Common Skin Conditions May Indicate HIV Infection in Women

Speaking at the American Academy of Dermatology's 2000 Annual Meeting in San Francisco, dermatologist M. Joyce Rico, MD, deputy chief of staff, VA New York Harbor Health System and associate professor of dermatology at New York University, New York City, NY, discussed the issues surrounding dermatological conditions and appropriate treatments for HIV-infected women.

Women are the fastest growing population at risk for HIV, the virus that causes AIDS, in the United States. Approximately 22 percent of the HIV-infected population in this country are women, and women of color are disproportionately affected80 percent are African American or Hispanic. Many of the skin conditions commonly associated with HIV or AIDS that affect women are often treated as a single problem rather than as an indication for further HIV testing.

Dermatologists, who are experts in treating sexually transmitted diseases (STDs), have often observed that common skin conditions like recurring yeast vaginal infections can actually be an early marker for HIV infection, but women and physicians tend to treat these infections without recognizing this. Women who are immune-suppressed often develop severe and treatment-resistant vaginal yeast infections with milky white discharge and white patches on moist surfaces. Oral medications may be required for these yeast infections. A recent study showed that 37 percent of patients who initially had recurrent vaginal yeast infections eventually sought care for HIV.

Too often patients and their physicians treat a specific incident of an STD or a yeast infection without looking at the overall pattern of these conditions, said Dr. Rico. We need to focus on the increasing number of cases of HIV in women and be aware that if a woman has specific recurring problems with certain dermatologic conditions, she may be at risk for HIV.

Some skin conditions occur so frequently in HIV-infected women that they are now considered signs of the disease. Herpes zoster (shingles), oral candidiasis (thrush), oral hairy leukoplakia (an unusual condition that causes small, white, fuzzy patches most often on the tongue) and molluscum contagiosum (a superficial infection caused by a virus) are among the conditions that often lead dermatologists to suggest an HIV test for patients.

Cervical and vaginal secretions are also an important reservoir of HIV. Viral loads (the amount of the virus in the system) can be detected in fluid obtained through cervical discharge. Until recently there has not been much attention [given] to the relationship between skin conditions and HIV infection in women, said Dr. Rico. Women and their physicians need to be aware that complacency is part of the tragedy of this epidemic.

Women acquire the HIV infection most frequently through heterosexual contact. Women infected with sexually transmitted diseases like herpes simplex, syphilis, or venereal warts (human papillomavirus or HPV) have an increased risk of also becoming infected with HIV. In one study, 24 percent of HIV-infected women were also infected with three or more HPV types. Since certain types of HPV are also a cause of cervical cancer, HIV-infected women are also at higher risk for cervical cancer due to their compromised immune system. HIV-infected women have a high incidence of cervical cancer and a 50 percent recurrence rate following treatment. While rare, invasive cervical carcinoma is an AIDS-defining illness.

One notable difference between men and women with cutaneous diseases is the low prevalence in women infected with HIV or AIDS of Kaposi's sarcoma (KS), a rare form of skin cancer. KS, which ranges in size from a pinhead to the size of a large coin, does not hurt or itch. It appears anywhere on the skin or in the mouth as pink, purple, dark red or brown lesions that are often mistaken for insect bites, birthmarks, or bruises. This cancer develops in about 15 percent of HIV/AIDS cases overall, with less than 2 percent of those cases developing in the female population.

Overall, the treatments for these skin conditions are not different for men and women with HIV, noted Dr. Rico. We've entered an era where people think that there are all kinds of great new drugs, so HIV isn't a threat anymore. The reality is that there is still a great deal of mortality and morbidity associated with HIV and AIDS. The sooner a woman is diagnosed, the sooner she can get the medical attention she needs. Despite advances in HIV treatment, women infected with HIV are less likely than men to receive appropriate care and followup. By paying attention to some dermatological markers, a woman may be able to get the help she needs sooner.

The American Academy of Dermatology (AAD), founded in 1938, is the largest, most influential, and most representative of all dermatologic associations. With a membership of over 13,000 dermatologists worldwide, the Academy is committed to: advancing the science and art of medicine and surgery related to the skin; advocating high standards in clinical practice, education, and research in dermatology; supporting and enhancing patient care; and promoting a lifetime of healthier skin, hair, and nails. For more information, contact the AAD at 1--DERM or www.aad.org.