Spontaneous remission to complete unresponsiveness to all therapy has been described for HIV-related psoriasis, particularly following commencement of ART and normalisation of CD4+ counts. (119, 120) Topical therapy includes emollients, coal tar, salicylic acid, vitamin D analogs, and corticosteroids. Referral to a dermatologist is indicated in cases refractory to topical therapies, with significant body surface …
Pityriasis rubra pilaris (PRP) refers to a group of rare inflammatory skin disorders with clinical and histological similarities to plaque psoriasis. (130) There are six clinical subtypes, with Type VI, discussed herein, being proposed in 1995 as a unique HIV-associated dermatosis. (131) Due to its rarity and potential for misclassification as psoriasis, data on the …
Classic, Type I PRP is characterised by orange-red plaques with fine scale, which develops over weeks-to-months in a rostrocaudal fashion. Typical features which may differentiate it from psoriasis include keratotic follicular papules and ‘islands of sparing’, referring to areas of uninvolved normal skin interspersed between otherwise generalised plaques. (130) Erythroderma (with >90% body surface area …
Diagnosis of PRP, including the HIV-associated Type VI subtype, relies on clinical findings and skin biopsy histopathological correlation. Up to 60% of PRP cases in retrospective studies were initially misdiagnosed as other inflammatory skin disorders, most commonly psoriasis, highlighting the diagnostic challenge in this disorder. (132)
Among patients with PRP in the setting of newly diagnosed HIV infection, commencement of ART alone has been reported to induce cutaneous remission. (133, 134) Due to its rarity, management guidelines are based on retrospective studies and case series, and may include topical steroids, retinoids and vitamin D analogs in cases with limited cutaneous involvement, …
Eosinophilic folliculitis (EF), previously referred to as Ofuji’s disease, is a common intensely pruritic condition often occurring in advanced HIV or the setting of IRIS, commonly 3-6 months post commencement of ART. (135) Although some believe that eosinophilic folliculitis and pruritic papular eruption (PPE) are part of the same disease spectrum, the distribution of both …
Eosinophilic folliculitis presents as intensely pruritic 2-3 mm erythematous oedematous urticarial papules centred on follicles and may have pustules. The distribution is typically over the forehead, neck, shoulders, trunk and upper arms. In women living with HIV, PPE may more predominantly involve the face and therefore mimic acne excoriae. (138) Due to the associated pruritus, …
The differential diagnosis is difficult and includes the common causes found in patients without HIV such as insect bite reactions, scabies, dermatitis herpetiformis, drug reactions, atopic dermatitis and bacterial folliculitis. Skin biopsy for histopathological assessment be helpful, however EF and PPE have overlapping histological features and thus should be used primarily to support clinical diagnoses. …
Depending on the cause, management varies, particularly if an infective cause such as scabies is found. Eosinophilic folliculitis and pruritic papular eruption can be difficult to manage with the pruritus often unresponsive to traditional therapies. Case reports of both EF and PPE remission following commencement of ART have been reported. (139, 140) Treatment options for …
Drug reaction, eosinophilia and systemic symptoms (DRESS) Drug reaction, eosinophilia and systemic symptoms (DRESS) is a rare severe cutaneous adverse reaction (SCAR) seen more commonly in PLWHIV. (143) DRESS can develop as a SCAR to medications, including ART agents such as abacavir or raltegrovir which demonstrate association with HLA genotypes HLA-B*57:01 and HLA-B*53:01, respectively. (144-146)
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