What is the recommended skin care treatment for a patient with Human Immunodeficiency Virus (HIV) presenting with skin lesions or skin tears on the penis and scrotum?

Management of Genital Skin Lesions in HIV-Positive Patients

For any HIV-positive patient presenting with penile or scrotal skin lesions or tears, you must obtain tissue diagnosis through biopsy or aspiration before initiating treatment, as the differential diagnosis is broad and includes infectious, malignant, and inflammatory etiologies that require vastly different management approaches. 1

Immediate Diagnostic Workup

The following tests must be performed as an early diagnostic step:

• Biopsy or aspiration of lesions for histological examination, microbial staining, and culture (bacterial, fungal, viral) 1
• Darkfield examination or direct immunofluorescence for Treponema pallidum 1, 2
• HSV culture or antigen test from ulcer base or vesicular fluid 2
• Serologic test for syphilis (if ulcers present ≥7 days) 1, 2
• Testing for Chlamydia trachomatis and Neisseria gonorrhoeae 2
• Blood cultures if systemic symptoms present 1

Critical Differential Diagnosis Considerations

HIV-positive patients have a significantly broader differential than immunocompetent hosts. The lesions could represent:

Infectious Etiologies:

• Bacterial: Haemophilus ducreyi (chancroid), Staphylococcus aureus (botryomycosis), necrotizing fasciitis (Fournier's gangrene) 1, 3, 4
• Viral: HSV-1 or HSV-2 (genital herpes), HPV 1, 2
• Fungal: More common in immunosuppressed patients 1
• Parasitic: Consider in appropriate epidemiologic context 1

Non-Infectious Etiologies:

• Malignancy: Kaposi's sarcoma (HHV-8 associated), squamous cell carcinoma, cutaneous infiltration of underlying malignancy 1, 5
• Inflammatory: Drug eruption, Sweet syndrome, erythema multiforme, leukocytoclastic vasculitis, Behçet syndrome, Crohn disease, fixed drug eruption 1, 2

Critical pitfall: Up to 25% of genital ulcers have no laboratory-confirmed diagnosis even after complete evaluation, and up to 10% of patients with genital ulcers have co-infections (e.g., HSV with syphilis) 1, 2

Empiric Treatment Approach (While Awaiting Biopsy Results)

If you must treat before diagnostic results are available, base empiric therapy on:

1. Morphology of lesions (vesicular vs. ulcerative vs. nodular vs. necrotic)
2. CD4 count and degree of immunosuppression 1
3. Prior antimicrobial prophylaxis 1
4. Local antimicrobial resistance patterns 1

For Painful Genital Ulcers (Suspect Chancroid or HSV):

If clinical presentation suggests chancroid (painful ulcer with tender inguinal adenopathy):

• Azithromycin 1 g orally single dose OR
• Ceftriaxone 250 mg IM single dose OR
• Erythromycin base 500 mg orally four times daily for 7 days 1

HIV-specific consideration: HIV-positive patients may require longer courses and heal more slowly; erythromycin 7-day regimen is preferred if follow-up assured 1

If vesicular/ulcerative lesions suggest HSV:

• Acyclovir 400 mg orally 5 times daily for 10 days (or until clinical resolution) 1
• HIV-infected patients may require more aggressive therapy and have prolonged episodes 1

For Skin Tears Without Clear Infectious Etiology:

• Gentle wound care with non-adherent dressings
• Avoid topical antimicrobials until infection confirmed
• Reassess in 3-7 days for clinical improvement 1

Follow-Up and Treatment Failure

Re-examine patient 3-7 days after initiating therapy 1:

If no clinical improvement, consider:

1. Incorrect initial diagnosis 1
2. Co-infection with another pathogen 1
3. Antimicrobial resistance 1
4. Need for surgical debridement (especially if necrotizing infection) 1
5. Profound immunodeficiency that cannot be reversed 1

Healing timeline: Symptomatic improvement should occur within 3 days; objective improvement within 7 days. Large ulcers may require >2 weeks for complete healing, and uncircumcised men heal slower 1

Special HIV-Related Considerations

• Immunocompromised patients may have atypical presentations where localized lesions represent systemic or life-threatening infections 1
• Fungi and mycobacteria are more likely causes in severely immunosuppressed patients 1
• Kaposi's sarcoma should be considered, especially with nodular or pigmented lesions 5
• Fournier's gangrene can present rapidly and requires emergency surgical debridement 3

Never delay biopsy in favor of empiric treatment alone in HIV-positive patients, as misdiagnosis can lead to significant morbidity and mortality. 1