HIV HIV Der ermatolo logy gy Up Update e 2019 2019 Toby - PDF document

12/13/19 HIV HIV Der ermatolo logy gy Up Update e 2019 2019 Toby Maurer, MD Indiana University/AMPATH Dept of Public Health San Francisco Professor emeritus UCSF 1 • No relevant disclosures 2 1

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12/13/19 TINEA 5 6 3

12/13/19 7 Psoriasis • Full blown when CD4 count below 100 • Known for decades that ARV’s control the disease • Until there is reconstitution-use acitretin 25 qd • Never have to go to biologics • After reconstitution-can get away with topical steroids e.g Triamcinolone 0.1% ointment bid 8 4

12/13/19 Ps Psoriasis 9 10 5

12/13/19 - HIV psoriasis responds beautifully to ARV’s. -pt is a non-adherent and RESPONDS as soon as his immune system encounters the ARV’s IS THIS A DIRECT EFFECT on HIS T CELLS? ARV’s controlling downstream inflammation 11 Blame it on the reservoir • Memory T cells that hide in the reservoirs and occasionally leave the reservoir to cause downstream inflammation • Big reservoirs have more risk of cells leaving and causing trouble • Big reservoirs have a chance to develop when ARV’s are started under CD4 of 500 12 6

12/13/19 Lo Low l level v viremi mia • Antiretrovirals only control what is in the PERIPHERAL blood stream and not the reservoir • ARV’s are controlling only downstream inflammation and not the RESERVOIR 13 An And What is so BAD AD about low level viremia ? • ACUTE and CHRONIC INFLAMMATION • TURNS ON OTHER VIRUSES • CAUSES PREMATURE AGING 14 7

12/13/19 Acu cute e In Inflam lammatio ion 15 16 8

12/13/19 Papular seborrheic Treatment: ketoconazole crème and HC 1% OINTMENT bid dermatitis If recalcitrant: protopic 0.1% ointment bid 17 CD4 60 when started ARV’s-got up to CD4 160- could not tolerate regimen-started a new regimen-now itchy rash 18 9

12/13/19 Eo Eosionophilic fo follicultis • Pruritic urticarial papules on the face/neck scalp and chest • CD4 under 50 OR when starting ARV’s • Not a drug reaction • DO NOT STOP ARV’s • Takes 12-16 wks until ARV’s kick in to control the inflammation • In the meantime-use intraconazole for acute inflammation 19 20 10

12/13/19 Eosinophilic folliculitis 21 Immune Reconstitution Herpes zoster 22 11

12/13/19 Immune Reconstitution Leishmeniasis 23 24 12

12/13/19 25 Chronic Inflammation of HIV 26 13

12/13/19 • We have known for decades that if you Chronic had a history of eczema AND you started ARV’s under CD4 200, you will always have Eczema blips of eczema even if you are fully reconstituted. 27 Consumed by itch then started ARV’s at CD4 315 28 14

12/13/19 29 • This is the Pruritic Papular Eruption of HIV • Often a presenting sign of HIV in the tropics • Thought to be exaggerated bug bite reaction • Responds to ARV’s in the first 12-16 wks but RECURS every 4 months • Signifies Chronic inflammation in persons starting ARVS’s with CD4’s under 500 30 15

12/13/19 HIV HIV IN INFL FLAMMATIO TION TUR TURNIN ING ON OTHER THER VIR VIRUS USES • Herpes simplex virus • Human papilloma virus 31 32 16

12/13/19 Ve Verrucous HSV 33 Verrucous HSV • Usually ACV resistant • Emerging as a problem worldwide • Suppressive doses of ACV used in recurrent HSV infection in HIV may be selecting out resistant strains • Treat with topical or injectable cidofovir 34 17

12/13/19 Po Post Cidofovir 35 Hum Human n Papi pilloma Vi Virus us • Still a burden on cutaneous skin and genital skin • Local destructive techniques to include liquid nitrogen and podophylin under occlusion • Cidofovir injections • Biopsy for SCC 36 18

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12/13/19 41 An And now • Myocardial infarcts so some • Kidney dysfunction • Dementia ex examples of • Squamous cell cancer Premat Pr ature • Kaposis sarcoma Aging Ag 42 21

12/13/19 Re Recurrence Rates of SCC • Higher recurrence rates of SCC in HIV infected vs uninfected -17% vs 3% • Ave years of known infection= 11 years • Virally suppressed and CD4 counts ave 350 Chren, Hausauer PREMATURE AGING? 43 44 22

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12/13/19 Ka Kaposis sa sarcoma • CD4 counts 500-800, virally undetectable for years , CD4 nadir never less than 300 • Compared to HIV infected subjects without KS: More CD57 + cells, CD28- cells and waning pools of naïve T cells suggesting immunosenescence (Unemori, AIDS March 2013) 47 The The Good d News • New drugs that infiltrate the reservoir are on the horizon • Starting antirretrovirals early ( high CD4 counts) shrinks the reservoir- less chance for downstream inflammation • START HIV MEDS AT THE EARLIEST TIME POSSIBLE!!!! • Pts can never go off antiretrovirals (ARV’s)-need constant control of inflammation 48 24

12/13/19 Syphilis • Many morphologies on the skin • Lots of syphilis-not picked up and spreading, reinfection • Biopsy if in doubt, empiric treatment • Monitor for reinfection or failed treatment-at 1 month, 3 months, 6 months, 12 months, 18 months post treatment 49 50 25

12/13/19 Drug eruption like rash that does not itch=syphilis 51 52 26

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12/13/19 24 year old woman 12 year old boy 30 year old man 55 New Presentation of Kaposis sarcoma 56 28

12/13/19 • Check HIV status-not all persons with KS are HIV infected • Seeing HIV negative gay men in large metropolitan area with HIV negative KS • If HIV infected, look for systemic symptoms: hemoptysis, melena, lymphedema-start chemotherapy and monitor • If HIV infected BUT no systemic symptoms-start ARV’s and wait for resolution at least 9-18 months • HIV negative gay men with KS-give us a call-injecting local chemo, starting CCR5 blockers, injecting local PD-1 inhibitors 57 KS-never went away with ARV’s or chemo- long term lymphedema 58 29

12/13/19 Long term sequelae 59 New Approaches • Trying different chemos • Starting pomolidomide • Systemic PD-1 inhibitor • Controlling lymphedema • Contact us-SF Dept of Public Health/NIH AIDS Malignancy Division-KS Centers of Excellence are being built for better diagnosis, optimal treatment regimens and opening access to clinical trials 415 -9998295; toby.maurer@ucsf.edu; toby.maurer@sfdph.org 60 30

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12/13/19 63 • Permethrin from head to toe and under nails- leave on for 8 hours and wash off • 3 days of clean clothes and linens-start the morning after permethrin is washed off • All other clothing in plastic garbage bags for 3 days Scabies • Repeat permethrin 1 week later- clothing does not need to be done • Itch will last for 3 wks-give TAC and antihistamine • Exploring use of ivermectin for everyday scabies 64 32

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12/13/19 • Check the seams of the clothing • Do not use kwell/permethrin Body lice • Needs new clothing-look for bacterial infection and treat that • Once clothing removed-pt will not itch 67 Happy Holidays 68 34