Patients with HIV disease often have several simultaneous or sequential cutaneous conditions with a progressively more intransigent clinical course, a key to suspecting underlying HIV infection. In general, noninfectious cutaneous abnormalities are not prognostic of rapid progression of immunosuppression, but they may be specific markers of the stage of HIV Excoriation of left facial plaen. For instance, eosinophilic folliculitis virtually always occurs in persons with helper T cell Excoriation of left facial plaen below Cutaneous abnormalities may worsen as HIV disease progresses e.
This chapter addresses cutaneous abnormalities in the following four groups: Staphylococcus aureus is the most common cutaneous bacterial infection in persons with HIV disease. Morphologic patterns that may occur include: Bullous impetigo is most common in hot, humid weather, presenting as very superficial blisters or erosions, most commonly seen in the groin or axilla.
Because the blisters are flaccid, they are short-lived; often only erosions or yellow crusts are present. These lesions closely mimic cutaneous candidiasis. Ecthyma is an eroded or superficially ulcerated lesion with an adherent crust.
Under this crust is often a plane of purulent material teeming with staphylococci. Removal of this crust is necessary to treat the lesion topically. Folliculitis due to S. Follicular pustules are the primary lesion. Gram's stain and culture confirm the diagnosis and allow selection of appropriate antibiotic therapy, such as dicloxacillin mg 4 times daily.
Often the follicular lesions of the trunk are intensely pruritic and may be mistaken for other pruritic dermatoses, such as scabies. Occasionally, follicular lesions extend more deeply, forming abscesses. Rarely, all follicles across several square centimeters are infected, forming a large, violaceous, hidradenitis-like plaque.
The plaque may be studded with pustules and have deep tracts connecting infected follicles. Rarely, abscess of the muscle pyomyositis may occur. The depth of the infection determines the treatment of cutaneous staphylococcal infections.
Very superficial lesions, like bullous impetigo, often respond to a 7- to day regimen of an appropriate antistaphylococcal antibiotic, such as dicloxacillin mg given orally 4 times daily. Deeper lesions often require courses of treatment lasting for months. In addition, combinations of antibiotics, especially a penicillinase-resistant penicillin or first-generation cephalosporin plus rifampin mg once dailyare often necessary to clear the infection.
Adjunctive topical therapy is helpful in beginning treatment and reducing recurrences. Washing the infected area once daily or every other day with an antibacterial agent Hibiclens, Excoriation of left facial plaen, or benzoyl peroxide wash helps remove crusts, dries lesions, and decreases surface bacterial concentration.
Loculated abscesses must be
Excoriation of left facial plaen and drained when fluctuant if antibiotics are to be effective. When cellulitis of any significance or symptoms of bacteremia are present, hospital admission for treatment with intravenous antibiotics is appropriate. Intranasal mupirocin may reduce carriage rate and prevent relapses. Chronic oral antibiotics may be required in some patients. Bacillary angiomatosis, a treatable opportunistic infection, was initially reported as atypical subcutaneous infection in patients with advanced HIV disease 12 and as epithelioid angiomatosis.
The term bacillary angiomatosis is being replaced by Bartonella infection because the infectious agents causing this condition have been identified as two species of Bartonella - B.
As proposed initially by Le Boit, Koehler, and others at the University of California, San Francisco, one of the agents causing bacillary angiomatosis, B. One epidemiologic study has demonstrated cat exposure and cat scratches as risk factors for acquiring bacillary angiomatosis. Bacillary angiomatosis initially was considered primarily a disorder of the skin, but
Excoriation of left facial plaen involvement is common.
Visceral disease may include osseous lesions, 16 hepatic and splenic involvement, 17 lymph node disease, pulmonary lesions, 3 brain lesions, 18 and widespread fatal systemic involvement. The most characteristic cutaneous lesions of bacillary angiomatosis resemble pyogenic granulomas -- fleshy, friable, protuberant papules-to-nodules that tend to bleed very easily Figure 2.
In addition, deep cellulitic plaques and subcutaneous nodules may occur. Lesions number from a few to hundreds. Clinically, the skin lesions are frequently misdiagnosed as vascular tumors, especially KS. A prominent vascular proliferation that forms an elevated papule histologically characterizes the lesions Figure 3.
Neutrophilic leukocytes are prominent in the interstitium. Basophilic aggregates are found adjacent to the vascular lumina, representing collections of the bacterium. Diagnosis is confirmed by identifying the causative organism in affected tissue using silver stains or electron microscopy. Systemic findings such as fever, night sweats, weight loss, and anemia are common in patients with bacillary angiomatosis. Reports describe mucosal lesions of the conjunctiva and upper respiratory tract.
Involvement of the liver and spleen with or without skin lesions is the most commonly diagnosed form of visceral disease. Liver and spleen biopsies may show large ectatic vascular spaces, a pattern called peliosis. Abundant bacilli are adjacent to these vascular spaces. Osseous lesions manifest as bone pain and may precede the appearance of skin lesions. Bone scans rarely reveal additional asymptomatic lesions. Isolated lymph node enlargement is another presentation. The diagnosis of visceral disease is made on the basis of biopsy of the affected organ and examination with silver stains or electron microscopy.
In the untreated patient, fatal widespread visceral disease may occur. Treating affected patients with erythromycin in full doses mg orally 4 times daily resolves the lesions, as does treatment with doxycycline mg orally twice daily. Cutaneous lesions usually resolve in 3 to 4 weeks, but therapy should for at least 8 weeks.
Patients with documented visceral disease should receive at least 4 months of therapy. Relapses can occur if treatment is not continued appropriately. Unlike KS, bacillary angiomatosis lesions do not respond to radiation therapy. Information on Pseudomonas aeruginosa infections in HIV-infected persons is limited to anecdotal evidence. Chronic ulcerations and macerated skin are susceptible to colonization by gram-negative bacteria, especially P. One patient with advanced HIV disease and with chronic leg ulcers due to excoriation and folliculitis developed Pseudomonas overgrowth.
He responded very slowly to intravenous antibiotic administration and local acetic acid soaks. Two other patients developed macerated toe webs that became colonized with P.
A third patient, while receiving zidovudine AZTdeveloped Pseudomonas sepsis, including multiple subcutaneous nodules that became fluctuant and required surgical drainage. The last patient we have seen with P. As long as the host immune system is still reasonably intact, the course of genital and orofacial HSV recurrences may be similar to the course in non-HIV-infected patients.
Clinicians should consider HSV in evaluating all ulcerative lesions, particularly perirectal ulcers and nonhealing ulcers anywhere on the body.
Lesions may appear as grouped blisters that rupture, crust, and heal in 7 to 10 days. More commonly, ulceration is the finding with no prior history of blisters. Once severely immunosuppressed, HIV-infected persons often experience chronic lesions that continue to expand and form large, crusted erosions 2 to 10 cm or larger in diameter Figure 4. Lesions may be quite painful, especially if located perianally or periorally. A Tzanck smear taken from the edge of the ulcer, stained with Giemsa or methylene blue, when positive for multinucleated epithelial giant cells gives rapid diagnosis.
Alternatively, fluorescent antibody testing or viral culture are diagnostic. If these are negative and clinical suspicion of HSV is high, clinicians should perform a biopsy of skin from the edge of the ulcer. A portion of the tissue should be cultured for "Excoriation of left facial plaen," which may be positive even when swab cultures are negative. In addition to routine histologic examination, clinicians should perform special stains and cultures for other possible infecting organisms, including spirochetes.
In the immunocompetent HIV-infected patient, either intermittent or chronic suppressive therapy may be used. The immunosuppressed patient with chronic ulcerative lesions should receive acyclovir to mg orally 5 times daily until the ulcers heal, which may take several weeks. Then, chronic suppressive therapy should be instituted with acyclovir mg orally twice daily to reduce recurrences.
The newer acyclovir analog antiviral agents are available with better absorption and higher bioavailability. Famciclovir mg 3 times daily and valaciclovir mg twice daily are alternatives. Untreated HSV lesions tend to enlarge slowly.
New lesions at distant sites may appear, probably due to cross-contamination rather than to hematogenous spread. HSV may rarely cause a necrotizing folliculitis that appears as 0. Excoriation of left facial plaen biopsy is usually required to establish the diagnosis, because the site of infection is the epithelium along the hair shaft in the dermis.
Large chronic perianal, perioral, or periungual ulcers that fail to heal with acyclovir treatment are often due to thymidine-kinase-negative, acyclovir-resistant HSV Unfortunately, recurrences may also be resistant to acyclovir and, foscarnet. Varicella zoster virus VZV infection is commonly seen early in the course of HIV infection, particularly in healthy-appearing individuals, before the onset of other symptoms. Because most HIV-infected persons have had varicella previously, the initial manifestation of VZV infection is usually herpes zoster.
During the course of HIV disease, herpes zoster often precedes thrush and oral hairy leukoplakia by about 1 year, 37 making it an important early finding and raising suspicion of HIV infection in persons at risk. Unlike zoster in individuals without HIV infection, this dermatomal eruption may be particularly bullous, hemorrhagic, necrotic, and painful in HIV-infected persons.
The duration of blisters and crusts is usually 2 or 3 weeks.
The approximate duration of significant pain is also Excoriation of left facial plaen or 3 weeks. Necrotic lesions may last for up to 6 weeks and heal with severe scarring. This dermatomal scarring is characteristic of HIV-infected patients and should be sought when evaluating at-risk individuals. In severe cases, and occasionally in severe cases in non-HIV-infected persons, excruciating and disabling pain may last for many months.
The clinical manifestations of disseminated VZV infection include typical widespread Tzanck-positive blisters with or without an associated dermatomal eruption. Excoriation disorder is an obsessive-compulsive spectrum mental disorder that is characterized Compulsive picking of face using nail pliers and tweezers. In addition to pyoderma, cellulitis or erysipelas may complicate excoriated insect legs, or face as “honeycolored” or golden crusting formed from dried serum.
Erythema and prominent hyperpigmentation involving the face and upper chest Note the linear hyperpigmentation consistent with pruritus with excoriation, and . Dystrophic calcification along the fascial plane of the biceps muscle in a child .
Excoriation disorder is an obsessive-compulsive spectrum mental disorder that is characterized by the repeated urge to pick at one's own hide to the extent that either psychological or earthly damage is caused. Although research strongly suggests that this urge to pick is a body-focused recurrent behavior requiring professional temperament health treatment, excoriation disorder's similarity in symptoms to issues like drug maltreat means proper treatment is rarely pursued.
Since the DSM-5 , excoriation ailment is classified as "L Excoriation disorder is defined as "repetitive and urgent picking of skin which results in tissue damage".
Its most official elect had been "dermatillomania" seeing that some time. As of the release of the fifth Diagnostic and Statistical Manual of Mental Disorders in May , excoriation disorder is classified as its own separate circumstances under "Obsessive Compulsive and Related Disorders" and is termed "excoriation skin-picking disorder".
The inability to lead the urge to pick is similar to the urge to compulsively capture pull to pieces one's own hair, i. Researchers have noted the following similarities between trichotillomania and excoriation disorder: Check out has also suggested that excoriation disorder may be thought of as a type of obsessive overwhelming disorder OCD.
Nevertheless, Odlaug and Grant have suggested that excoriation disorder is more akin to riches abuse disorder than OCD. Odlaug and Grant procure recognized the following similarities between individuals with dermatillomania and patients with addictions:. Odlaug and Grant along argue that dermatillomania could have several different psychogenic causes, which would extenuate why some patients non-standard like more likely to would rather symptoms of OCD, and others, of an addiction.
They suggest that treating certain cases of excoriation as an addiction may yield more success than treating them as a form of OCD.
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Patients with HIV disease often have several simultaneous or sequential cutaneous conditions with a progressively more intransigent clinical course, a key to suspecting underlying HIV infection. In general, noninfectious cutaneous abnormalities are not prognostic of rapid progression of immunosuppression, but they may be specific markers of the stage of HIV disease.
For instance, eosinophilic folliculitis virtually always occurs in persons with helper T cell counts below Cutaneous abnormalities may worsen as HIV disease progresses e. This chapter addresses cutaneous abnormalities in the following four groups: Staphylococcus aureus is the most common cutaneous bacterial infection in persons with HIV disease. Morphologic patterns that may occur include: Bullous impetigo is most common in hot, humid weather, presenting as very superficial blisters or erosions, most commonly seen in the groin or axilla.
Because the blisters are flaccid, they are short-lived; often only erosions or yellow crusts are present. These lesions closely mimic cutaneous candidiasis.
Ecthyma is an eroded or superficially ulcerated lesion with an adherent crust. Under this crust is often a plane of purulent material teeming with staphylococci. Removal of this crust is necessary to treat the lesion topically.
Of age and adolescent dermatomyositis, polymyositis and myositis overlapping with another connective tissue cancer are rare systemic autoimmune diseases with a chief feature of weakness and muscle swelling.
Cutaneous findings specific to the underlying condition are present in many patients with these disorders. Some lesions are highly idiosyncratic of the idiopathic provocative myopathies IIM , outstandingly in dermatomyositis. Some cutaneous findings are common but not individual to the IIM and others are less again observed in patients with these illnesses.
Many of these manifestations also make different grades of plague activity or damage. That photoessay reviews the classification and assessment of the cutaneous manifestations of the IIM and presents eg photographs of many of the lesions of and k IIM accumulated from the clinical undergo of cosmopolitan experts in these conditions.
The effect of that work is to ease better appreciation of the diverse cutaneous manifestations associated with these inflammatory myopathies. See accompanying review spread Review of the classification and assessment of the cutaneous manifestations of the idiopathic rousing myopathies. As with all of the Dermatology On the web Journal's ezines, click on each epitome for a full-size enlargement. The following slides are examples of cutaneous manifestations seen in patients with the idiopathic inflammatory myopathies, including full-grown and unsophisticated dermatomyositis, polymyositis, and myositis associated with other connective tissue diseases.
The framework for that photo-essay is modified from the Cutaneous Assessment Sucker for the assessment of myositis, which is designed to catalogue and declivity the savagery of the cutaneous findings described in the full-grown and under age idiopathic frantic myopathies [ 1 ].
What's going on with my man??papules); Plane warts (small skin-coloured flat-topped papules with a smooth surface Actinic lichen planus (children and young adults / face, neck and dorsal . with a velvety texture); Papular prurigo (itch / cape area / excoriated papules). Sarcoid (mainly face and neck but can affect any site / lesions often also be seen in cases of plane warts, molluscum contagiosum, and cutaneous mucinosis ) .. cape area / excoriated papules); Grover's disease (usually middle-aged and ..
Pelt problems are among the most iterative medical holys mess in returned travelers. A recent Canadian study of 1, returned travelers with dermatologic scrapes confirmed that finding. No matter how, both of these studies are prejudiced in that they do not append skin disputeds point that were diagnosed and, in tons cases, beyond managed until travel or that were self-limited.
Outside problems superficially fall into either of the following categories: Max skin botherations are lassie and are not accompanied by fever. Diagnosis of skin predicaments in returned travelers is based on the following:. It is important to recognize that skin conditions in returned travelers may not drink a travel-related cause. Insect bites Propriety, the uttermost common grounds of papular lesions, may be associated with unessential infection or hypersensitivity reactions.
Bed annoy and flea bites may produce grouped papules consort with Box for the sake more skinny about bed bugs. Flea bites lean to force hemorrhagic centers.
Scabies infestation usually manifests as a generalized or regional pruritic, papular quantity. Scabies burrows may bestow on as papules or pustules in a short linear pattern on the shell, frequently in the snare spaces of the fingers.
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- Erythema and prominent hyperpigmentation involving the face and upper chest Note the linear hyperpigmentation consistent with pruritus with excoriation, and .. Dystrophic calcification along the fascial plane of the biceps muscle in a child .
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Dermatology Online Journal
General dermatology - morphology
Treatment with effective antimycobacterial agents may cure HIV-infected patients with localized disease. Herpesvirus-like DNA sequences and Kaposi's sarcoma. This most often occurs as a complication of juvenile dermatomyositis, but may also be seen in patients with adult dermatomyositis, and overlap myositis particularly overlapping with systemic sclerosis. Treatment of Papillomavirus Lesions Treatment is primarily cosmetic; the exact same methods are used as in immunocompetent patients.
The exact dosing for the two imidazoles is unknown, but probably is to mg fluconazole and to mg itraconazole daily. Recognizing Depression Back to School: Linear extensor erythema of the arm in an African American patient, demonstrated as hyperpigmentation.
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