise him to take only short showers or baths and to avoid hot water, which causes vasodilation that makes pruritis worse.¹⁴ Urge him to use only gentle skin care products and avoid harsh cleansers and deodorant soaps.¹⁴

Most important, be sure he and his family are clear about which skin reactions he can wait to report to his healthcare provider and which ones warrant an immediate call.

Skin disorders are a very visible reminder of the toll HIV takes on the body. But armed with a solid understanding of what can be done to combat them, you'll be better equipped to offer patients the support and education they need as they face the long-term challenge of living with HIV/AIDS.

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REFERENCES

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PATIENT INFORMATION

Skin care tips for patients with HIV

Almost every patient with HIV develops skin problems at some point. In addition to following your doctor's instructions and taking all your medications, as prescribed, there are steps you can take to make your skin less itchy and prevent rashes from spreading:

• Wash your hands thoroughly and often.
• Use mild soaps like Dove or Neutrogena. Avoid soaps that contain deodorant.
• Take short baths or showers in cool or warm—but not hot—water.
• Don't use a washcloth, which can be abrasive. Pat your skin dry instead of rubbing it.
• After bathing and before going to bed, apply a water-based skin lotion such as Aquaphor or Eucerin. Avoid lanolin-based creams or ointments, and use only skin care products that are fragrance-free.
• Keep your lotion in the refrigerator so it will be cool when you put it on, which may help reduce itchiness.
• Wear loose-fitting clothes to avoid chafing your skin.
• Keep your fingernails short.

Sources: 1. Kouba, D. J., & Martins, C. R. "A clinical guide on supportive and palliative care for people with HIV/AIDS. Chapter 9: Dermatologic problems." 2003. ftp://ftp.hrsa.gov/hab/pall/chap9.PDF (24 Mar. 2006). 2. Tuthill, J., & Garnier, S. R. "A clinical guide on supportive and palliative care for people with HIV/AIDS. Chapter 25: Pevention of skin breakdown." 2003. ftp://ftp.hrsa.gov/hab/pall/chap25.PDF (24 Mar. 2006).

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