Pruritus and cutaneous inflammatory conditions in HIV disease

Abstract

Inflammatory and pruritic conditions of the skin are common features of HIV disease. A number of these are specific to HIV infection, whereas others that are seen in the general population may demonstrate increased prevalence or severity in association with HIV. Some conditions, such as lichen planus, demonstrate a decreased prevalence in HIV disease. Clinically, the pattern of inflammatory and pruritic conditions associated with HIV infection reflects not anergy, but rather an inflammatory state. This is mirrored by findings indicating significant disruption of the normal cytokine environment and cell populations within the immune system in HIV-infected patients. Progression in HIV disease is associated with a shift in cytokines from a TH1 to a TH2 predominant state,1 and hypereosinophilia and increased levels of IgE are seen in advanced disease.2,3 Diagnosis can usually be made based on morphology; see Table 1. Advances in the treatment of HIV infection have altered the spectrum of inflammatory conditions seen in patients on therapy, and they have to a great extent disrupted the classic associations between HIV disease parameters and the appearance of given conditions. While the introduction of highly active antiretroviral therapy (HAART) has occasioned a dramatic reduction in the prevalence of certain previously common conditions, other conditions once associated with advanced disease are now seen in patients with relatively higher CD4 counts. This implies a persistent immune dysfunction despite improving HIV disease parameters, and it suggests that the partial reconstitution of the immune system associated with HAART may not impart the same immunological behavior as an undamaged immune system. Irregularities in the responses of the reconstituted immune system will likely evolve as patients remain on HAART for longer periods, and the pattern of cutaneous conditions seen in the HIV-positive population may change accordingly. Therapy for pruritus in HIV infection includes standard modalities used in HIV-negative patients. Additionally, therapies have emerged for the treatment of conditions specific to HIV disease, and for those conditions whose clinical pattern may differ in association with HIV. Many drugs must be used with caution in HIV patients, who may be susceptible to hypersensitivity reactions, drug interactions, and idiosyncratic reactions.