Challenges remain in HIV-associated dermatology in Africa
Dr. Ncoza Dlova detailed the continent's burden of HIV, as well as comorbidities and skin signs that should prompt HIV tests (1,202 words, 6 minutes)
Dr. Ncoza Dlova outlined the state of HIV dermatology in Africa in the Dr. Mercy Alexis Keynote presentation at the virtual Colloquium on Black Skin on Saturday, Aug. 21.
The colloquium was presented as part of the Skin Spectrum Summit’s Summer of Dialogue on Black and Brown Skin.
Dr. Dlova is Dean and Head of Dermatology at the Nelson R. Mandela School of Medicine at the University of KwaZulu-Natal in Durban, South Africa. She has a special interest in ethnic skin and hair diseases.
There has been significant progress in reducing the burden of HIV worldwide. Dr. Dlova noted the annual number of new HIV infections has decreased by 47% since a peak in 1996. However, she noted 37 million people are still living with HIV, and there are approximately 5,000 new infections recorded daily.
“The vast majority of people living with HIV are located in low and middle-income countries. It is estimated that 66 per cent live in Sub-Saharan Africa,” she said.
Cutaneous manifestations of HIV contribute to the social stigmatization of patients, even 20 years after the introduction of highly active antiretroviral therapy (HAART), said Dr. Dlova. Yet understanding the relationship between HIV infection and the skin remains underdeveloped.
Some of the science on HIV and dermatology in Africa addressed by Dr. Dlova included:
Human Papilloma Virus (HPV) infection results in a growing burden of high-grade squamous intraepithelial lesions (HSIL) and squamous cell carcinoma among people living with HIV, so these two conditions should be suspected when warts do not respond to treatment.
Acquired epidermodysplasia verruciformis (EDV) is common in Africa, particularly in vertical transmitted HIV. It does not improve with HAART and typically involves the face and trunk at the sun-exposed areas.
Rates of Kaposi sarcoma have decreased 60 to 70% since the introduction of HAART treatment; however, patients living with HIV still have an 800-fold increase in the risk of the condition compared to the general public.
The prevalence of atopic dermatitis and other pruritic disorders may be as high as 37.5% in patients living with HIV. Lower CD4 T cell counts have been associated with high rates of pruritus and atopy, and HIV infection provokes a Th-2 predominant immunophenotype similar to that seen in patients with atopic dermatitis who have defective skin barrier. Dr. Dlova recommended that patients with severe, intractable itch or newly diagnosed prurigo nodularis be sent for HIV testing.
Varicella-zoster reactivation frequently occurs in newly immunocompromised individuals, so individuals younger than 50 years presenting with varicella-zoster virus infection should be tested for HIV.
Individuals with herpes simplex virus-2 (HSV-2) infections are two to three times as likely to transmit HIV. Non-healing verrucas also on the genital area should raise suspicion of HIV or AIDS.
Bottom line:
Despite advances in treatment, HIV/AIDS remains a serious, ongoing issue in Africa. More needs to be understood about how the condition interacts with the skin and comorbid dermatologic conditions.
From the literature on HIV dermatology
Psoriasis and liver damage in HIV-infected patients
Noting the frequency of psoriasis in HIV-infected patients and the prevalence of nonalcohol fatty liver disease (NAFLD) in patients with psoriasis, the authors of this paper conducted a retrospective, observational study to identify prevalence and risk factors for NAFLD in these patients.
They found that steatosis is common in HIV-infected patients, with severe psoriasis as an independent risk factor for the condition.
Viral and immunological markers of HIV-associated Kaposi sarcoma recurrence
This study involved individuals on antiretroviral therapy who were in remission for HIV-associated KS after undergoing cytotoxic cancer chemotherapy. The investigators considered sociodemographic and clinical parameters, cytokines and chemokines, HIV viral load, and CD4 counts.
They found that higher interleukin (IL)-5 and -6 levels and lower HIV viral loads were more common in patients with sustained remission. In contrast, lower interferon γ-induced protein 10 kDa (IP-10) levels were associated with sustained remission.
Non-melanoma skin cancer in people living with HIV: From epidemiology to clinical management
The authors of this literature review detail the incidence of non-melanoma skin cancers (NMSCs) among people living with HIV (PLWH). In particular, they examine any differences in the clinicopathological features of basal cell carcinoma and squamous cell carcinoma between PLWH and HIV-negative persons. They also touch on differences in efficacy and safety of treatments and response to immunomodulators and on any differences in rates of metastatic disease and outcomes.
Oral isotretinoin therapy in recalcitrant molluscum contagiosum in an immunocompromised patient
This case report involves a 20-year-old HIV-positive individual receiving antiretroviral therapy. The patient was experiencing widespread molluscum contagiosum, which was not responding to topical therapy. When the investigators tried treating him with oral isotretinoin, he experienced a dramatic improvement in his molluscum contagiosum. The paper’s authors note that more studies are needed to confirm the effectiveness of this approach to treating molluscum contagiosum, but write that the availability, low cost, and safety profile of oral isotretinoin could make it a good therapeutic option.
VIDEO: Dermatology in HIV - Nancy Rihana, MD
At the intersection of skin and society
A new book collecting stories about Métis culture, history, and nationhood was published this August in English and Michif, reports the CBC.
The book, Stories of Métis Women: Tales My Kookum Told Me, is book six in the Indigenous Spirit of Nature Series published by Durvile & Uproute Books.
Durvile & Uproute Books description of the book notes: “Many people may also think that Métis simply means 'mixed,' but it does not. They are a people with a unique and proud history and Nation. In this era of reconciliation, Stories of Métis Women explain the Métis Nation's story from their own perspective. The UN has declared this ‘The Decade of Indigenous Languages’ and Stories of Métis Women is one of the few books available in English and Michif, which is an endangered language.”
Stories includes a link to an accompanying documentary hosted on the Vimeo video sharing site, and DVD copies of the film are also available.
Bailey Oster and Marilyn Lizee edited the book.
Oster is a Métis woman with roots in the Red River Settlement and St. Paul des Métis. She was elected as the youngest ever vice-president of New Dawn, the Métis Women's Organization within Alberta at 19 years old and still currently holds the position, the news outlet reports.
Lizee is a consultant for the Métis Nation of Alberta, creating cultural training programs for the general public and the Métis Nation.
This week
Aug. 31 is International Day for People of African Descent
September is Childhood Cancer Awareness Month
Sept. 4 is World Sexual Health Day
Something to think about in the week ahead...
Looking Ahead
Registration is now open for the 7th Annual Skin Spectrum Summit on Nov. 4 and 6, 2021. The Summit is Canada’s leading ethnodermatology medical conference for physicians.
This year the Summit will be separated into modules for easier learning. Modules are:
Common Skin Concerns in Skin of Colour
Complex Skin Concerns in Skin of Colour
Aesthetic Medicine for Skin of Colour
Skin Cancer and Wound Care
Teledermatology, Technology, and Education
Skin Conditions in Underserved Communities
Skin Spectrum Weekly will bring you more news on faculty and topics for this year’s Summit as we get closer to the date.
More information on the 2021 and prior Summits is available at SkinSpectrum.ca
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