Viral Skin Infections in HIV Patients with Darker Skin

00:01 So if one moves on to clinical manifestations of HIV, if we start with viral skin infections in HIV patients, what do we expect to see.

00:11 In acute HIV exanthem, this is a skin rash that can develop within 2 to 6 weeks after the initial infection with HIV.

00:19 It occurs in about 50 to 70% of cases.

00:23 Those with an acute HIV syndrome.

00:26 However, not all the patients may present with this viral exanthem.

00:31 And how does it present? Patients may present with symmetrical Maculopapular erythematous rash.

00:37 As you can see on this picture here, it may involve the face, palms, soles, trunk, and limbs.

00:45 The severe symptoms of a viral exanthem only occur in about 25% of patients, so most patients will have the zero HIV infection and may not present with symptoms.

00:59 That is, they may be asymptomatic and may not seek treatment.

01:05 Herpes simplex virus infection is another viral infection that we see in patients with HIV. It's most common in HIV infected patients, particularly in children.

01:16 It may be severe, chronic, and recurrent.

01:20 This is a young baby with herpes simplex virus, which is quite extensive, necrotic with excoriations as well.

01:27 As you can also see the crusting which is used to secondary bacterial infection, which may occur as a complication.

01:36 One m ay also see larger ulcerative, necrotic and widespread lesions of herpes simplex virus in patients with advanced HIV or AIDS. The ulcer may last for more than a month, and it may be defined as chronic, and it is an AIDS defining illness.

02:00 So what I'm trying to say is, if you've got an ulcer, which has been there for more than a month, so one can actually use that as a criteria for labeling patients as having AIDS.

02:13 The treatment of herpes simplex virus infection is similar to that of patients who do not have HIV that is immunocompetent patients, but it may require longer duration and it may be recurrent as well. Still, on viral infection, we're speaking about chickenpox or varicella can occur at any stage of HIV, it tends to be profuse, atypical with ulcerated lesions.

02:41 It can be hemorrhagic, erythematous, and hyperkeratotic.

02:48 There's a high risk of dissemination of varicella zoster in patients with HIV. For example, patients may develop pneumonitis, what we call as varicella zoster virus pneumonitis.

03:04 Herpes zoster is another skin infection which is caused by varicella zoster virus, and it may also occur in patients with HIV.

03:14 In fact, when HIV started in the late 80s, herpes zoster was the most common presentation of HIV that we saw in my country.

03:25 The uniqueness of herpes zoster in patients who are immunocompromised with HIV, it tends to be persistent, ulcerative disseminated, and may actually lead to scarring, and some patients may have multi dermatomal involvement of herpes zoster.

03:43 So as mentioned the lesions may be deeper and more painful.

03:47 And one may also have post-inflammatory hyperpigmentation.

03:54 The treatment of herpes zoster is similar to that of immunocompetent patients, but one may need longer duration of treatment.

04:05 What about molluscum contagiosum? It occurs in about 5 to 18% of HIV infected individuals.

04:12 It's more common in children.

04:15 It tends to also involve to involve atypical sites.

04:20 The face may be involved with big giant molluscum lesions and may also get extensive involvement of the other areas, for example the neck.

04:33 Extensive, large, confluent, disfiguring lesions due to episode two, molluscum contagiosum may also occur.

04:42 Interestingly, if you look at this picture of this patient, this patient has got extensive molluscum together with ulcerative herpes simplex virus infection involving the genital area. So it's not uncommon in HIV patients to see more than one skin condition.

05:01 Up to 3 to 4 skin conditions may be seen in just one patient.

05:08 So how do we treat molluscum? Of course, the treatment is similar to standard treatment, but may be needed for longer periods, and one may need to be more aggressive with the different forms of treatment.

05:21 So it tends to be recalcitrant and challenging to treat.

05:24 And the therapies that result in wounds, for example curettage, are less favorable in HIV patients due to an elevated risk of infection. Moving on to human papillomavirus infection, it's common words.

05:41 As we've spoken about in our previous lecture, the Verruca vulgaris, Verruca plana, and Condyloma acuminata that we normally find on the genital area.

05:52 It tends to persist despite HAART.

05:56 It is caused by multiple HPV types serotypes, and there is a high risk for developing malignancies.

06:05 I must say that during the HIV era, before there was HAART treatment, this was a nightmare to treat in patients.

06:12 Extensive gross lesions, very challenging to manage and very challenging for the physicians treating these patients.

06:22 This is an example of a common wart of Verruca vulgaris.

06:26 This is what you would normally see in an immunocompetent patient.

06:30 Isolated lesions. This is a patient with Verruca Plana.

06:37 We spoke about this as well.

06:40 And one can also get acquired Epidermodysplasia Verruciformis where you have extensive verruca plana involving an extensive body surface area. In fact, there has been cases of acquired epidermodysplasia verruciformis presenting as erythroderma in patients with HIV AIDS.

07:05 And genital warts. We refer to as Condyloma acuminata.

07:09 That can be quite extensive.

07:11 And this is a young baby child who had this condition and had vertical transmission of HIV. And sometimes, when one sees Condyloma cuneata on the genital areas, especially in children, we always have to think about child abuse.

07:30 However, in the era of HIV, it is quite common to have Condyloma acuminata involving the genital area, but bear in mind that in children, when you see condyloma in the genital area at the back of your mind, do think about child abuse and refer appropriately when needed.

07:55 So the treatment of HPV is similar to Standard treatment.

07:58 However, there are poor clearance rates in HIV patients as I have mentioned. It's a nightmare for for dermatologists or primary care physicians. One may need more than one application of therapy.

08:12 Longer duration of treatment.

08:14 Numerous visits for the patients.

08:16 And one may also need a combination of treatments, for example, combining immune therapy with cryotherapy or electrocautery, etc., and sometimes surgical excision to debulk the lesions.