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Dermatology & HIV
Effects on the Mind and Body

Appearance affects us all in important ways. The perception of our own physical appearance is due to both an overall sense of well being or its lack, and to the reality of physical appearance. Alterations of social interactions occur due to true physical changes from illness or medication such as lipodystrophy or other stigmatizing changes from obvious abnormalities of the skin such as the purple swollen tumors of KS, the large innumerable warty facial growths due to molluscum contagiosum, the sores of Herpes Simplex, infections of Staph induced impetigo or the scratched-at itchy red bumps over the face and upper trunk that occur in folliculitis.

The treating physician must keep in mind the profound adverse effect on the psyche of those affected by HIV - related skin disease. Not only does this contribute negatively to mood and stimulate depression, but the effect on the health of individuals through the mind-body relationship may not be overstated. The most critical part of care is early recognition by both patient and treating physician so that early therapy can be initiated and unnecessary disfigurement avoided.

Molluscum is one of the easiest to treat conditions, as it is compromised of individual skin colored papules or bumps that may be permanently lifted from the skin by a dermatologist with minimal scarring if treated when small. Larger lesions may be shrunken in size by cryosurgery or other modalities before destructive therapies that leave residual marks are attempted.

Herpes viruses such as Herpes Simplex, Varicella-Zoster virus and Epstein-Barr virus, as well as impetigo-like blisters caused by Staph Aureus, Strept or Candidal infections, must also be differentiated as to cause and treated early. Blisters may be superficial, predominating in skin folds and filled with purulent material suggesting yeast or bacteria and necessitating oral, topical and intranasal therapy as means of eradicating colonization. Deeper seated erosions with surrounding erythema tend to suggest Herpes and are often more painful. Because of the Protean manifestations of many of these organisms in the presence of low viral loads and or low CD4 counts, the diagnosis is often dependent on biopsies, immunofluorescence studies, and the use of all available forms of cultures .

As with many forms of skin disease, the appearance of folliculitis belies the underlying cause. A detailed drug history, a contact exposure history, as well as a history of medical diseases are first necessary to help sort out drug hypersensitivity rashes from rashes due to scratching from other diseases such as hepatitis or renal azotemia. A skin biopsy is often helpful to differentiate the above category of hypersensitivity-like reactions from viral/herpetic, bacterial/mycobacterial or other infectious causes. It is also helpful in establishing idiopathic entities such as eosinophilic folliculitis and acneiform type folliculitis from these others.

Therapy should be directed at the underlying infections when known and otherwise must involve the unusual assortment of sometimes seemingly unrelated and "shotgun" therapies. These include the use of antibiotics, antifungals, ultraviolet phototherapy and topical steroids.

The spectrum of conventional skin diseases, such as seborrheic dermatitis and psoriasis, present a problem not only because they are disfiguring and socially alienating diseases, but because their altered pattern of presentation is more severe and so feels stigmatizing to the individuals afflicted. For example, the recognition of the less well-defined borders of psoriasiform dermatitis may be important to the initiation of the proper therapeutic intervention with an oral retinoid or phototherapy.

Not enough can be said about the demoralizing effects of lipodystrophy, other than that it is a byproduct of life-sustaining medicines and so is to be tolerated as a "necessary evil."

An empathetic approach to the whole patient includes the taking into account of how patients feel about their illness. An awareness of the effect HIV and its therapy has on body habitus and appearance will make a treating clinician initiate diagnosis and referral that will lead to early treatment and minimize unaesthetic alteration in the appearance of patients who know that, when you look good, you feel better.
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