Dermatological manifestations of human immunodeficiency virus/acquired immunodeficiency syndrome in era of highly active antiretroviral therapy.

Sir,

Dermatological manifestations are seen at every stage of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and are often earliest and the only sign of HIV/AIDS. The advent of highly active antiretroviral therapy (HAART) has been largely beneficial to patients with HIV associated skin disease, but novel side effects of these drugs have emerged.[12] Thus, we had conducted cross sectional observational study to know the epidemiological profile of cutaneous manifestations of HIV in patients who were on HAART.

This study was conducted in Dermatology Outpatient Department of SMIMER, Surat, from April 2010 to January 2011, with prior permission from institutional ethical committee. 150 HIV positive patients who were referred from antiretroviral therapy (ART) center and were on HAART were included in the study. Children below age of 18 years, pregnant women and patients with transient nevirapine induced rash were excluded from the study. Detailed history of selected patients was recorded in a predesigned proforma. Cases were thoroughly examined and investigated.

Out of 150 cases, 107 (71.33%) were males and 43 (28.66%) were females. Majority of the patients were from age group of 31–40 years comprising 76 (50.66%) cases, followed by 41 (27.33%) in age group of 18–30 years, 25 (16.66%) in 41–50 years, and 8 (5.33%) cases were above the age of 51 years. Maximum number of cases observed were of adverse cutaneous drug eruption (ACDE) comprising 31 cases (20.66%), followed by herpes zoster (HZ) 22 (14.66%), dermatophytosis 19 (12.66%), papular and pruritic eruption (PPE) of HIV 18 (12.00%), herpes genitalis 15 (10%), pyoderma 12 (8%) and variable prevalence of other dermatosis.

Broadly out of total patients, nearly 63.34% of patients were of infectious etiology, 20.66% were of drug reactions and 16.66% were of inflammatory conditions. This finding is corroborated with study done by Calista et al.[1]

ACDE was the most common findings [Table 1] (20.66%) and was consistent with study done by Calista et al.[1] Their study also had reported 20% prevalence of ACDE in patients who were on HAART. Sharma et al. in their study have reported 44.4% ACDE in patients on HAART.[3] Out of 31; 29 patients had maculopapular rash, one patient had fixed drug reaction and one patient had Stevens–Johnson syndrome. In our study, 94 patients who were on nevirapine, 20 patients (21.27%) had experienced exanthematous rash. This finding was consistent with study done by Ward et al.[2] Sharma et al. reported nevirapine rash to the tune of 11.8%.[4]

Table 1

Cutaneous manifestation of HIV/AIDS

Second most common presentation was HZ (14.66%). This finding is corroborated with study done by Hengge et al.[5] Two patients had 2nd attack of HZ; two had multidermatomal HZ [Figure 1], three had HZ ophathalmicus (HZO). CD4+ count in two patients with 2nd attack of HZ was 226 cells/μmm and 436 cells/μmm. On other hand in patients with HZO median CD4+ count was 90 cells/μmm, suggesting advanced degree of immunosuppression.

Figure 1

Herpes zoster involving ophthalmic and maxillary division of trigeminal nerve

Dermatophytosis was next manifestation that had accounted for 12.66%, and is comparable to study done by Hengge et al.[5] Median CD4 count was 230 cells/μmm; suggesting the early stage of HIV infection.

PPE remains the most common noninfectious cutaneous manifestation in HIV. PPE and eosinophilic folliculitis may be the part of same spectrum of disease and this can complicate the interpretation of published studies. In our study we have restricted the use of terminology to PPE only and were accounted in 12% of cases which is comparable to study done by Calista et al.[1] Median CD4 count was 179 cells/μmm; this lower CD4+ count suggests the advanced stage of HIV disease.

Herpes genitalis excluding the case of perineal herpes simplex; was present in 10.00% cases; is comparable to other studies.[5] Median CD4 count was 198 cells/μmm, suggestive of moderate degree of immunosuppression.

All the three cases of perineal herpes simplex were presented with itching and burning sensation over scrotum without any typical history of vesicles formation and pain [Figure 2]. Thus this atypical presentation should be kept in mind to diagnose the case of perineal herpes simplex. Median CD4 count in perineal herpes simplex was 178 cells/μmm; lower than the cases of herpes genitalis.

Figure 2

Herpes simplex involving scrotum

Bacterial infection was another common finding that had accounted for 8.00% cases; and this finding is corroborated with study done by Rodger and Leslie[6] and Maurer.[7] Most of the cases presented with furuncle with its typical presentation. Median CD4 count was 174 cells/μmm.

It seems that there is reduction in opportunistic infections, infective dermatosis and malignancy after advent of HAART.

HZ in particular is immune reconstitution inflammatory syndrome related and PPE remains on higher side. Variety of ACDE is an emerging challenge with more number of cases recently on ART.