Ward 86 Primary Care Approach to the HIV Patient with Pruritus

Updated
Contributors:
Ser-Ling Chua, DTM&H, MRCP Toby Maurer, MD

Pruritus is a common symptom among HIV-infected patients, particularly those not virologically suppressed by antiretroviral therapy (ART). The most common underlying diagnoses in HIV patients are as follows:

Our approach to clinical management of pruritus is to choose the most likely cause, empirically treat the condition, and maximize the effectiveness of ART for any patient not fully virologically suppressed. We refer to a dermatologist:

Diagnostic approach

Patients with chronic itching may present with:

Key elements of the initial evaluation should include:

Empiric Treatment

  1. Common pruritic skin conditions that can be aggravated by uncontrolled HIV infection or low absolute CD4 T-cell counts

    1. Xerosis (dry skin)
    2. Seborrheic dermatitis
    3. Psoriasis

  2. Uniquely HIV-associated pruritic skin conditions

    1. Eosinophilic folliculitis
    2. HIV papular pruritic eruption (occurs only in tropical regions)

  3. Infections/infestations

    1. Staphylococcal folliculitis
    2. Hepatitis C-associated vasculitis
    3. Herpes zoster
    4. Scabies
    5. Bedbug or flea bites

  4. Drug rash

    1. Morbilliform
    2. DRESS (drug reaction with eosinophilia and systemic symptoms)
    3. Fixed-drug eruption
    4. Photodermatitis

  5. Skin conditions caused by chronic scratching and rubbing

    1. Prurigo nodularis
    2. Lichen simplex chronicus
    3. Atopic eczema

    1. Patients whose symptoms or clinical findings do not improve with empiric therapy.

    2. Patients with chronic diseases such as psoriasis that require more than intermittent topical therapy.

    3. Patients with serious drug reactions such as DRESS.

    1. A rash (the morphology and location of which can be very helpful in making a preliminary diagnosis)

    2. Skin findings that have developed because of scratching or rubbing; or

    3. No apparent skin changes

    1. A detailed history that includes:

      1. The temporal evolution of pruritus and rash, including location, appearance, and change over time
      2. Recent changes in medications
      3. Prior history of skin disease
      4. Contact with pets that might harbor fleas or any people who might have scabies

    2. Physical examination focusing on rash location, morphology (ie, macules, papules, pustules, vesicles, nodules, scaling, coalescence of skin lesions, and dry skin), and the precise location and extent of skin lesions.

    3. Using the information gained from this evaluation to choose the most likely diagnosis (see Table 1).

    1. Symptomatic treatment for pruritus:

      1. Avoid overwashing and irritation of the skin with soap or shower gels--suggest use of non-soap cleansers (eg, those made by Aveeno, Cetaphil, or Neutrogena).
      2. Liberal use of emollients or moisturizers twice daily.
      3. Hydroxyzine 10-25 mg PO at bedtime (can take Q6H during the day if needed) or doxepin 25-75 mg PO at bedtime. Caution should be paid to risk of sedation and cognitive changes with these drugs, particularly in patients over age 65.

    2. First-line treatment for specific skin conditions is included in Table 1).

References

  1. Serling SL, Leslie K, Maurer T. Approach to pruritus in the adult HIV-positive patient. Semin Cutan Med Surg. 2011 Jun;30(2):101-6.
Table 1. Preliminary Diagnosis and Empiric Treatment for Pruritus
Condition Skin Findings ART Improves Condition? First-Line Empiric Therapy
Pruritic skin conditions aggravated by uncontrolled HIV infection
Xerosis Xerosis (dry skin) commonly involves the trunk and extremities. Yes On face and neck, use a low-potency topical corticosteroid such as hydrocortisone 1%.
On the trunk and limbs, use a medium- to high-potency topical corticosteroid such as triamcinolone 0.1%, fluocinonide 0.05%, or clobetasol 0.05%. (Caution: limit duration of clobetasol use to avoid side effects).
Ointments are more effective than creams.
Seborrheic dermatitis Erythema, pruritus, and scaling typically located around the eyebrows, scalp, nasolabial folds, chest, and flexural areas. Yes Topical ketoconazole 2% ointment and topical hydrocortisone 1% ointment mixed together.
Psoriasis Typically symmetrically distributed, erythematous plaques with a silvery scale and sharply defined margins. Elbows, knees, and scalp are most common sites of involvement. Itching may be minimal. Yes Medium-potency topical corticosteroid such as triamcinolone 0.1% ointment. Use hydrocortisone 1% ointment BID for face and groin. Refer to dermatologist if this does not control disease.
Eosinophilic folliculitis Intensely pruritic, erythematous, hair-follicle-based papules and pustules with an upper body central distribution, including scalp and face. Most cases occur in patients with a CD4 count of <100.
Diagnosis should be confirmed by skin biopsy.		 Yes Topical corticosteroids (see section on Xerosis/Atopic eczema).
Start ART if not receiving (true for other conditions as well). For more severe cases, use itraconazole 100 mg BID and titrate up to 200 mg BID (caution: drug-drug interactions).
Infections/infestations
Staphylococcal folliculitis Erythematous, hair-follicle-based pustules (sometimes papules) on the neck, trunk, and extremities. Sometimes Doxycycline 100 mg BID, or trimethoprim-sulfamethoxazole DS BID, or clindamycin 300 mg BID for 14-21 days; emollients; consider mupirocin ointment intranasally first 5 days of every month to eradicate.
Staphylococcus: Avoid Hibiclens, Ivory, or Irish Spring soap, and other drying agents that may break the skin barrier. Bathing in diluted bleach (1/4 cup of bleach added to a bathtub of water) once or twice a week may help.
Hepatitis C-associated vasculitis Raised, purpuric lesions on the lower extremities. Cryoglobulins may be detected in serum. No Treat HCV.
Herpes zoster Before rash occurs, there is often a prodrome of pruritus in a dermatomal distribution, with or without pain. Typical rash consists of clustered vesicles in a dermatomal distribution that subsequently crust. In patients with very low CD4 counts, disseminated vesicles or papules, not corresponding to a dermatomal distribution, may occur. Not acutely Acyclovir 800 mg QID or Valacyclovir 1 g TID for 5 days.
Scabies Very pruritic, small, erythematous, papules, often excoriated, typically on interdigital webs, wrists, flexor surfaces, and genitals. Not acutely 5% permethrin cream applied to entire body except face, left on for 8 hours; repeat after 1 week. Patients must wash and dry all clothes and bed linen and treat intimate contacts. Ivermectin for refractory cases.
Flea bites/bedbug bites Pruritic urticarial papules on legs and arms (fleas) or on posterior surfaces (bedbugs). Not acutely Eradicate infestation. This may require a professional exterminator. Can use fluocinonide 0.05% cream on bites.
Drug rash
Morbilliform drug rash Erythematous macules or papules, primarily on trunk and proximal extremities, that coalesce over time. Common causes are sulfa drugs, efavirenz, darunavir, and nevirapine. No Discontinue suspect drug; rechallenge to confirm diagnosis.
Drug reaction with eosinophilia and systemic symptoms (DRESS) Typically begins with a morbilliform rash occurring within 6 weeks of initiating the causative drug and progresses to eosinophilia, fever, transaminitis, facial edema. Sulfa drugs and anticonvulsants are the most common causes. Raltegravir can cause DRESS. No Discontinue suspect drug and provide supportive medical care. Systemic corticosteroids may be indicated in severe cases. Be aware of long-term cardiac and thyroid sequelae.
Fixed-drug eruption A dark macule with sharply defined margins that may progress with continued drug exposure to an edematous plaque or blistering. No Discontinue suspect drug; do not rechallenge to confirm diagnosis.
Photodermatitis drug reaction A lichenoid or eczematous eruption on sun-exposed skin. Sulfa drugs are a common cause. Sometimes Discontinue suspect drug if possible; topical fluocinonide 0.05%; sunscreen.
Skin conditions caused by chronic scratching and rubbing
Prurigo nodularis Bilateral, symmetric, dome-shaped nodules that usually begin on the extremities. Yes Fluocinonide 0.05% or clobetasol 0.05%.
Lichen simplex chronicus Bilateral, symmetric, hyperkeratotic plaques that usually begin on the extremities and then become hypopigmented. Yes Fluocinonide 0.05% or clobetasol 0.05%.
Atopic eczema Eczema is characterized by thickened skin and excoriated and fibrotic papules, which most commonly involve the posterior neck, flexor forearms and wrist, and behind the knees. Yes On face and neck, use a low-potency topical corticosteroid such as hydrocortisone 1%.
On the trunk and limbs use a medium- to high-potency topical corticosteroid such as triamcinolone 0.1%, fluocinonide 0.05%, or clobetasol 0.05%. (Caution: Limit duration of clobetasol use to avoid side effects).
Ointments are more effective than creams.
Positive Health Program and University of California, San Francisco Logo

About This Series

This series offers clinical practice recommendations for management of HIV-related conditions from the Ward 86 staff of the Positive Health Program at San Francisco General Hospital. Learn more.

Editor: Mark Jacobson, MD

Coeditors: Susa Coffey, MD; Diane Havlir, MD; Monica Gandhi, MD

See all Recommendations.

Contact us with feedback or to suggest topics: [email protected]

Subscribe to receive updates when new entries are posted.