Alterations in HIV expression in AIDS patients with psoriasis or pruritus treated with phototherapy

Generalized Pruritus and Gradual Loss of Vision as the Presenting Complaints of Acute HIV Infection: Management Challenges during COVID-19 Pandemic

Background

Although the prevalence of HIV is low in Bangladesh, there is a potential for an increased number of cases. This is because of high cross-border mobility (India and Myanmar) of people and increased injection drug abusers amongst youth in the cities and rural areas, HIV can present in many ways, from asymptomatic to advanced disease, including various atypical (generalized itching) and advanced (loss of vision) manifestations. A high degree of suspicion is required to diagnose HIV in a country like Bangladesh. Early diagnosis and prompt treatment are essential to have a better outcome.

Methods

Here, we report two thought-provoking cases where patients were suffering from generalized itchy lesions (pruritic papular eruption) throughout the body for a long time and gradual loss of vision in another case.

Results

Due to lack of suspicion, initially, HIV screening was not done. Both patients visited several health centres, but no diagnosis was made. Moreover, COVID-19 pandemic worsens the situation. Finally, they were diagnosed with HIV; unfortunately, one of them lost her vision due to CMV retinitis and another patient died of other complications.

Conclusion

Ongoing COVID-19 pandemic put many challenges to ensure optimum care, especially for patients with long-sufferings like HIV. Clinicians have to have a very high degree of suspicion while dealing with patients presented with rare manifestations, particularly in a low endemic clinical setting.

Itching as the onset of pain (part 3)

Itchy skin is an extremely unpleasant symptom that can provoke insomnia, depression, irritability, loss of appetite. There are several theories of itching. According to one of them, itching is a modified pain caused by a slight irritation of the nerve endings in the skin. According to the second, itching is an independent symptom, in the formation of which nervous, humoral and vascular mechanisms are involved. Other theories consider itching as a reaction of the autonomic nervous system or a hereditary pathological condition. According to recent studies, itchy skin is characterized by the absence of a universal peripheral mediator of itching. The trigger for itching is the action of pruritogen – a mechanical, chemical, thermal or electrical stimulant directly or indirectly through mediators. Free ends of type A delta fibers and type C fibers play a crucial role in itching and pain. If this was previously confirmed only by clinical observations, now there are neurophysiological studies that support the theory that itching and pain fibers are one with different activity thresholds. Today, it is unacceptable that there are separate specific receptors for different sensations. It is now assumed that there are mixed receptors for heat, cold, pain, itching and touch [95]. Systematic use of substances included in the list of drugs and manifested by mental and physical dependence on them – drug addiction, one of the diseases of society. But drug addiction is sometimes forced, according to medical indications, in cases of palliative conditions. Depending on the stage of the person after taking the drug or in the interval between drug use, one of the signs of use may be severe itching of the skin. And after excluding both the main diseases that cause itching and other secondary causes of itching, it can be assumed that a person has idiopathic generalized pruritus (itching) of unknown origin (GPOU). The itching of the elderly, which is quite common in the elderly, as a manifestation of concomitant, often combined, somatic pathology, but may also be due to physiological changes, both on the skin and on the physiological aging of nerve endings.

HIV-associated psoriasis: Epidemiology, pathogenesis, and management

People living with HIV (PLWH) are affected by a higher incidence skin disorders, which are often associated with high morbidity and mortality. In particular, psoriasis affects PLWH severely and for a longer time than the general population. Human immunodeficiency virus (HIV) infection is characterized by a progressive decrease in CD4⁺ T-cell count, and it could seem paradoxical that psoriasis exacerbations are more frequent in this subset of patients than the general population, even though it is commonly observed at any stage of infection. For a long time, there have been limited therapeutic choices for PLWH affected by psoriasis. The introduction of the combined antiretroviral therapy dramatically changed the natural course of both HIV and psoriasis in PLWH, leading to an improvement of quality and duration of life. However, the clinical severity of psoriasis in PLWH often requires the use of immunosuppressant drugs. Knowledge about their safety and efficacy are limited to case-reports, small case-series and studies, therefore their use has not yet entered the routine. Further studies are needed to determine if immunosuppressive drugs can be safely and effectively used in PLWH affected by psoriasis and other autoimmune disorders.

Inflammatory Noninfectious Dermatoses of HIV

Since the advent of HIV/AIDS, a variety of inflammatory noninfectious skin conditions have been described in HIV-infected patients. This review will discuss a group of inflammatory, noninfectious dermatoses that, although not exclusive to HIV/AIDS, are commonly observed in HIV-infected patients and pose an apparent paradox in a disease that supposedly involves suppression of cellular immunity.

Ultraviolet phototherapy for pruritus

Ultraviolet-based therapy has been used to treat various pruritic conditions including pruritus in chronic renal failure, atopic dermatitis, HIV, aquagenic pruritus and urticaria, solar, chronic, and idiopathic urticaria, urticaria pigmentosa, polycythemia vera, pruritic folliculitis of pregnancy, breast carcinoma skin infiltration, Hodgkin's lymphoma, chronic liver disease, and acquired perforating dermatosis, among others. Various mechanisms of action for phototherapy have been posited. Treatment limitations, side effects, and common dosing protocols are reviewed.

An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report

Summary These guidelines for use of narrowband (TL-01) ultraviolet B have been prepared for dermatologists by the British Photodermatology Group on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment of patients with a variety of dermatoses and photodermatoses, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of background photobiology.

Eosinophilic pustular folliculitis: a comprehensive review of treatment options

Eosinophilic pustular folliculitis (EPF), also known as Ofuji disease, is a disease that manifests with follicular papules or pustules. Its variants include a classic type that occurs most commonly in Japan, an HIV-associated type, an infantile type, a type that occurs on the palms and soles, a rare medication-associated variant, and a rare neoplasia-associated variant.A wide range of medications has been used to treat EPF. Topical corticosteroids are the first-line treatment option for EPF. Topical tacrolimus seems to be useful initial therapy as well. Oral indometacin (50-75 mg/day) is an effective treatment of classic EPF although it can induce peptic ulcers. For treatment of HIV-associated EPF when topical corticosteroids and indometacin do not work, various other treatments should be considered. These treatment options include cetirizine 20-40 mg/day, metronidazole 250 mg three times a day, itraconazole starting at a dosage of 200 mg/day and increasing to 300-400 mg/day, and topical permethrin. If these treatments do not work phototherapy with UVB is the 'gold standard' of treatment and is often curative. Treatments with less certain risk-benefit ratios but with some efficacy include PUVA (psoralen + UVA) photochemotherapy, oral corticosteroids, synthetic retinoids (i.e. isotretinoin 1 mg/kg/day), and acitretin (0.5 mg/kg/day), oral cyclosporine (ciclosporine) 5 mg/kg/day, interferon (IFN)-alpha-2b, and IFNgamma. Minocycline 100mg twice daily and dapsone 50-100mg twice daily have been used with some effect. The use of highly active antiretroviral therapy for HIV has resulted in the amelioration of EPF as CD4 cell counts rise above 250/mm(3). The diversity of clinical presentations and affected populations make it seem that EPF is a reaction pattern as much as a disease and that therapy should be tailored to the variant of EPF and the underlying etiology.

Vitiligo in association with human immunodeficiency virus infection

Autoimmune disorders such as vitiligo have been previously reported in patients with human immunodeficiency virus (HIV) infection. We describe a case of vitiligo in association with HIV where a rising CD4 lymphocyte count due to highly active antiretroviral therapy (HAART) closely correlated with changes in the skin. This effect, to our knowledge, has not been previously observed.

Activation of HIV in human skin by ultraviolet B radiation and its inhibition by NFkappaB blocking agents

To determine whether ultraviolet B (UVB) irradiation leads to activation of HIV in human skin, we conducted prospective and controlled studies in two academic medical centers in Texas from July 1995 to April 1999. HIV-positive patients with UV-treatable skin diseases were enrolled at each center, 18 subjects at one and 16 at the other. In one center, specimens from lesional and nonlesional skin biopsies were taken before and after sham- or UVB-irradiation administered in vivo or in vitro. In the other center, UVB phototherapy was administered three times weekly and specimens from skin biopsies were taken before and after 2 weeks (six treatments). Cutaneous HIV load was assessed using reverse transcriptase-polymerase chain reaction and reverse transcriptase-polymerase chain reaction in situ hybridization. UVB irradiation led to a 6-10-fold increase in the number of HIV in skin. To ascertain a role for nuclear factor kappa B (NFkappaB) in UVB-inducible HIV activation, two types of blockers, NFkappaB oligonucleotide decoy and sodium salicylate, were tested; each inhibited UVB-inducible HIV activation in skin partially. We conclude that UVB irradiation leads to increased numbers of HIV in human skin via processes that include release of cytoplasmic NFkappaB.

Etanercept for the treatment of human immunodeficiency virus-associated psoriatic arthritis

Etanercept may play an important role in modulating the inflammatory activity and progression of human immunodeficiency virus (HIV)-associated psoriasis and psoriatic arthritis. We report the case of a 45-year-old homosexual man with a CD4 cell count of less than 0.05 x 10(9)/L and an HIV viral load of 4200 copies/mL (while receiving highly active antiretroviral therapy) who developed extensive psoriatic plaques, 4.5-kg weight loss, onychodystrophy, and psoriatic arthropathy with severe periarticular bone demineralization. The arthritis progressed despite the use of several disease-modifying medications, including corticosteroids, hydroxychloroquine, and minocycline. Because of uncontrolled, progressive, and disabling arthritis and resulting profound disability, he was treated with etanercept. Within 3 weeks, his psoriasis had improved dramatically and his joint inflammation had stabilized. For the next 4 months, immunologic and viral parameters remained stable, but his clinical course was complicated by frequent polymicrobial infections. Etanercept was thus discontinued despite continued improvements in his psoriasis, psoriatic arthritis, and functional status. While both cutaneous and joint manifestations of psoriasis improved dramatically, the experience with this patient dictates that caution and careful follow-up must be exercised when prescribing etanercept in the setting of HIV infection.

HIV and AIDS in inpatient dermatology. Approach to the consultation

In the inpatient setting, the dermatologic consultant is called on to address the whole spectrum of cutaneous disease seen in HIV/AIDS patients, with severity varying from severe life-threatening to less serious conditions that dramatically affect quality of life. Rather than reviewing a "laundry list" of conditions associated with HIV/AIDS or the most severe conditions, this article aims to demonstrate a systematic approach to inpatient dermatology consultation in HIV/AIDS patients and to briefly review several common and interesting topics frequently addressed in the inpatient setting (e.g., medications issues, and phototherapy in HIV-infected patients).