HIV Management Guide for Clinical Care and ARV Guidelines

HIV Management Guide for Clinical Care and ARV Guidelines

Dermatological Conditions

Dermatological Conditions

James Pham1,2, Deshan Sebaratnam1,2  Faculty of Medicine and Health, University of New South Wales  Department of Dermatology, Liverpool Hospital  Last reviewed: Jan 2024  Next review due: March 2029  Acknowledgement: We would like to acknowledge Alexis Lara Rivero, Mark Kelly, Cassy Workman & Margot Whitfeld as the original authors of this section and David Wong for …

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Clinical History Taking and Physical Examination

As with any clinical presentation, history taking may offer clues to diagnosis (Table 2).  Note the distribution, type of rash and any other associated physical findings including: oral, hair, nail and genital changes   Table 2          History essentials in the setting of cutaneous presentations  HIV status  Current and nadir CD4 cell count, and viral load results  …

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Viral infections

Many viral infections, including those presenting with or limited to cutaneous involvement, occur more frequently in PLWHIV. (2) Common viral skin infections include those caused by Herpesviridae (including herpes simplex-1 and -2 and varicella zoster viruses), human papilloma viruses and Pox viruses. Given the underlying immunodeficiency in this demographic, viral infections may present atypically leading …

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Herpes simplex virus

Serological studies estimate approximately 67% and 16% of the global population are living with Herpes Simplex Virus (HSV)-1 and -2, respectively. (6, 7). Both HSV-1 and -2 are typically acquired in childhood or early adulthood, primarily through vertical or sexual transmission, and are never cleared. (8) In the immunocompetent population, HSV infection is typically latent …

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Diagnosis

The diagnosis of mucocutaneous HSV may be made on clinical grounds alone in the majority of cases. Vesicular fluid should be swabbed to confirm the presence of HSV using polymerase chain reaction (PCR) or nucleic acid amplification testing (NAAT), and exclude other alternate or concurrent viral pathogens (including varicella, discussed below) as well as bacterial …

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Management and Prevention

There is no difference in management between HSV-1 and HSV-2 infection. Few randomised, controlled trials have been performed in PLWHIV. Aciclovir, famciclovir and valaciclovir have all been shown to be safe and effective as both intermittent and continuous therapy for HSV-2 clinical and subclinical infection in HIV-positive individuals. (21)   In the majority of situations, mucocutaneous …

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Varicella zoster virus

Varicella zoster virus (VZV) may result in cutaneous disease in primary infection as well as secondary reactivation in the context of immune latency, where it is referred to as herpes zoster (HZ). (27) HZ occurs up to 20-fold more frequently in PLWHIV compared to their seronegative counterparts (28) particularly among men who have sex with …

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Diagnosis

The   diagnosis   of   VZV   infection   is   usually   clinical, however VZV PCR of vesicular fluid should be used for confirmation.  VZV IgM is detected in acute chickenpox and in about 70% of people with HZ, whereas VZV IgG cannot differentiate acute and past infection or prior immunisation. (35). 

Management, prevention and vaccination

Antiviral treatment for primary VZV infection is indicated in neonates, children and adults with HIV infection or other immunodefiencies, as well  those with severe disease. These include oral valaciclovir, famiciclovir or aciclovir (dosages and durations provided in Table 3). Treatment should begin within 24–48 hours of onset, however in immunocompromised patients (including people living with …

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Cytomegalovirus and Epstein-Bar Virus

Other herpesviridiae including cytomegalovirus (CMV) and Epstein-Bar virus (EBV) do not typically present with chronic mucocutaneous lesions. In PLWHIV, mucocutaneous CMV infection is regarded as an AIDS-defining condition. (15)    Clinical Presentation  In PLWHIV and CD4+ count below 200 cells/μL, both CMV and EBV infection may result in chronic mucosal or perianal ulceration, correlating with the …

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