HIV: SKIN PROBLEMS-PURPLE OR BLACK SPOTS
The skin is commonly affected in people with HIV infection. The conditions affecting the skin include a diverse array of infections and an unusual tumor called Kaposi’s sarcoma. Other skin conditions—psoriasis, seborrhea, molluscum, fungal infections, and allergic rashes—are also common in people without HIV infection, but are more common and more severe in people with HIV infection. Since most of these conditions are treatable, people should see their physicians, especially if the skin problem is painful, disfiguring, or accompanied by a fever.
As expected, the diagnosis of a skin condition is largely dictated by its appearance. In many cases, a diagnosis can be established simply by observation, but occasionally diagnosis will require a biopsy.
Purple or Black Spots-Purple or black spots on the skin are characteristic of Kaposi’s sarcoma (KS), a tumor of the cells of the blood vessels. In most cases, there are several tumors, each approximately a quarter of an inch to an inch in diameter. They can usually be felt as a nodule or a fleshy collection of tissue. They can—but do not usually—cause pain. In light-skinned people, the tumors are usually red-purple or purple; and in dark-skinned people, they are very dark brown or black. The tumors are not like freckles, either in color or to the touch.
KS tumors can appear any place on the skin, including the face, scalp, back, chest, abdomen, arms, legs, or inside the mouth. They appear most commonly on the tip of the nose, around the eyes, on the ears, behind the ears, and on the arms, the legs, the chest, and the genitals. Usually there are several tumors in different places. At times the tumors occur symmetrically, appearing in almost identical places on both arms, on both sides of the face, or on both feet.
Kaposi’s sarcoma is second only to Pneumocystis pneumonia as the initial AIDS-defining diagnosis in people with HIV infection. KS can occur when the CD4 cell count is relatively high, though sometimes KS does not occur until late in the infection, after PCP or another
AIDS-defining diagnosis.
Some have argued that KS is a sexually transmitted disease because it is extremely common in gay men with HIV infection and is quite unusual in hemophiliacs, children, or those who became infected through transfusions. If KS is sexually transmitted, the safer sex practices that prevent transmission of HIV also seem to prevent transmission of KS: among gay men with HIV infection, KS is disappearing.
KS on the skin is suspected based on its appearance and is diagnosed with a biopsy of the tumor. This is a simple outpatient procedure; Novocain is injected into the skin to make the procedure painless.
The treatment of KS is controversial. Many people do not have serious problems with the disease, and the overall prognosis is substantially better than when PCP is the original
AIDS-defining diagnosis. Most people simply have KS on the skin, and though they may also have KS on their internal organs, it usually causes no problems. Moreover, many of the treatments for KS are either ineffective or have serious side effects. Cosmetic problems can often simply be covered with opaque makeup. Treatment can be considered necessary under several circumstances: if people have KS tumors on the face or other exposed areas of the body that they feel are unsightly or carry the stigma of AIDS; if the tumors are obstructing lymph channels and causing swelling of the legs, abdomen, or face; if KS is causing pain, most commonly on the bottoms of the feet or roof of the mouth; if KS has spread to internal organs and is causing disabling or serious symptoms, like pneumonia or problems of the gastrointestinal tract; or if KS is causing fever, fatigue, weight loss, and similar symptoms.
The usual treatment of skin tumors is radiation, freezing, or drugs. If KS has spread to internal organs, the treatment consists of taking the same drugs used to treat other cancers. A drug called interferon, taken by injection, is effective in some cases, but generally works best early in the course of KS, when the CD4 count is above 400.
The best advice about treating Kaposi’s sarcoma will come from any physician with extensive experience in this area, particularly from an AIDS physician, from a dermatologist, or from a cancer specialist (an oncologist). Which physician does the treatment will depend on which therapy is used: radiation treatment will require referral to a radiation therapist, cancer chemotherapy will require referral to an oncologist, and interferon will require referral either to a dermatologist, an oncologist, or a specialist in AIDS or infectious diseases. The person contemplating interferon treatment for KS should be forewarned that interferon is the substance produced by the body during flu that causes the aches of influenza. The same achiness is a common side effect of interferon treatment.
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