Appendix F: HIV-Related Complications of the Skin, Lymph Nodes, and Mucous Membranes
| Disease | Etiology and presentation | Treatment |
|---|---|---|
| Enlarged lymph nodes, nodules, or masses | ||
| Generalized lymphadenopathy | May be HIV-related or result of OIs such as TB,atypical mycobacteria, histoplasmosis, coccidioidomycosis, lymphoma, Kaposi’s sarcoma, Epstein-Barr virus, toxoplasma, tularemia, CMV, or Castleman’s disease; also seen in immune reconstitutionsyndrome (see Section 3.9.7 and Protocol 3.26);less often lymphoma. | Treatment should be directed at the specific OI. If no OI can be identified, consider initiating ART. |
| Kaposi’s sarcoma | Firm subcutaneous brown-black or purple nodules at any cutaneous site, especially face, chest, genitals,and extremities. | May resolve with ART. Surgical excision, intralesion or systemic chemotherapy, radiation, cryotherapy, or laser therapy in specialist centers may be successful if the sarcoma is extensive and widespread. |
| Lymphoma | Increased risk in patients with HIV. Often in body cavities or CNS. Hard, painless lymph nodes are typical. May be associated with fever. | If specialized care centers are available, consider biopsy and treatment based on definitive diagnosis. |
| Salivary gland enlargement | Enlargement of submandibular, parotid, and other glands; may be mistaken for lymphadenopathy. Should rule out abscess and lymphoma. If parotid swelling, consider mumps in differential diagnosis. | Usually resolves or improves with ART. If evidence of pus or infection present, consider drainage and treatment with dicloxacillin 250-500 mg orally 4x/day for 10-14 days or clindamycin 150-300 mg orally 4x/day for 10-14 days. Promote good oral hygiene |
| Sexually transmitted infections | May present with inguinal mass or adenopathy. | See Section 2.6. |
| Tuberculosis | Typically a single swollen lymph node, most commonly in the cervical chain; may be generalized. Lymph nodes initially firm and small can become large and fluctuant. Suppuration with drainage and chronic fistulization may occur. Diagnosis can be confirmed on biopsy or aspirate. | See Section 2.4. |
| Infected skin lesions (lesions that are red, tender, warm, pustular, or crusty) | ||
| Abscess or folliculitis | Most commonly caused by Staphococcus aureus. | Incise and drain fluctuant abscesses with sterile technique. Start dicloxacillin 50-500 mg orally 4x/day or cephalexin 500 mg orally 4x/day or clindamycin 150-400mg orally 4x/day. Treat for 7-14 days or until resolved. Follow-up in 1-2 days to confirm improvement. |
| Impetigo | Red, tender, warm papules, often with a honey-colored crust. Frequently on the face (around themouth), trunk, and groin of adults. Contagious. May appear as ulcerating lesions. | Dicloxacillin 250-500 mg orally 4x/day or cloxacillin 250-500 mg orally 4x/day or erythromycin 250-500 mg orally 4x/day or clindamycin 150-400 mg orally 4x/day. |
| Other lesions | Eczema, psoriasis, contact dermatitis, prurigo nodularis, and other lesions can mimic infection. | See sections on eczema, psoriasis, contact dermatitis, and prurigo nodularis in this table. Generally do not require antibiotics unless superinfection is present. |
| Cellulitis | Skin is red and warm; patient may be systemically unwell with fever. May progress to more severe soft tissue infection, | Start dicloxacillin or cephalexin 500 mg orally 4x/day for 7-14 days or until resolved. |
| Severe soft tissue infection | Rapidly progressing skin infection, may involve subcutaneous fascia, pyomyositis, systemic toxicity. May be life- or limb-threatening. | Start benzathine benzylpenicillin 4 MU IV 6x/day. Add clindamycin 600 mg IV or orally 3x/day. If IV not available, start dicloxacillin and clindamycin orally. May need hospitalization and possibly specialist care or surgery. |
| Skin conditions that present as blisters or vesicles | ||
| Adverse drug reactions | Some drug reactions can cause generalized blistering or small bumps. A peeling rash involving the eyes or mouth can represent a very serious drug reaction causing Stevens-Johnson syndrome. | Stop all medications. Administer oral antihistamines. If Stevens-Johnson syndrome is suspected, hospitalize for supportive care. If reaction is severe, give prednisone 1-2 mg/kg orally, tapering 5-10 mg every 1-3 days. If patient was on ABC, do not reintroduce (may be fatal). See Protocol 3.7. |
| Contact dermatitis | Typically limited to the area in contact with the causative agent. | Hydrocortisone 1% cream or ointment 3x/day. If severe, with blisters or edema, consider prednisone 1 mg/kg/day orally, tapering 5-10 mg/day over 7-10 days. |
| Herpes simplex | Vesicles with an erythematous base. Usually oral, genital, or peri-rectal. Generally in clusters. May have a history of recurrence. | If first episode or severe reaction, administer acyclovir400 mg orally 5x/day for 10 days. See Protocol 3.21. |
| Herpes zoster | Vesicles with an erythematous base in a dermatomal distribution. Lesions in more than one dermatome or lesions in eye are considered to be disseminated (or complicated) disease. | All patients with HIV should be treated with antiviral therapy regardless of timing of lesion onset. Administer acyclovir 10 mg/kg IV over 1 hour 3x/day for 7 days. Administer analgesia as required. See Protocol 3.21. |
| Skin conditions that present as generalized or itching rashes | ||
| Adverse drug reactions | Generalized widespread red rash with small papules, usually on trunk. Blistering or a peeling rash involving the eyes or mouth can represent a very serious drug reaction leading to Stevens-Johnson syndrome. | Stop all medications. Administer oral antihistamines. If Stevens-Johnson syndrome is suspected, hospitalize for supportive care. If reaction is severe, give prednisone 1-2 mg/kg orally, tapering 5-10 mg every 1-3 days. If patient was on ABC, do not reintroduce (may be fatal). See Protocol 3.7. |
| Eosinophilic folliculitis | Itchy papules and pustules most commonly on the head, trunk, and upper part of extremities. Difficult to differentiate from infective follicultis; a biopsy will reveal eosinophilic infiltrate in the follicular epithelium. May occur with immune reconstitution. | Usually resolves once ART is initiated. Permethrin cream and topical steroid creams can help; antihistamines for pruritis. |
| Scabies (also head and body lice) | Rash and excoriations on the torso. Burrows can often be seen in the web space between the fingersand on the wrist. The face is usually not affected. Itching can persist for two weeks after treatment. | Permethrin cream 5% (preferred): apply from chin to toes. Wash hair if involved. Leave on for 8-10 hours, then wash. Repeat in one week. Safe for children >2 months of age. Alternative: lindane 1%, same usage as permethrin. Seizures can occur from coverage of broad areas. Do not use in children or pregnant women. Trim fingernails, wash clothes and bedding. |
| Norwegian scabies(Scabies crustosta) | Usually in advanced immunosupression (CD4 <100cells/mm3 ). Can mimic psoriasis. Itching may be absent. Extensive crusting. | Permethrin cream 5%: leave on for 24 hours; 6% sulfur on days 2-7. Repeat for several weeks. Single-dose ivermectin 200 mcg/kg reported to be effective. |
| Prurigo nodularis | Hyperpigmented, hyperkerototic, often excoriated papules and nodules up to 1 cm. May be due to insect bites. Scratching results in worsening pruritis. | Give oral antihistamines. Insecticides and bed-netting may be effective in preventing new lesions. Topical corticosteroid cream may help; can use high-potency steroid creams under an occlusive dressing. Aim to break the itch-scratch cycle, which may take several weeks or months. Condition may also improve with ART. |
| Early secondary syphilis | Macular rash on trunk palms and soles. | Single-dose benzathine benzylpenicillin 2.4 MU IM. |
| Oral and skin lesions caused by fungal infections | ||
| Candidiasis (skin) | In children: causes a diaper-rash-type rash involving the trunk and extremities. In adults: causes flat or slightly raised red lesions; also common in the mouth (see section on oral lesions elsewhere in this table). | Topical ketconazole, miconazole, clotrimazole, econazole, or nystatin, all 2x/day. |
| Dermatophytic fungi | Red, often itchy lesions; may cause changes in skin pigment. Lesions can occur in the groin (T. cruris), on the feet (T. pedis), or on the body (T. corporis). T. capitis (ringworm) causes pale round scaling patches on scalp or round patches with thick reddish edges on the body or web of the feet. It is harder to treat than the aforementioned fungal infections. | Topical ketoconazole, miconazole, clotrimazole, econazole, or nystatin, all 2x/day, or single-dose fluconazole 150 mg orally or 150 mg/week orally for 2-4 weeks. Ringworm: topical ketoconazole 2x/day may be sufficient if lesions are few or small. If extensive, consider fluconazole 150 mg/week orally for 2-4 weeks or griseofulvin 500 mg/day orally for 4-6 weeks. In children: griseofulvin 10-20 mg/kg/day until hair regrows, usually 6-8 weeks. |
| Seborrhea | Very common in HIV-infected individuals. Can present as mild dandruff or patches of scaly areas with indistinct borders. Common in the scalp, hairline, central face; also seen in body folds and chest. Usual etiology is Malassezia species. | Ketoconazole (1% or 2%) shampoo or lotion. If severe, consider corticosteroid cream and ketoconazole. Often resolves or improves with ART. |
| Tinea versicolor | Typically causes areas of hypopigmentation. May be confused with vitiligo, which is not an infectious disease and will not respond to antifungal agents. | Usually resistant to topical agents. Administer single-dose ketoconazole 200 mg or 400 mg orally for 7 days, or single-dose fluconazole 400 mg orally. |
| Other skin lesions | ||
| Dry skin (xerosis) | Often very itchy; antihistamines do not provide much relief. | Apply humectants or moisturizing creams. |
| Eczema | Red rash; often, itchy, flaking lesions that may have whitish patches or scaling; may become super-infected. Often on the groin and face (especially in children), under the arms, on the elbows, and elsewhere. Can be confused with contact dermatitis or psoriasis. | Apply topical corticosteroid creams. Treat itching with antihistamines. Dry the skin gently and avoid harsh or perfumed soaps. |
| Insect bites | Fleas: lower legs. Mosquitoes and other biting insects: arms and legs. | Fleas: wash clothes and bedding; do not allow pets and other animals in the house. Mosquitoes and other biting insects: use bed nets with insecticide; use topical insect repellant as needed; give antihistamines for itching. Monitor for signs of superinfection. |
| Leprosy | Skin patches with no sensation to soft touch, heat, or pain; not itchy. Can occur in any location of the body. Hypopigmented, pale or reddish; flat, raised, or nodular. Chronic (>6 months). | If never treated in the past, treat with multidrug therapy per WHO guidelines. |
| Longitudinal pigmented nail beds | Seen in almost 50% of persons on AZT; more common in dark-skinned patients. Occurs 4-8 weeks after initiating treatment. | No treatment necessary. |
| Molluscum contagiosum | Pearly white or flesh-colored papules with central umbilication; most common on the face and genitals. Diagnosis is usually made by clinical appearance. | Usually no treatment needed. Lesions will disappear in patients responding to ART. |
| Psoriasis | Thick, red, scaling patches with distinct margins. Often on elbows, knees, scalp, hairline, and lower back. May be itchy. | Coal tar ointment 5% in salicylic acid 2%. |
| Warts (human papilloma virus) | Flesh-colored papules or raised areas of skin; common in genital or perianal area. | Topical treatment with cryotherapy or topical podofilox 0.5%. |
| Lesions of the mucous membranes | ||
| Angular cheilitis | Sores at the corners of the mouth. Most often caused by candidiasis but can also be present with malnutrition and vitamin B deficiency. | Consider empiric fluconazole 100 mg/day orally for 10-14 days; provide nutritional supplementation. |
| Aphthous ulcer | Cause is unknown; however, HIV, HSV, CMV, and drug reactions can also cause ulcers of the mouth. | Topical lidocaine or triamcinolone hexacetonidein orabase; if severe and refractory, consider prednisone 40 mg/day orally for 1-2 weeks. |
| Gingivitis/ periodontitis | Redness or dead tissue around teeth and gum line; receding gum line; painful chewing. Can become necrotizing and cause loss of teeth. | Metronidazole 500 mg orally 2x/day for 7-10 days. Promote good oral hygiene. If necrotizing, may need dental consultation for debridement and teeth extraction. |
| Oral hairy leukopenia | Whitish or grayish, feathery, irregular-appearing lesions, usually at base of tongue or gums. | Usually improves or resolves with ART. |
| Thrush (candida) | White plaques on an inflamed base on tongue, palate, buccal mucosa, or oropharynx. | Fluconazole 200-400 mg/day orally for 10-14 days; see Section 3.9.4 and Protocol 3.22 on candidal infections. |
Sources: Bartlett JG. The Johns Hopkins Hospital 2005-6 guide to medical care of patients with HIV infection. Baltimore, MD: Johns Hopkins University, 2005; Sande MA, Gilbert DN, Moellering RC. The Sanford Guide to HIV/AIDS Therapy. Hyde Park, VT: Antimicrobial Therapy, 2005.
»
- Printer-friendly version
- Login or register to post comments
