Thread by @BCMIDFellowship

1/@HoustonAETC lunch & learns are 🔥! ​

@MelanieGoebelMD gave a fantastic talk on primary manifestations of skin diseases in PWH (people with HIV)​

Let's review rapid-fire style...​

#IDFellows #IDTwitter #DermTwitter #MedTwitter ​@idfellows @MedTweetorials

https://twitter.com/HoustonAETC/status/1303742056511279118

2/​
30YOM with well-controlled HIV and several months of this itchy red rash with silvery scales:

3/What is the most likely diagnosis?

4/Answer: Psoriasis​

🔸Overall prevalence in PWH ≈ non-PWH ​
🔸But PWH have ⬆️ psoriatic arthritis, inverse psoriasis (axilla, intertriginous areas), and severe psoriasis​
🔸Tx: ART, topical steroids, systemic treatment (methotrexate)

5/​
60YOM with unsheltered homelessness, HIV (CD4=7). He developed several months of this intensely pruritic skin eruption involving the "V" area of his chest, dorsal forearms, and face. He is not on any medications.

6/What is the most likely diagnosis?

7/Answer: Photodermatitis (darkening of skin exposed to sun) ​​

🔸5% of PWH, CD4 <200, 6x more likely in AA ​
🔸HIV is photosensitizing➡️dysfunctional free radical scavenging pathways ​
🔸⬆️risk w TMP-SMX, NSAIDS, some ART​
🔸Tx: ART, sun protection, topical steroids

8/​
26YOM with HIV (CD4=22) developed these nodular itchy lesions on his face, trunk, and limbs over 2 months:

9/What is the most likely diagnosis?

10/Answer: Prurigo nodularis​

🔸Associated with other systemic diseases👉DM, CKD, CVD, HCV​
🔸⬆️ frequency if CD4 < 50​
🔸Pathogenesis unknown, ⁉️ Th2 cytokines​
🔸Tx: ART, topical steroids, antihistamines, emollients, phototherapy, thalidomide (refractory PN)

11/​
20YO developed severe generalized itching and multiple discrete papules over her face, trunk, arms, and the dorsum of her hands over 4 months. HIV test was positive.

12/What is the most likely diagnosis?

13/Answer: Papular pruritic eruption​

🔸Pruritic, skin-colored papules, +/- post-inflammatory hyperpigmentation
🔸Common in sub-Saharan Africa, tropics​
🔸Pathophys: bug bites hypersensitivity
🔸⬇ CD4 ⬆️severity of eruption​
🔸Tx: ART, antihistamines, topical steroids

14/​
22YOM with HIV on ART has this recurrent dry pruritic rash in his right elbow flexure:

15/What is the most likely diagnosis?

16/Answer: Atopic dermatitis​

🔸Seen in 30-50% of PWH​
🔸Common in those with CD4 nadir < 200​
🔸Pathogenesis: hypereosinophilia, high levels of IgE secondary to Th1-Th2 imbalance​
🔸Rx: topical steroids, antihistamines​
🔸Recurs even with appropriate ART

17/​
38YOF with worsening itchy scaly patches on her arms and legs over several years. She recently tested positive for HIV (CD4=37).

18/What is the most likely diagnosis?

19/Answer: Xerosis (severe dry skin)​

​🔸Very common (20% in PWH)​
🔸Severity correlates with declining CD4​
🔸Pathogenesis: changes in microcirculation, decreased skin innervation, altered mast cell population in skin​
🔸Tx: ART, emollients, antihistamines

20/​
42YOM with HIV started ART 3 months ago. He recently developed this intensely itchy follicular papular eruption involving his face, chest, and back:

21/What is the most likely diagnosis?

22/Answer: Eosinophilic folliculitis​

🔸⬆️risk if CD4<250​
🔸Can present as IRIS​
🔸Pathogenesis: ⬆️IL-4 and IL-5 👉Peripheral eosinophilia, elevated IgE in 25-50%​
🔸Tx: ART, topical steroids, phototherapy, itraconazole

23/​
No clues for this one. Picture = 1000 words.

24/What is the most likely diagnosis?

25/Answer: seborrheic dermatitis​

🔸Inflammation of sebaceous glands 👉erythema, scaling of central face, nasolabial folds, scalp​
🔸Seen in up to 80% of PWH 👉worse w/ ⬇️CD4​
🔸Pathogenesis: ? Hypersensitivity to fungus​
🔸Tx: topical antifungals, oral itraconazole if severe

26/Today, we covered the primary manifestations of skin diseases in HIV. ​

Stay tuned for part 2 in the upcoming weeks!

27/Additional references:​

pubmed.ncbi.nlm.nih.gov/21261982/​
pubmed.ncbi.nlm.nih.gov/16377853/​
iasusa.org/dermatologic-m…