Skin Problems

The skin is commonly affected in people with HIV infection. The con­ditions affecting the skin include a diverse array of infections and an unusual tumor called Kaposi’s sarcoma.

As expected, the diagnosis of a skin condition is largely dictated by its appearance. In many cases, a diagnosis can be established simply by observation, but occasionally diagnosis will require a biopsy.

Purple or Black Spots

Purple or black spots on the skin are characteristic of Kaposi’s sarcoma (KS), a tumor of the cells of the blood vessels. In most cases, there are several tumors, each approximately a quarter of an inch to an inch in di­ameter. They can usually be felt as a nodule or a fleshy collection of tis­sue. They can—but do not usually—cause pain. In light-skinned people, the tumors are usually purple; and in dark-skinned people, they are very dark brown or black. The tumors are not like freckles, either in color or to the touch.

KS tumors can appear any place on the skin, including the face, scalp, back, chest, abdomen, arms, legs, and inside the mouth. They ap­pear most commonly on the tip of the nose, around the eyes, on the ears, behind the ears, and on the arms, the legs, the chest, and the genitals. Usually tumors appear in different places. At times the tumors occur symmetrically, appearing in almost identical places on both arms, on both sides of the face, or on both feet. KS can cause edema (swelling) of the leg or the face. It can also cause disease in such internal organs as the gastrointestinal tract or the lungs.

KS is caused by a virus called Kaposi’s sarcoma herpes virus (KSHV), or human herpes virus 8 (because there are seven previously known herpes viruses). KS is not the same as the herpes virus that causes genital infections or cold sores; it is only related to that virus. Among gay men with HIV infection, KS is disappearing, due to changes in be­havior, to reduced rates of HIV infection in gay men, and to higher CD4 counts following HAART.

When KS on the skin is suspected, it can be diagnosed with a biopsy of the tumor. The skin biopsy is a simple outpatient procedure; Novo­cain is injected into the skin to make the procedure painless.

The treatment and prognosis depend on the severity of immune sup­pression and the number and location of the KS tumors. When KS tu­mors are few and confined to the skin, the prognosis is good and treat­ment is usually done for cosmetic reasons or for relief of any unpleasant symptoms: cosmetic problems can often simply be covered with opaque makeup. Skin tumors can also be treated with radiation, freezing, laser treatment, or injection of a drug called vinblastine. When the CD4 count stays below 150, when there are more than twenty-five skin tumors, or when the internal organs are involved, treatment is often cancer chemo­therapy. If the tumors are obstructing lymph channels, treatment can be radiation or cancer chemotherapy.

The best advice about treating Kaposi’s sarcoma will come from any physician with extensive experience in this area, particularly from an AIDS physician (see chapter 7), from a dermatologist, or from a cancer specialist (an oncologist). Which physician does the treatment will de­pend on which therapy is used: radiation treatment will require referral to a radiation therapist, cancer chemotherapy might require referral to an oncologist, and drug injections are usually done by a dermatologist or an oncologist.

Red Rash

A rash is usually either diffusely red all over or red only in spots or blotches.

The most common cause of a red rash covering large areas of the body in people with HIV infection is an adverse reaction to a drug. The most common offending drug is a sulfa drug—especially trimethoprim­sulfamethoxazole (Bactrim, Septra), the drug usually taken for the treat­ment or prevention of Pneumocystis jiroveci pneumonia. Sulfa drugs are also treatments for many other infectious diseases in people with and without AIDS. Rashes that are a reaction to sulfa drugs are especially common in people with HIV infection: 30 percent to 50 percent of peo­ple with HIV infection have these rashes. In addition to rashes, many people also have fever, low white blood cell counts, or tests showing hep­atitis. All these symptoms disappear when the sulfa drug is stopped. Many people tolerate trimethoprim-sulfamethoxazole if they take it again, especially if they take it in a lower dose.

Rashes are also caused by other drugs, including dapsone, clindamy­cin, penicillin, amoxicillin, sulfadiazine, voriconazole, atovaquone; and several anti-HIV drugs, including abacavir, efavirenz, fosamprenavir, nevirapine, and atazanavir. Most skin rashes cause no serious problems, even with continued use of the drugs causing them. Rashes often itch, and the itching may be treated with steroid creams or antihistamines like atarax. If the drug causing the rash is stopped, the rash usually improves within 48 hours; if the rash doesn’t improve, it is caused by something else. If the drug is really important to treatment, it may be worth “rid­ing it out,” because the rash may improve even with continued use of the drug that caused it.

A few conditions or drugs require special attention. Abacavir or nevirapine may cause a rash that indicates a serious problem, especially within the first 8 weeks of starting abacavir and the first 16 weeks of starting nevirapine.

Other types of skin reactions are serious and require medical atten­tion: skin rashes that involve the mouth or eyes, cause fever, cause blis­ters, or cause joint pain and weakness.

Itchy Skin

People with HIV infection often have itchy skin. When the itchiness is accompanied by a rash, the cause is usually a reaction to a drug as out­lined above. Almost any drug can cause itchiness, but those that do most commonly are the same ones listed above that also cause a rash.

Many people with HIV infection develop bumps, called nodules, that itch so badly that people actually tear the skin with scratching. The condition is called prurigo nodularis, which is Latin for “itchy nod­ules.” The cause is unknown. The treatment is to soothe the itching and thereby stop the cycle of scratching-bleeding lesions-scars-more scratching. Applying steroid creams and covering the lesions often helps. Sometimes the steroid is injected into the nodules. Sometimes the nod­ules are removed with surgery, either by lasers or with cryotherapy. Sometimes the treatment is antihistamines, taken by mouth, or photo­therapy—a light treatment called PUVA.

Itchy skin without bumps or a rash could be scabies, a highly con­tagious infection whose symptoms are pinhead-sized bumps with ulcers on top of them. They itch more at night. Scabies is treated with a lotion applied over the whole body. People who have been in close contact with the person with scabies should also be treated.

Itchy skin without bumps or a rash could also be a symptom of a serious underlying disease like liver or kidney disease, or lymphoma.

Finally, some people with HIV infection itch but have no bumps or rash, and no underlying disease. They just itch. In this case, the best treatment is oatmeal baths, menthol lotions, anesthetics applied to the skin, or antihistamines or cortisone taken by mouth.

Blisters

Blisters are small, fluid-filled bubbles that often break, becoming open sores filled with clear fluid or pus. Blisters can occur in groups in one specific area of the skin, or they can be distributed all over the skin. Like red rashes, blistering rashes can be caused by adverse reactions to drugs. The most common causes of blistering rash in people with HIV infec­tion, however, are two related viruses, herpes simplex and herpes zoster.

Herpes simplex infection. Infection by the herpes simplex virus is ex­tremely common in healthy people, causing water blisters, pain, and fever. There are actually two different types of herpes simplex viruses: Type 1 and Type 2. Type 1 most frequently causes the infection of the mouth called cold sores (see below, “Mouth Problems”). Type 2 most frequently causes sores on the genitals and the anal region and is re­garded as a sexually transmitted disease. When the infection is on the mouth, transmission is usually through oral contact (like kissing) with a person who is infected with the virus and who may or may not have ap­parent sores on the mouth. When the infection is in the genitals, trans­mission is usually through sexual contact; the person who is the source of the infection may or may not have sores on the genitals.

After the initial infection clears up, the virus remains in the nerves nearby and is either silent with no symptoms, or it is periodically reac­tivated. When the virus is reactivated on or in the mouth, it causes what people call cold sores. When the virus is reactivated on the genitals, it causes sores on the genitals or in the anal region. These reactivations are less severe than the initial infection.

Studies of blood tests show that 50 percent of people have had her­pes simplex on the mouth and 20 to 30 percent have had herpes simplex on the genitals, even though most do not recall it. Most of these people have either no problems or rare outbreaks; some have attacks more fre­quently, but these are brief, not severe, and restricted to the lips or gen­itals.

Treatment is generally successful in providing relief from an out­break of sores, if taken early enough. Acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) are the usual drugs. They are taken by mouth. Occasionally, people have strains of herpes that are resistant to these drugs and require foscarnet (Foscavir), given by vein. The relief with treatment is usually temporary; treatment does not eliminate the herpes virus and does not cure the infection. When the outbreaks recur frequently enough, treatment is taken continuously.

We now think that herpes on the genitals is important in transmit­ting HIV infection, probably because the sores are an easy place for HIV to enter. The sores can be obvious blisters, but they can also be tiny and go unnoticed. The drugs used to treat genital herpes—acyclovir, valacy­clovir, and famciclovir—all reduce herpes outbreaks, including any tiny sores, and in general reduce the amount of herpes virus that is shed. This means that chronic use of the drugs for genital herpes will reduce not only the outbreaks and transmission of herpes, but also the transmission of HIV.

Herpes zoster, or shingles. Herpes zoster is caused by the same virus that causes chickenpox. Like herpes simplex, the herpes zoster virus stays quiet or dormant in the nerve cells. Every adult who had chicken­pox during childhood has the shingles virus living in his or her nerves for life. Usually the virus causes no problems. Sometimes, however, many years or decades after the original bout with chickenpox, it be­comes active, causing a disease called shingles. It seems to become active at times of stress or in people with weakened immune systems, but some­times it becomes active for no apparent reason. The assumption is that the virus is continually present but is held in check by the normal im­mune defenses. Shingles is common not only in people with HIV infec­tion, but in the elderly and in others as well. Shingles, although it is more common in the late stages of the infection, is one of the few complica­tions of HIV infection that can occur with a high CD4 count.

The symptoms of shingles are blisters that are identical to those seen with chickenpox. The blisters are small and filled with a watery fluid; later, the blisters break, the fluid becomes pus, scabs form, and the skin heals. Unlike the blisters of chickenpox, however, the blisters of shingles are often extremely painful. In addition, they are not spread all over the body, but instead are distributed in bands or lines on the chest, the ab­domen, down the leg, on the arm, or on the face. In most cases, the blis­ters occur on only one side of the body and stop abruptly at the middle of the body. The blisters follow this pattern because they are following the path of the nerve in which the virus is living, and each nerve serves only one side of the body.

The worst complication of this infection is pain. The pain may come before the blisters appear, or it may accompany the blisters. The pain may also occur months or even years after the blisters are gone and the skin is healed; this pain is called post-herpetic neuralgia. Fortunately, people with HIV infection who get shingles do not often develop post­herpetic neuralgia. This complication is most common in people over 60 years old, with or without HIV infection.

A note about transmission: the blisters contain the virus that causes herpes zoster. Adults who have had chickenpox already have this virus, have antibodies to it, and are not susceptible when exposed to someone with chickenpox or shingles. However, young children and the occa­sional adult who has escaped chickenpox could become infected with the virus that causes herpes zoster. These people may acquire chicken­pox by contact with the blisters or by inhaling the virus. To prevent transmission, people who have not had chickenpox should carefully avoid contact and should even avoid being present in the same room. People who are hospitalized should expect strict isolation precautions— gloves, masks, and gowns—to be taken, to prevent transmission to the health care workers. The so-called varicella vaccine now prevents chick­enpox and will protect people who have not had chickenpox. This vac­cine should not be taken by people with HIV infection because it is a “live vaccine” that could cause the disease if the immune response is im­paired. Chickenpox in people with advanced HIV infection can be se­vere and can be prevented. Many people who think they never had chick­enpox do have antibodies, which indicates that they did in fact have it but didn’t know it. For the person with HIV infection who is exposed to chickenpox or to zoster and who has no history or antibody-evidence of prior chickenpox, the recommendation is an expensive immune globu­lin called VZIG.

Shingles is not life-threatening and inevitably cures itself. But it can be especially severe in people with advanced HIV, or when the eyes are involved. And people are in pain—potentially terrible pain—so treat­ment is generally recommended. The treatment is with famciclovir or valacyclovir. Treatment makes the blisters clear faster and may reduce the pain, but it needs to be started early. Drugs such as nortriptyline may be taken to control the pain. Famciclovir and valacyclovir may be taken by mouth, but hospitalization for intravenous treatment with acyclovir is sometimes advocated. Foscarnet and cidofovir are usually effective against strains of the virus that are resistant to oral drugs.

Thick, Discolored Nails; Red, Flaking Circles

Thick, discolored toenails or fingernails are usually caused by a fungus. Patches of red, flaking skin, on the feet or in the groin area, are called ath­lete’s foot or jock itch. When the patches of red, flaking skin are in cir­cular patterns on the scalp or the skin, they are called ringworm. Ath­lete’s foot, jock itch, and ringworm are caused by fungi. These fungi cause infections of the skin and nails but are not capable of causing much else. Treatment of ringworm with antibiotic ointments—clotrimazole (com­mercial name, Lotrimin) or miconazole—applied on top of the involved area is usually effective. Most of these ointments are available without prescription. When the nails are involved, when large areas of the skin are affected, or when ointments do not work, other antibiotics, like itra­conazole or griseofulvin, can be taken as pills and are usually effective.

Small, Colorless Bumps

A crop of small, colorless bumps is usually caused by a virus called Mol- luscum contagiosum. Each of the bumps often has a central indentation. The most common location is on the face, especially around the mouth, and in the genital region. Molluscum contagiosum seems to be especially common in people with HIV infection. The major problem is cosmetic. No antibiotics are successful, but a dermatologist can remove the bumps by freezing, electrosurgery, curetting, or a topical treatment.

Flaking, Scaling Rash in Patches

Red, scaling patches, most frequently on the scalp, face, ears, chest, and genitals, are symptoms of seborrhea. Some people have the patches sym­metrically on both cheeks, in what is called a “butterfly” distribution. Many people simply have seborrhea on the scalp, where it is referred to as dandruff.

Seborrhea appears to be caused by a fungus, generally involves only the skin, and, at least when severe, is usually cared for by dermatolo­gists. Seborrhea occurs in 50 to 80 percent of people with HIV infection. As the infection progresses, seborrhea is more frequent and more severe.

The treatment of seborrhea of the scalp is to use shampoos con­taining coal tar, available without prescription at drugstores. For best re­sults, apply the shampoo, then leave it on for twenty to thirty minutes before rinsing it off. Seborrhea on the rest of the skin can be treated with ointments containing cortisone or ketoconazole. Cortisone ointments are available without prescription, but severe or persistent cases of seb­orrhea are best treated with stronger concentrations of cortisone, which require a prescription.

Excessive Bleeding

Excessive bleeding from nosebleeds, cuts, and injuries may be a symptom of idiopathic thrombocytopenic purpura (ITP). The gums may bleed ex­cessively with toothbrushing, or small razor cuts might bleed excessively. Other symptoms are easy bruising and bloody or tarry stools that result from intestinal bleeding. Some people will have many small red dots about the size of a pinhead on the lower legs and feet, called petechiae, which are tiny hemorrhages. Others have larger hemorrhages into the skin, called purpura. Unlike other red rashes, these hemorrhages do not disap­pear when pressure is applied to them. In other words, if you push on the red spot, the spot does not clear for several seconds but remains red.

Idiopathic thrombocytopenic purpura means low numbers (penia) of blood platelets (thrombocytes) that promote blood clotting, causing bruises or hemorrhages in the skin (purpura) for reasons that are unex­plained (idiopathic). The cause of ITP is unknown: for some reason, ei­ther the body produces antibodies that attack blood platelets or the bone marrow stops making platelets. The purpose of the platelets is to help the blood to clot, explaining ITP’s excessive bruising and bleeding. ITP can occur in people who do not have HIV infection. It can occur in peo­ple with HIV infection either when the CD4 count is high or when it is low, but usually when it is low.

Most people who have ITP are unaware of it; ITP is usually discov­ered with routine laboratory testing when a complete blood count (CBC) shows that the number of blood platelets is low. The usual count in healthy persons is 150,000 to 300,000 platelets per milliliter of blood. People with HIV infection often have slightly lower counts—80,000 to 120,000 platelets per milliliter—though these counts cause no problem. People with ITP often have counts that are lower yet — 5,000 to 30,000 platelets per milliliter.

Treatment of ITP may consist of drugs, like corticosteroids, that sup­press the antibodies attacking the platelets, drugs directed against HIV, or gamma globulin given intravenously. The treatment chosen depends on the situation. If bleeding is active and severe, people will need trans­fusions and injections of platelets. If the platelet count is low and bleed­ing intermittent, physicians will always treat HIV first. If that fails, the next step is cortisone and sometimes gamma globulin (which is very ex­pensive). If the person has no symptoms, the physician simply advises precautions and follows up with periodic platelet counts. The major worry with ITP is the possibility of internal bleeding, during which large amounts of blood could be lost or vital organs like the gastrointestinal tract, the brain, or the lungs could be damaged. Obviously, the person with extremely low platelet counts should be extremely careful to avoid cuts and injuries. This means using an electric shaver and avoiding any­thing that would cause cuts or bruises.