Speaking at the American Academy of Dermatology's 2000 Annual Meeting in San Francisco, dermatologist M. Joyce Rico, M.D., deputy chief of staff, VA New York Harbor Health System and associate professor of dermatology at New York University, New York, NY, discussed the issues surrounding dermatological conditions and appropriate treatments for HIV-infected women.
Dermatologists, who are experts in treating sexually transmitted diseases (STDs), have often observed that common skin conditions such as recurring vaginal yeast infections can actually be early markers for HIV infection. Women and physicians tend to treat the yeast infections without recognizing that recurrent yeast infections may be an indication of a compromised immune system. Oral medications may be required for these yeast infections, rather than over-the-counter creams.
A recent study showed that 37% 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 dermatology conditions, she may be at some 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 important reservoirs 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 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 papilloma virus -- HPV) have an increased risk of also becoming infected with HIV. In one study, 24% of HIV-infected women were also infected with three or more HPV types. Certain types of HPV are also a cause of cervical cancer. HIV-infected women also are at higher risk for cervical cancer due to their compromised immune systems. Women with HIV have a high incidence of cervical cancer and a 50% recurrence rate following treatment. While rare, invasive cervical carcinoma is an AIDS-defining illness (added to the CDC definition in 1993).
One notable exception between men and women in cutaneous diseases is the low prevalence in women of Kaposi's sarcoma (KS), a rare form of skin cancer. KS lesions range in size from a pinhead to the size of a coin and do not hurt to touch. 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% of HIV/AIDS cases overall, with less than 2% of these 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 any more. 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 follow-up. By paying attention to some dermatological markers, a woman may be able to get the help she needs sooner."