Dermatology and HIV in Africa
Skin manifestations of HIV still used to single out and stigmatize patients with the virus (1,800 words, 9 minutes)
HIV in sub-Saharan Africa continues to be associated with infectious and inflammatory skin conditions that can lead to patients being stigmatized by their community, Dr. Ncoza Dlova said during a presentation at the 7th annual Skin Spectrum Summit on November 6.
HIV can also make patients more vulnerable to conditions caused by the human papillomavirus, she said.
Dr. Dlova is a dermatologist in South Africa and dean and head of the University of KwaZulu-Natal’s School of Clinical Medicine.
While HIV infection rates are declining globally, they only decreased by 16% between 2013 and 2017 in Africa, said Dr. Dlova. Five thousand people a day are infected with HIV worldwide, and approximately two-thirds of those living with HIV are in sub-Saharan Africa, she said.
Because HIV infection is common in this region, the skin manifestations of the condition are well-recognized by the public and have led to the stigmatization of individuals with these skin signs, Dr. Dlova said.
One of the common skin manifestations of HIV has long been Kaposi sarcoma, Dr. Dlova said.
“For many years, we saw Kaposi sarcoma (KS) and infections with a prototype of HIV cutaneous manifestations,” said Dr. Dlova. “Looking at patients with facial lipodystrophy foretold the immune status and contributed to the social stigmatization of patients.”
The frequency of KS has declined worldwide with highly active antiretroviral therapy (HAART) for treating patients with HIV, said Dr. Dlova. But the HIV-infected population remains at much higher risk than the general population.
She said there had been reports of HIV-negative men who have sex with men (MSM) developing KS due to the high incidence of human herpesvirus-8. Rates of KS are much lower in female HIV patients, she said.
The Human papillomavirus (HPV) accounts for a growing number of high-grade squamous intraepithelial lesions (HSIL) and squamous cell carcinoma among people living with HIV, particularly in MSM, said Dr. Dlova. She said that widespread HPV vaccination could change the epidemiology of HSIL or squamous cell carcinoma.
Dr. Dlova stressed that physicians should consider a diagnosis of HSIL or squamous cell carcinoma if warts do not respond to treatment.
Acquired epidermodysplasia verruciformis is also relatively common in Africa, particularly in cases of mother-to-child transmitted HIV, said Dr. Dlova. It does not respond HAART and is typically seen in sun-exposed areas. It can increase the risk of developing squamous cell carcinoma, particularly with sun exposure. Sunscreen is recommended for these patients to reduce the risk of cancer development, she said.
Dr. Dlova recommended starting patients on HAART immediately upon diagnosis of HIV. And she also suggested biopsies for any suspicious lesions.
Several other skin conditions may be associated with HIV, Dr. Dlova noted. These include:
Rates of atopic dermatitis, erythrodermic psoriasis and other pruritic disorders are much higher in patients with HIV.
Varicella-zoster virus reactivation is more likely to occur in newly immunocompromised patients. Because this virus is very rare in young patients, HIV tests should be done on anyone under 50 who presents with the infection. The reactivation of the virus could also be a sign of immune reconstitution inflammatory syndrome.
Patients with the herpes simplex virus are more likely to become infected with HIV, and non-healing verrucous ulcers on the genital area may be a sign of HIV or AIDS.
Bottom Line: HIV continues to be associated with a multitude of infectious, inflammatory and neoplastic skin manifestations, including Kaposi sarcoma, epidermodysplasia verruciformis, herpes simplex and varicella-zoster. The human papillomavirus can make patients with HIV more vulnerable to high-grade squamous intraepithelial lesions and squamous cell carcinoma. These conditions may be a sign of HIV. The morbidity and mortality associated with these conditions have improved because of new targeted therapies and vaccines, which should be used when possible.
From the literature on cutaneous manifestations of HIV
Mucocutaneous manifestations of people living with HIV in current antiretroviral therapy era
This study included people living with HIV who had been referred to an infectious diseases clinic following referral to a dermatology clinic due to skin lesions.
Among the 144 patients, the most common mucocutaneous manifestation of HIV seen was seborrheic dermatitis (28.5%). The authors found no statistical differences in dermatological findings between patients based on CD4 counts—a marker of the immune system's health. Patients with CD4 counts lower than 200 most often had three or more dermatological conditions.
Leprosy as immune reconstitution inflammatory syndrome in patients living with HIV: Description of French Guyana's cases over 20 years and systematic review of the literature
This article is a general description of leprosy occurring as part of immune reconstitution inflammatory syndrome (IRIS). The authors highlight the clinical and therapeutic specifics of this condition.
The description was developed by conducting a literature review on patients living with HIV (PLHIV). Each patient had an advanced infection and developed leprosy or a leprosy reaction within six months of starting HAART. Six of the patients were reported in French Guiana. The authors conducted a systematic review of the literature and added the results to an overall analysis. In total, 73 PLHIV were included.
Study findings showed that leprosy as IRIS in PLHIV mainly presents as borderline tuberculoid leprosy in a T1R state, sometimes with ulcerated skin lesions. The investigators also note that response to multidrug therapy was usually good in the study patients. They write that systemic corticosteroids are necessary and efficient in cases of neuritis.
Histoplasmosis in Africa: Current perspectives, knowledge gaps, and research priorities
The authors of this paper note that there has been an increase in the detection of histoplasmosis cases in some countries in Africa during the past two decades. They say this is probably due to growing advocacy on the continent regarding fungal diseases.
Histoplasmosis cases in Western and Central African countries tend to be African histoplasmosis. This is probably attributable to the gradual increase of medical mycology advocacy efforts in Africa. Histoplasmosis cases are dominated by African histoplasmosis, which typically appears with lesions affecting the skin, bones, and lymph nodes. This form is usually not linked to human immunodeficiency virus (HIV)/AIDS. Classical histoplasmosis is more common in Southern and Northern Africa. It primarily affects the lungs and is associated with immunosuppression, including HIV/AIDS.
The authors write that details regarding the actual burden, strain diversity, infection route, and genetic basis of African histoplasmosis remain unclear. They also identify knowledge gaps in the availability of species-specific diagnostic tools and compliance with recommended antifungal therapy.
Epidermal barrier function in human immunodeficiency virus-infected South African infants compared with uninfected
This cross-sectional descriptive study included 43 HIV positive and 86 HIV negative unexposed African infants. All participating children had average birth weight for their age, no pre-existing dermatoses or co-infections, and received vaccinations at appropriate times. The HIV-positive infants were on antiretroviral (ARV) therapy.
The investigators found that trans-epidermal water loss (TEWL) rates were significantly higher for HIV-positive children on both the dorsal arm and inner forearm. There was a slight difference between the skin surface hydration (SSH) values on the dorsal arm, but it was not significant. A marginally significant difference was seen in SSH values on the inner forearm, with the average values higher in the HIV-positive group. In both groups, TEWL rates and SSH values were significantly lower on the dorsal arm compared to the inner forearm.
VIDEO: HIV & the Skin – 20 07 2021
At the intersection of skin and society
On March 10, The SOCAN Foundation announced the five recipients of the 2022 SiriusXM Black Canadian Music Awards.
SOCAN (Society of Composers, Authors and Music Publishers of Canada) created the awards to recognize and celebrate the artistic merit demonstrated by Black music creators.
The 2022 recipients are Falana, IDMAN, Jon Vinyl, Maurice Moore, and Shopé, who will each receive $5,000.
For the first time, in addition to the five main award recipients, five Special Distinctions awards of $1,000 were also presented: B.ROB, Haviah Mighty, Liza, Lu Kala, and Shad.
To learn more about all of the 2022 winners, click here.
“This award is an opportunity to highlight Black creators. I’m happy to have been a part of the Black Canadian Awards since its inception [in 2020], and am thrilled to continue to see such incredible talent come through the submissions,” said Keziah Myers, Executive Director at ADVANCE Music Canada and Award jury member, in a press release. “This year’s winners are bringing fresh sounds to the industry, and we are ecstatic to see them honoured in this space [through SOCAN Foundation].”
Myers was part of the SOCAN Foundation committee that created the Black Canadian Music Awards and served as a jury member for the last two years.
Winners were selected, from hundreds of applications, by a jury and advisory council of prominent Black artists and industry leaders. In addition to Myers, jury members include Jordan Sowunmi (Lead, Music Editorial and Content Strategy at TikTok); Kentya Kurban (Community Engagement Co-ordinator at Music BC Industry Association); Michael Assante (Creative Executive, Rap and R&B, at SOCAN); Owen Lee (artist, singer-songwriter, musician, vocal director); Vivian Barclay (Managing Director at Warner Chappell Music Canada); and Widney Bonfils (Director, A&R at Universal Music Canada).
“We’d like to extend a sincere congratulations to all the incredibly talented and deserving winners of this year’s Awards,” said Kayla J. Schwartz, Senior Manager, Communications & Canadian Content Development at SiriusXM. “We’re so proud to continue partnering with the SOCAN Foundation on spotlighting Black creators in Canada and can’t wait to see what’s next for this year’s recipients.”
This week
March 21 is International Day for the Elimination of Racial Discrimination
March 22 is World Water Day
March 25 is The International Day of Remembrance of the Victims of Slavery and the Transatlantic Slave Trade
Something to think about in the week ahead…
Next week
The American Academy of Dermatology has posted a page of advice on how to fade dark spots on the skin in darker skin tones. This is a patient-targeted piece that explains where dark spots come from, and methods dermatologists recommend to treat them, products to avoid, and good habits for preventing the development of dark spots. Next week’s edition of Skin Spectrum Weekly uses this article as a jumping-off point for coverage of recent hyperpigmentation research.
Coming soon
On April 23, 2022, Chronicle Companies will be presenting the 2022 Summit on Atopic Dermatitis. This one-day virtual medical educational event addresses an unmet need for education on the incidence of and latest therapies for atopic dermatitis (AD) among dermatologists and general practitioners.
Co-chairs Drs. Neil Shear and Marissa Joseph will lead a discussion of the most current treatments for all disease severities. The conference will also emphasize AD diagnosis in skin of colour and will provide resources for patient and caregiver support.
Registration for the Summit on Atopic Dermatitis is open and available at this link.