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

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

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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 12/13/19 3 4 2 12/13/19 TINEA

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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

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  • No relevant disclosures

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TINEA

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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

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Ps Psoriasis

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  • 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

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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

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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

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An And What is so BAD AD about low level viremia ?

  • ACUTE and CHRONIC INFLAMMATION
  • TURNS ON OTHER VIRUSES
  • CAUSES PREMATURE AGING

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Acu cute e In Inflam lammatio ion

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Papular seborrheic dermatitis

Treatment: ketoconazole crème and HC 1% OINTMENT bid If recalcitrant: protopic 0.1% ointment bid

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CD4 60 when started ARV’s-got up to CD4 160- could not tolerate regimen-started a new regimen-now itchy rash

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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

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Eosinophilic folliculitis

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Immune Reconstitution Herpes zoster

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Immune Reconstitution Leishmeniasis

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Chronic Inflammation of HIV

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Chronic Eczema

  • We have known for decades that if you

had a history of eczema AND you started ARV’s under CD4 200, you will always have blips of eczema even if you are fully reconstituted.

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Consumed by itch then started ARV’s at CD4 315

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  • 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

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HIV HIV IN INFL FLAMMATIO TION TUR TURNIN ING ON OTHER THER VIR VIRUS USES

  • Herpes simplex virus
  • Human papilloma virus

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Ve Verrucous HSV

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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

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Po Post Cidofovir

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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

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An And now so some ex examples of Pr Premat ature Ag Aging

  • Myocardial infarcts
  • Kidney dysfunction
  • Dementia
  • Squamous cell cancer
  • Kaposis sarcoma

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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?

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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)

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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

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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

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Drug eruption like rash that does not itch=syphilis

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24 year old woman 12 year old boy 30 year old man

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New Presentation of Kaposis sarcoma

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  • 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

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KS-never went away with ARV’s or chemo- long term lymphedema

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Long term sequelae

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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

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Scabies

  • 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

  • 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

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Body lice

  • Check the seams of the clothing
  • Do not use kwell/permethrin
  • Needs new clothing-look for bacterial infection

and treat that

  • Once clothing removed-pt will not itch

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Happy Holidays

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