Woman with HIV and Occasionally Pruritic Facial Rash

A 40-year-old woman with HIV infection has had an occasionally pruritic facial rash for several months. The rash is not associated with any systemic symptoms.

Which of the following seems the most likely cause of the rash?

• Herpes simplex
• Molluscum contagiosum
• Verruca plana (flat warts)

DISCUSSION:

The patient has molluscum contagiosum, a benign DNA poxvirus infection that usually remains localized in the epidermis. Patients do not exhibit systemic signs and symptoms, although, on occasion, lesions may become secondarily infected. Children and immunocompromised patients (ie, those who are immunosuppressed or HIV-positive or who are taking corticosteroids) may exhibit more extensive lesions.

Transmission is primarily by direct contact, including sexual contact. The typical lesions are pearly to fleshcolored, smooth, dome-shaped papules that develop a soft, indented core (umbilication). The 2- to 6-mm lesions may appear anywhere on the body, although they rarely involve the palms, soles, or mouth. Large, disfiguring lesions may develop in immunocompromised patients, especially those with HIV disease.

The diagnosis is usually made clinically, based on the lesions' distinctive appearance. Treatment is not mandatory, because the lesions generally resolve spontaneously and heal without scarring, unless secondary infection has occurred. Treatment methods include curettage, cauterization, cryotherapy, and application of such topical preparations as podophyllotoxin cream, trichloroacetic acid, and cantharidin. Genital lesions are treated in order to minimize spread by sexual contact.

Without treatment, lesions may persist from 2 to 12 months. The lesions of immunocompromised patients may persist for years. Reinfection may occur.

This patient had been treated with a variety of medications, none of which cleared the lesions-presumably because of her persistently elevated viral load.

Other entities in the differential. The lesions of herpes simplex virus (HSV) infection consist of clustered vesicles on an erythematous base. The vesicles evolve to pustules or ulcerated lesions, which eventually form a crust. Recurrence at or near the same site is common, especially along the distribution of a sensory nerve. Patients with primary lesions usually have associated systemic symptoms, including malaise, fever, and generalized discomfort. HSV-1 lesions erupt above the waist, especially in the perioral region (herpes labialis). HSV-2 lesions generally occur in the genital area.

Although most HSV infections are self-limited, the use of antiviral therapy may reduce the duration of symptoms and help prevent transmission and dissemination. Herpes labialis is usually treated with oral acyclovir, valacyclovir, or famciclovir. Topical agents are available but are thought to be less effective than oral medications.

Verruca plana (flat warts) are lesions caused by the DNA-containing human papillomavirus, of which there are many types. Flat warts typically develop on the face and backs of the hands as small individual papules of approximately one-quarter inch in diameter. Warts are common in children, usually between the ages of 12 and 16 years, although they may occur in adults. Infection occurs either by direct contact with an infected person or after direct contact with the virus, which may remain viable in a warm, moist environment. In most cases, warts disappear spontaneously within 6 months to 3 years; however, recurrence is common. Warts may be removed by a number of techniques, including laser therapy, surgery, and application of liquid nitrogen.