Dermatoses of Pregnancy, HIV Derm

What conditions are specific for HIV and warrant HIV testing??

- Oral hair leukoplakia - Kaposi Sarcoma

Pemphigoid gestationis complications

- Preterm delivery - Small babies - 10% risk of blistering in neonate (d/t transmission of maternal antibodies --> baby) - Small risk of autoimmune thyroiditis in mother

HIV-associated lipodystrophy syndrome

- associated with antiretroviral therapy - *abn distribution of body fat often with metabolic abnorms (insulin resistance and dyslipidemia*

Prognosis of pemphigoid gestationis

- often flares at deliver - can start post partum (20% of cases) - Recurrence with menses or OCP use (RARE)

Dx of PUPPP

- usually clinical Biopsy can be used to r/o pemphigoid gest but is not helpful for making dx of PUPPP - bx of PUPPP: nonspecific

How many HIV pts have derm disease?

*80-90%* (skin lesions may be the 1st sign of HIV) - defect in cell mediated immunity predisposes HIV pts to certain infections (many with skin findings) *HIV + pts have increased risk of* - Neoplasms (ie Kaposi) - Inflammatory dermatoses (ie Seborrheic dermatitis, Atopic) - Psoriasis - Drug reactions (including photosensivity) - Common derm diseases (ie SK's and seborrheic dermatitis are often WORSE in HIV + pts

Types of Kaposi Sarcoma

*Classic*: primarily affects men of Mediterranean and Jewish origin - typically on feet and legs *Endemic*: several types described in sub-Saharan Africa before the AIDS epidemic, typically not associated with immune deficiency *Epidemic*: AIDS-associated type, is characterized by more aggressive and widespread mucocutaneous lesions *Iatrogenic*: associated with immunosuppressive drug therapy, typically seen in solid tpx pts

Kaposi Sarcoma Treatment

*HAART*: marked decline in AIDS related KS - less aggressive KS and signif decr in morbid and mortal when pts are on HAART *REFER* to derm, HIV specialist or oncologist for management of HIV KS Tx depends on severity *Local tx options*: cryotherapy, radiation therapy, intralesional chemotherapy, or topical retinoid Systemic chemotherapy is used for symptomatic systemic disease and widespread or rapidly progressive cutaneous involvement

Skin diseases associated with CD4 <200

*Infection*: Epstein-Barr virus (oral hairy leukoplakia), Candida, Molluscum contagiosum, Histoplasmosis, Coccidiomycosis *Inflammatory*: Psoriasis, Seborrheic dermatitis, Acquired icthyosis, Atopic dermatitis, Xerosis *Neoplasm:* Kaposi sarcoma Other: Eosinophilic folliculitis

ICP Treatment

*Resolves after deliver*: commonly early induction @ 37-38 weeks. (earlier if cholestasis is severe) Tx goals: *decrease circulating bile acids* - Vit K supplementation if bleeding probs *Ursodeoxycholic acid (Ursodiol)*: 1st line tx - decreased pruritus and bile acids in serum

PUPPP Treatment

*Symptomatic* - topical steroids - Oral prednisone - 2nd gen antihistamines - if sxs persist after delivery --> derm

Pemphigoid gestationis

*autoimmune blistering disease* in 2nd or 3rd tri of pregnancy Presents with pruritic papules and vesicles/bulla 50% of cases involve the umbilicus

Lab hallmark of ICP

*elevated serum bile acids* - bilirubin, transaminases and alkP may also be elevated

Lipodystrophy treatment

*lipoatrophy*: adjusting antiretroviral tx - elective fillers/injectables (may be covered by insurance in this setting) *Lipohypertrophy*: surgical procedures to remove fat (liposuction) - wt loss via diet/exercise

HIV associated lipodystrophy presentation

*lipoatrophy*: loss of subQ fat (most obvi in face, extremities and butt) *lipohypertrophy*: MC in abdomen (where fat is visceral) in the neck, dorsocervical ("buffalo hump"), breasts, trunk

Treatment of Psoriasis in HIV pts

*mild to mod disease*: topical treatment (steroids, retinoids, vit D analogs) *moderate to severe*: phototherapy, oral retinoids *refractory, severe disease*: refer to HIV specialist and derm (for immunotherapy) *HAART therapy in HIV+ pts with psoriasis will improve skin dz!*

Candidiasis tx in HIV pts

*oral candidiasis*: generally responds to local nystatin or clotrimazole - some pts need these oral or IV *esophageal candidiasis*: SYSTEMIC TX - if no improvement in 72 hrs --> endoscopy Thrush in pts W/O RF's (ie inhalers, oral Abx) should raise concern for HIV

PUPPP

*pruritic urticarial papules and plaques of pregnancy* - Common (1/300 pregnancies) Onset: 3rd tri Mostly affect primigravids

What areas are affected by Kaposi Sarcoma?

*skin is MC*: commonly on trunk, extremities and face - Mucous membranes, GI tract, LNs and lung may also be involed - Look in pts mouth!! (*oral lesions classically on the hard palate*)

Psoriasis in HIV pts

- *Inverse and erythrodermic psoriasis are most common in HIV + pts* - Test for *syphilis* if pts presents with *guttate* lesions (syphilis rash may mimic guttate psoriasis) - psoriasis may worsen in course of HIV infection - *psoriatic arthritis is more common and more severe in HIV+ pts *

Intrahepatic Cholestasis of pregnancy presentation

- *generalized pruritus* +/- jaundice - ABSENCE of primary lesions (no rash) - Biochem abnorms consistent with cholestasis (*incr total bili, alkP, GGT and increased bile acids*) NO hx of exposure to hepatitis or hepatotoxic drugs

Kaposi Sarcoma (KS)

- *vascular neoplastic condition related to infection with HHV-8 (human herpesvirus 8)* - presents as red or brown/violaceous macules, patches, plaques or nodules

HIV and Skin Cancer

- BCC and SCC are common in fair skinned HIV + pts ( BCC much more common than SCC) - HPV genital SCC (cervical, rectal, penile) are common in HIV pts - Melanoma is more aggressive in HIV pts

Atopic eruptions of pregnancy treatment

- Benign (no risk to mother or fetus) Control the eruption with *topical steroids* - Oral steroids in refractory cases and refer to derm - Eruption may persist after pregnancy as chronic dermatitis

Skin diseases associated with CD4 <50

- Cryptococcosis - Pruritic papular eruption (insect bite hypersensitivity)

Crusted Scabies

- Immunosuppressed or neuro impaired are at increased risk of developing hyperkeratotic scabies (formerly norwegian scabies) Presentation: *thick, scaling, white-gray plaques with minimal pruritus and fissures* - commonly on *scalp, face, back, butt, feet* - Fissures = portal for bacteria entry --> sepsis --> death Immunocompetent persons who contact pts with this will develop typical scabies

Molluscum in HIV

- Lesions are more numerous, more verrucous and larger in HIV pts (also LESS likely to spontaneously resolve) Dx: clinical usually Tx: HAART leads to resolution of MC

Crusted scabies Tx

- Much harder to treat that non-crusted (typical scabies) d/t VERY LARGE # of mites - Isolation and barrier protection to prevent outbreaks in healthcare facilities - Pts should be monitored for bacterial infection (sepsis risk) *Combination therapy*: - Multiple doses of *oral ivermectin* 200 mcg/kg/dose depending on severity - *topical permethrin 5%* 1-2x weekly

4 Dermatoses of Pregnancy

1. Pemphigoid gestationis 2. PUPPP: Pruritic urticarial papules and plaques of pregnancy 3. Atopic eruption of pregnancy 4. Intrahepatic cholestasis of pregnancy

Oral candidiasis (Thrush) in HIV pts

Candida is a normal flora of oropharynx and GI tract *Thrush is most common fungal dz in HIV+ pts* - Oropharyngeal candida and candida esophagitis (MCC of odynophagia and dysphagia in HIV pts) may coexist

Dx of atopic eruptions of pregnancy

Clinical dx (nonspecific path) - begins earlier in pregnancy (mean 18 weeks) - 80% of pts have previous history of atopic dermatitis

Atopic eruption of pregnancy definition

Encompasses other pruritic inflammatory dermatosis that appear or worsen during pregnancy - Atopic dermatitis in pregnancy - Prurigo of pregnancy (Besnier) (Prurigo = intensely itchy papules) - Pruritic folliculitis of pregnancy

PUPPP Prognosis

Excellent prognosis: no maternal or fetal risks - generally resolves post partum (w/in days)

Intrahepatic Cholestasis of Pregnancy (ICP) Complication

For mother: - Bleeding - Intestinal malabsorption - Cholelithiasis For the fetus: - Prematurity - fetal distress - DEATH

Thursh appearance

Lesions most characteristically appear as *white plaques on the tongue or buccal mucosa that can be scraped off* with a tongue blade (or dry gauze), producing bleeding or red macular atrophic patches

How is Kaposi sarcoma dx?

Skin biopsy from center of firm lesion CXR, FOBT may be needed to assess associated internal lesions (depending on pts sxs)

Pemphigoid gestationis dx

Skin biopsy/histopath - Subepidermal blister with eosinophils - *Immunofluorescence* = (definitive dx) with linear band of C3 +/- IgG at the basement membrane

PUPPP Clinical findings

Typical lesions: *red urticarial papules surrounded by pale halo* - most cases the eruption *starts within the abd striae* sparing periumbilical area and progresses (blisters may occur and umbilicus may be involved BUT LESS COMMON)

Treatment of pemphigoid gestationis

mild = topical steroids Widespread = refer to derm - Oral steroids (safe in prego, cat B)

Pathophys of intrahepatic cholestasis of pregnancy (ICP)

thought to be d/t increased estrogen *Estrogen*: - promotes cholestasis - inhibits reuptake of bile acids into hepatocytes - inhibits bile transport proteins