HIV-Associated Pruritus

Abstract

With the advent of highly active antiretroviral therapy (HAART), life-threatening opportunistic infection has become less common in patients with HIV infection and longevity has increased dramatically. With increased longevity, the problems of living with a chronic disease have become more prominent in this patient population. Disorders such as fat redistribution and metabolic abnormalities can result from antiviral medications and from HIV disease itself. Pruritus is one of the most common symptoms encountered in patients with HIV. The spectrum of skin diseases in such patients encompasses dermatoses of diverse etiologies; a few are peculiar to patients with HIV while others are not. Some of these conditions may cause severe and sometimes intractable pruritus that provokes scratching, picking, disfigurement, sleep loss, and significant psychological stress. Moreover, the expense of ongoing medical treatments can be daunting. Skin rash can sometimes be the initial presentation of HIV infection or serve as a harbinger of disease progression. Causes of pruritus include skin infections, infestations, papulosquamous disorders, photodermatitis, xerosis, drug reactions, and occasionally lymphoproliferative disorders. Drug eruptions are particularly common in patients who are HIV positive, presumably as a result of immune dysregulation, altered drug metabolism, and polypharmacy. Itching can also result from systemic diseases such as chronic renal failure, liver disease, or systemic lymphoma. Workup of pruritus should include a careful examination of the skin, hair, nails, and mucous membranes to establish a primary dermatologic diagnosis. If no dermatologic cause is found, a systemic cause or medication-related etiology should be sought. Idiopathic HIV pruritus is a diagnosis of exclusion and should only be considered when a specific diagnosis cannot be established. The management of HIV-associated pruritus should be directed at the underlying condition. Phototherapy has been found to be useful in the treatment of several HIV-associated dermatoses and idiopathic pruritus as well. Unfortunately, some of the treatments that have been suggested for patients with HIV are anecdotal or based on small uncontrolled studies. The last decade has seen a surge in the utilization of HAART which, to some degree, reconstitutes the immune system and ameliorates some dermatologic diseases. On the other hand, some skin diseases flare temporarily when HAART is started. Unless frank drug allergy is suspected, HAART does not need to be stopped.

New insights into HIV‐1‐primary skin disorders

“…This condition is found in more than 20% of people with HIV-1 [41]. It presents mainly on extremities, and it denotes one of the main causes of pruritus in AIDS patients [42]. Its pathogenesis has been suggested to include changes in the microcirculation, the nutrient supply of the skin, and in the production of sweat and oil in the skin [43].…”

Immune reconstitution inflammatory syndrome associated with dermatophytoses in two HIV-1 positive patients in rural Tanzania: a case report

“…In another study conducted in Brazil, 10–25 % of unselected patients starting ART developed IRIS with 52–78 % of these patients presenting with cutaneous features [ 1 , 9 ]. Tinea-IRIS lesions can be visible on patient’s skin, and despite not being associated with mortality can cause a decrease in the quality of life [ 10 ]. Moreover, it requires a high index of suspicion to be treated.…”

Infectious differential diagnosis of chronic generalized pruritus without primary cutaneous lesions: a review of the literature

“…Chronic pruritus has been – and still is – a common symptom in patients with human immunodeficiency virus (HIV) even in the new era of highly active antiretroviral therapy (HAART) and combination antiretroviral therapy (cART) . A study in the United States in 2012 has reported a 45% prevalence rate in 201 HIV‐infected patients, an estimate which is close to the 31% documented by a study in Spain on 303 HIV‐infected patients in 2003 …”

“…A range of primary skin disorders (such as xerosis, atopic dermatitis, seborrheic dermatitis, psoriasis, infections like scabies or dermatophyte infections, etc.) may be the etiology of pruritus or might be the reason for exacerbation, relapse, or more severe manifestations of an underlying skin disorder . Chronic pruritus may also be associated with systemic disorders in HIV‐infected patients (e.g.…”

“…Chronic pruritus may also be associated with systemic disorders in HIV‐infected patients (e.g. lymphomas, chronic renal diseases, diabetes mellitus and other endocrinopathies, hepatic diseases like cholestasis, and drug reactions) …”