|Year : 2023 | Volume
| Issue : 1 | Page : 11-14
Clinico-epidemiological profile of genital dermatoses in people living with HIV: A shifting paradigm from venereal to nonvenereal dermatoses
Supreet Kaur Dhillon, Mahendra M Kura
Department of Dermatology, Venereology and Leprosy, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
|Date of Submission||29-Mar-2022|
|Date of Decision||13-Jul-2022|
|Date of Acceptance||08-Oct-2022|
|Date of Web Publication||06-Jun-2023|
Dr. Supreet Kaur Dhillon
OPD No. 42, Second Floor, Main OPD Building, Grant Government Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: The protean mucocutaneous manifestations of HIV and the resultant opportunistic infections are well documented. Genital dermatoses can be either venereal or nonvenereal in origin. As the presence of HIV infection greatly increases the chances of acquiring another sexually transmitted pathogen, these are often presumed to be venereal in origin. Aims: The aims of the study were to record the different morphologies of genital skin lesions in seropositive patients and to classify them as venereal or nonvenereal in origin. Settings and Design: This was an observational study undertaken in seropositive patients with genital skin lesions attending the outpatient department of dermatology at a tertiary health-care center. Subjects and Methods: One hundred and seventy-seven seropositive patients with genital lesions were enrolled. A detailed history was taken; the genital and dermatological examination was performed. Statistical Analysis Used: None. Results: Males predominated the study population with the majority (79.1%) falling into the reproductive age group of 15–49 years. Nonvenereal genital dermatoses (59%) outnumbered sexually transmitted infections (STIs) (41%) out of which the most frequently encountered were dermatophytosis, scabies, and intertrigo. Other entities recorded were inflammatory dermatoses, cutaneous adverse drug reactions, and tumors. The most common STIs were herpes genitalis (55.4%) and anogenital warts (32.5%). Conclusion: This study showed that nonvenereal genital dermatoses are more common than STIs in people living with HIV. Our findings reiterate the fact that genital lesions should be approached with caution as a presumptive and hasty diagnosis of STI adds greatly to the morbidity of the patient in terms of guilt and shame, and adversely affects the quality of life.
Keywords: Genital dermatoses, HIV, nonvenereal genital dermatoses
|How to cite this article:|
Dhillon SK, Kura MM. Clinico-epidemiological profile of genital dermatoses in people living with HIV: A shifting paradigm from venereal to nonvenereal dermatoses. Indian J Sex Transm Dis 2023;44:11-4
|How to cite this URL:|
Dhillon SK, Kura MM. Clinico-epidemiological profile of genital dermatoses in people living with HIV: A shifting paradigm from venereal to nonvenereal dermatoses. Indian J Sex Transm Dis [serial online] 2023 [cited 2023 Sep 23];44:11-4. Available from: https://ijstd.org/text.asp?2023/44/1/11/363116
| Introduction|| |
HIV infection can result in numerous mucocutaneous manifestations due to the disease itself during seroconversion and also secondary to the myriad of opportunistic infections and neoplasms that ensue following immunosuppression. The most frequent route of transmission of HIV is through heterosexual intercourse. The presence of HIV infection greatly enhances the risk of acquiring other sexually transmitted pathogens and the converse holds true as well. The interaction of HIV with herpes simplex virus (HSV), Treponema pallidum, and human papillomavirus (HPV) has been well studied. Due to the altered immunological profile, sexually transmitted pathogens can present with atypical morphologies posing difficulty in diagnosis and management. Moreover, nonvenereal dermatoses can also involve the genitalia in the seropositive population as in the seronegative counterparts. The present study was undertaken to record the different morphologies of genital dermatoses in people living with HIV (PLHIV) infection and to classify them as venereal or nonvenereal according to their mode of transmission.
| Subjects and Methods|| |
An observational, descriptive study was conducted at the department of dermatology of a tertiary care health center for 18 months from January 2019 to June 2021. Permission from the institutional ethics committee was obtained for the same. One hundred and seventy-seven seropositive patients with skin lesions in the genital area who provided written informed consent were enrolled. The operational definition for genital lesions included skin lesions occurring over the external genitalia, perineum, and perianal region. A detailed history was taken and genital and complete dermatological examination were performed. Required serological and/or histopathological investigations were performed in case of multiple clinical differential diagnoses to reach a final diagnosis. The data were tabulated in an Excel spreadsheet and analyzed. The mean age of the study participants was calculated along with the most and least common venereal and nonvenereal genital dermatoses which were expressed as percentages of the total number.
| Results|| |
A total of 177 seropositive patients with genital skin lesions were studied. Males predominated the study population, forming 67.8% of the study cohort out of which the majority (79.1%) fell in the reproductive age group of 15–49 years. The mean age of the study participants was 41.04 years. The majority of the study participants (89.23%) were on antiretroviral therapy (ART). The cohort of patients currently not on ART in our study included those who were recently diagnosed and not yet initiated on ART and defaulters with poor adherence. The sociodemographic profile of the study participants is depicted in [Table 1]. The high-risk population identified was drivers (7.91%), laborers (7.35%), and commercial sex workers (0.56%). The rest of the study participants belonged to other occupations such as hotel workers, security guards housemaids, teachers, and shopkeepers. However, we noted a predominance of nonvenereal genital dermatoses among laborers and hotel workers, and an equal preponderance of venereal and nonvenereal genital dermatoses in drivers, whereas sexually transmitted infections (STIs) were more common among security guards, commercial sex workers, and unemployed study participants [Table 2]. History of high-risk behavior in the form of multiple sexual partners, anogenital or orogenital intercourse, men having sex with men, commercial sex workers, and injectable drug use was present in 32.20% of the study participants.
|Table 2: Distribution as per occupation and associated genital dermatoses|
Click here to view
The most frequent symptom was rash with raised or itchy skin lesions in 71.75% followed by a genital ulcer in 11.29%. Others included painful skin lesions, fluid-filled lesions, genital discharge, and swelling. In 38.98% of the cases, the duration of genital lesions ranged between 1 and 6 months, 19.78% of the participants reported to the health-care facility within a week of the onset of genital lesions, whereas 6.21% of the cases had long-standing neglect of their genital dermatoses with them presenting to the health-care facility more than 1 year after the onset of genital lesions. The genital dermatoses presenting acutely included infections such as herpes genitalis and candidiasis, whereas entities such as squamous cell carcinoma, Bowen's disease, condyloma acuminata, and angiokeratomas were reported to the health center much later than their onset. This corroborates with their respective incubation period. Upon analyzing the duration of HIV infection, it was found that 27.68% of our study participants were diagnosed with HIV infection more than 10 years ago, 14.68% between 8 and 10 years, whereas only a minority of PLHIV with genital dermatoses had a duration of HIV infection shorter than 6 months. Thus, the majority of PLHIV presenting with genital dermatoses had a long-standing duration of HIV infection. The genital dermatoses encountered in this far end included benign and malignant neoplasms as well as asymptomatic infections like anogenital warts.
The mean CD4 count among the study cohort was found to be 423.28 cells/μL.
A total of 203 dermatoses were recorded in the study cohort. The etiological distribution according to the final diagnosis and the mean CD4 cell count is represented in [Table 3]. Upon analyzing the mode of transmission, nonvenereal genital dermatoses (59%) [Table 4] were found to outnumber the STIs (41%) [Table 5]. The highest mean CD4 count was associated with bacterial infections (476.13) and the lowest was noted with tumors (345.78).
The most common group overall was infections and infestations, including the STIs out of which viral infections were the most numerous (38.92% of all cases overall) followed by fungal infections (31.03%). Viral infections encountered were herpes genitalis (22.67%), anogenital warts (13.3%), molluscum contagiosum (2.46%), and one case of herpes zoster involving the L1, L2, and L3 dermatomes with ulcerative skin lesions. Fungal infections included dermatophytosis (26.11%) and cutaneous candidiasis (4.93%). Bacterial infections recorded were syphilis (2.46%) and folliculitis (1.48%) and scabies (7.88%) was the only parasitic infestation that we came across.
Inflammatory dermatoses were intertrigo (4.43%) and one case each of lichen planus, flexural psoriasis, and seborrheic dermatitis. Cutaneous adverse drug reactions involving the genital mucosa included fixed drug eruption, erythema multiforme, and Steven–Johnson syndrome with culprit drugs being doxycycline and cotrimoxazole. Tumors noted were benign lesions such as scrotal angiokeratomas of Fordyce (1.48%) and scrotal steatocystomas (0.5%), premalignant dermatoses like Bowen's disease (1.48%), and malignancies such as squamous cell carcinoma (1.97%), vulval intraepithelial neoplasm (0.5%), and Kaposi's sarcoma (0.5%). Other miscellaneous entities recorded were frictional erosion, frictional hyperpigmentation, and posttraumatic ulcer.
Most of our study participants had skin lesions or medical conditions corresponding to the WHO clinical stage III (18.64%), whereas cases with stages II and IV pathologies were 2.83% and 11.86%, respectively.
However, out of the total 177 study participants, 117 (66.10%) patients had a genital dermatosis that could not be used to stage the HIV disease as per the WHO clinical staging of 2007. Thus, it can be inferred that it may not always be possible to classify the stage of HIV disease as per the genital lesions as not all genital dermatoses are included as stage-defining illnesses.
| Discussion|| |
The mucocutaneous manifestations in HIV infection can occur due to the virus itself, primarily during the phase of seroconversion illness, and also due to opportunistic infections and neoplasms that are common in this group. In the earlier decades of the 80s and 90s, a strong association between STIs and HIV was reported and every genital lesion in this cohort of PLHIV was invariably linked to or found to be of venereal origin. However, with the increasing use of effective ART contributing to a longer life span of PLHIV, the issue of skin lesions involving the genital area changes as other nonvenereal dermatoses are also common entities. Effective use of syndromic management of STIs under the national program also contributed significantly to the reduction of conventional bacterial STIs such as chancroid and syphilis. Genital diseases that are sexually transmitted hold importance in HIV as they both share a common mode of transmission and similar preventive measures. However, we should be cautious to note that in seropositive patients with genital lesions, the genital disease may not always be transmitted sexually and it is vital to differentiate between venereal and nonvenereal genital dermatoses.
The interaction between other sexually acquired pathogens and HIV is manifold. Coinfection with HSV is known to increase the HIV viral load and accelerate disease progression. Infection with multiple subtypes of HPV is common in the seropositive group with a greater risk of malignant transformation. Atypical morphologies of these STIs are also frequent such as chronic nonhealing ulcers and hypertrophic lesions in herpes genitalis, widespread molluscum contagiosum, and ulcerative skin lesions in secondary syphilis. Some of the unusual morphologies encountered in our study included hypertrophic lesions of recurrent herpes genitalis, chronic erosive herpes, and long-standing florid genital warts resulting in phagedena of the glans penis [Figure 1], giant molluscum contagiosum [Figure 2], and multidermatomal herpes zoster involving L1, L2, and L3 dermatomes with ulceration. The most common STI in our study was herpes genitalis (54.32% of all STIs) which is in concordance with studies by Chugh et al. (48.15%) and Chopra et al., Herpes genitalis has emerged as the leading cause of genital ulcers, both among the seronegative as well as the seropositive group, the rise in cases favored by the global HIV pandemic and over-the-counter use of antibiotics.
|Figure 1: Hypertrophic lesion of recurrent herpes genitalis with sites of previously healed lesions showing postinflammatory hypopigmentation, large ulcer of chronic erosive herpes genitalis for 4 months in a seropositive female with a CD4 count of 126 cells/μL, warts with penile edema which upon retraction showed phagedena of the glans penis|
Click here to view
|Figure 2: Giant molluscum contagiosum in a seropositive female in virological and immunological failure with a CD4 count of 33 cells/μL, perianal Bowen's disease, and flexural psoriasis|
Click here to view
However, in our study, nonvenereal genital dermatoses (59%) outnumbered STIs (41%). We recorded twenty-two different entities of nonvenereal genital dermatoses, the most common being dermatophytosis and cutaneous candidiasis. Others included intertrigo, Bowen's disease and flexural psoriasis [Figure 2], lichen planus, cutaneous adverse drug reactions, scrotal angiokeratomas, and squamous cell carcinoma.
There is a need to educate PLHIV to reduce the associated stigma as lesions in the genital region are often presumed to be sexually transmitted both by the patient and an inexperienced clinician. This would also promote prompt health-seeking behavior and progression to florid stages and malignant transformation could be averted. An element of neglect was observed in numerous cases in our study like a male presenting with florid genital warts for 4 years, leading to phagedena and mutilation of the external genitalia. He suffered from multiple other medical illnesses such as dementia, diabetes, seizure disorder, and biliary cirrhosis. The contribution of concomitant illnesses to the neglect of genital dermatoses in PLHIV cannot be ignored. Stigma is a common factor in both HIV and genital dermatoses. The misconception that all lesions in the genital area are sexually transmitted adds to this. Factors contributing to this stigma include feelings of guilt, low self-esteem, uncleanliness, and unworthiness. A tendency for delayed presentation, often with a history of long-term self-management, or unsuccessful treatment has also been reported. Another retrospective study of genital dermatoses in HIV-positive men reports a mean diagnostic delay of 20 months.
There is a paucity of studies exploring genital dermatoses in the general population with most research being carried out among nonvenereal genital dermatoses in the community. Thus, a head-on comparison between our findings and the prevalence of venereal versus nonvenereal genital dermatoses in the seronegative population was not possible.
| Conclusion|| |
Nonvenereal genital dermatoses continue to be a major burden among PLHIV accounting for more than half of all diagnoses in our study. Genital lesions are a cause of considerable morbidity among their sufferers and result in a delay in seeking treatment, progression to the florid stage, or malignancy with adverse effects on quality of life.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shaw GM, Hunter E. HIV transmission. Cold Spring Harb Perspect Med 2012;2:a006965.
Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992;19:61-77.
Duffus WA, Mermin J, Bunnell R, Byers RH, Odongo G, Ekwaru P, et al
. Chronic herpes simplex virus type-2 infection and HIV viral load. Int J STD AIDS 2005;16:733-5.
Clifford GM, Gonçalves MA, Franceschi S, HPV and HIV Study Group. Human papillomavirus types among women infected with HIV: A meta-analysis. AIDS 2006;20:2337-44.
Mayer KH, Collis TK, Celum CL. The clinical manifestations and treatment of sexually transmitted diseases in human immunodeficiency virus-positive men. Clin Infect Dis 2001;32:611-22.
Chugh S, Garg VK, Sarkar R, Sardana K. Clinico-epidemiological profile of viral sexually transmitted infections in seropositive patients attending a tertiary care hospital in North India. J Int Assoc Provid AIDS Care 2017;16:331-7.
Chopra D, Sandhu I, Bahl RK, Bhatia R, Goyal A. Prevalence of sexually transmitted infections in HIV positive and HIV negative females, in a tertiary care hospital – An observational study. Indian J Sex Transm Dis AIDS 2015;36:59-63.
Gbery IP, Djeha D, Kacou DE, Aka BR, Yoboue P, Vagamon B, et al
. Chronic genital ulcerations and HIV infection: 29 cases. Med Trop (Mars) 1999;59:279-82.
Mertz KJ, Trees D, Levine WC, Lewis JS, Litchfield B, Pettus KS, et al
. Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The genital ulcer disease surveillance group. J Infect Dis 1998;178:1795-8.
Singhal RR, Patel TM, Pariath KA, Vora RV. Premalignant male genital dermatoses. Indian J Sex Transm Dis AIDS 2019;40:97-104.
Shim TN, Hawkins D, Muneer A, Minhas S, Freeman A, Jameson C, et al
. Male genital dermatoses in HIV. Sex Transm Infect 2013;89:A143.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]