Let’s talk about how to manage inflammatory skin conditions in people living with HIV
Despite significant advancements in the treatment and management of HIV/AIDS, many people living with HIV experience skin problems as either standalone conditions or resulting from HIV infection itself. Research shows that over 90% of people living with HIV in a recent U.K. based hospital study had skin conditions. But what are some of the common skin issues associated with HIV? Also, how can treating these skin issues maintain and improve the quality of life of people living with HIV?
Eczema
People living with HIV are at a higher risk of developing eczema compared to the general population. Ezema can present in many different ways, but it is commonly seen as itchy rashes on the arms, legs, chest, back and face that look red or purple depending on the person’s skin colour.
The management of mild eczema in people living with HIV involves avoiding exacerbating factors, moisturizing the skin and using topical prescription treatments. Topical prescription medications may include corticosteroids, calcineurin inhibitors, photodiesterase-4 inhibitors and Janus kinase inhibitors. The management of moderate-to-severe eczema is a unique challenge due to many oral or injectable treatment options modulating the immune system across the entire body, rather than just the area where there is eczema.
Unfortunately, the data on the use of oral or injectable eczema treatments in people with HIV has been limited, as people with HIV have been excluded from clinical trials. However, there is data from small case series and case reports which have shown significant symptom improvement without adverse effects, infections, or alterations of CD4 counts or viral load. Additional research is needed to understand the role of oral or injectable therapies in the treatment of eczema in people living with HIV.
Psoriasis
Psoriasis is a common skin condition caused by localized skin inflammation, which can also cause itchy skin that usually looks red or even dark brown or purple, usually covered by white scale. Psoriasis usually occurs on the elbows, knees, lower back and scalp. Research involving over 102,000 patients has shown that HIV is an independent risk factor for people developing psoriasis. Additionally, compared to the general population, HIV-associated psoriasis may be more severe and more resistant to treatment.
Guidelines from the National Psoriasis Foundation suggest that topical treatments can be used as the first-line therapies for mild-to-moderate HIV-associated psoriasis, including topical corticosteroids, tazarotene, coal tar, vitamin D3 analogs and phosphodiesterase-4 inhibitors. In people with moderate-to-severe disease, the National Psoriasis Foundation recommends phototherapy and oral retinoids. A 2019 study also recommended oral apremilast in addition to these for moderate-to-severe HIV-associated psoriasis. For people experiencing treatment-resistant disease, oral or injectable agents may be used with caution, primarily due to concerns about over-suppression of the immune system. Similar to eczema, more research is needed on the safety and efficacy of new psoriasis treatments, such as biologics, due to the previous exclusion of patients with HIV from clinical trials.
Seborrheic dermatitis
Seborrheic dermatitis is a chronic dermatological condition seen in approximately 6.3% of people living with HIV, compared with 3.7% of individuals without HIV. In 1985, before antiretroviral therapy was available, the prevalence of seborrheic dermatitis was much higher (at 45%) for people living with HIV. It is characterized by red patches and dandruff, commonly occurring on the scalp and face. Compared to people who are HIV-negative, people living with HIV tend to have seborrheic dermatitis that extends into the armpits and groin regions, and it is often thicker and greasier.
The management of HIV-associated seborrheic dermatitis is similar to the approach used in the general population, involving topical antifungal treatments such as shampoos, sometimes mild topical exfoliants to break up thick scale, and other prescription anti-inflammatory topical treatments, such as steroid options and non-steroid options, to reduce inflammation. Starting antiretroviral therapy early is also critical, as being on HIV treatment not only suppresses the HIV virus but also improves seborrheic dermatitis.
Pruritic papular eruption
Pruritic papular eruption of HIV is a unique dermatological manifestation associated with advanced HIV infections and is characterized by itchy, small and firm raised bumps, also called papules, or pustules, which are pus-filled bumps, along the arms and legs. Pruritic papular eruption frequently occurs in people with low CD4 counts (less than 200 cells/mm3). The World Health Organization recommends that antiretroviral therapy be used as the primary treatment for pruritic papular eruption, with additional treatment of antihistamines and topical corticosteroids for itch management.
Itching
Itching is a common symptom of many dermatologic conditions, but it can also occur outside of skin disorders. Previous research on a sample of 200 patients living with HIV in the United States found that chronic itch, which is categorized as lasting more than six weeks, was present in 45% of patients, and that itching had a great impact on people’s quality of life. Itching in people living with HIV may be caused by a number of reasons, including skin infections and infestations, inflammatory skin conditions, drug reactions or kidney and liver conditions. Itching may sometimes even be idiopathic, meaning without a known cause. Treatments for itching try to target the underlying reason and recommended options can include starting antiretroviral therapy to control HIV, taking antihistamines or using topical treatments like steroid options and non-steroid options.
Takeaways
Given the impact of skin issues on the quality of life of people living with HIV, it is very important that healthcare professionals are aware of these complications. HIV specialists, dermatologists, family physicians and nurse practitioners can all screen patients for these common skin issues. People living with HIV are encouraged to talk to their doctors about any skin issues.
Daniel Rayner is a medical student at Western University. Daniel has a master of science in health research methodology from McMaster University.
Dr. Eric McMullen is a dermatology resident at the University of Toronto. He holds a medical degree from McMaster University.
Dr. Philip Doiron holds a degree in pharmacy from Dalhousie University. He completed medical school at McMaster University, followed by a dermatology residency at the University of Toronto and a fellowship in HIV dermatology and male genital skin disease at the Chelsea and Westminster Hospital in London, U.K. He holds a master’s in health science education from McMaster University. He currently works as an Assistant Professor and Clinician Teacher at Women’s College Hospital and the University Health Network.
We would like to thank the following Ontario-based dermatologists and dermatology residents for their help in writing and reviewing this blog post: Dr. Robert Bobotsis, Dr. Shakira Brathwaite, Dr. Panteha Eshtiaghi and Dr. Fabian Rodriguez-Bolanos.