What is the best approach to manage dyschromatosis in a patient with Human Immunodeficiency Virus (HIV) infection?

Management of Dyschromatosis in HIV-Infected Patients

Dyschromatosis in HIV-infected patients is primarily managed by initiating or optimizing antiretroviral therapy (ART), as pigmentary changes are often manifestations of HIV disease itself, opportunistic infections, or drug reactions that improve with immune reconstitution. 1, 2

Initial Diagnostic Approach

Determine the Underlying Cause

The first step is distinguishing between HIV-related pigmentary changes, drug-induced hyperpigmentation, and infectious etiologies:

• HIV disease itself can cause diffuse hyperpigmentation, particularly in advanced immunosuppression, affecting nails, oral mucosa, and skin even without antiretroviral exposure 3, 4
• Antiretroviral medications are common culprits, with zidovudine being the most notorious for causing longitudinal melanonychia and mucocutaneous pigmentation 2, 3
• Opportunistic infections may present with atypical pigmentary changes due to immunosuppression 4
• Drug reactions occur more frequently in HIV-positive patients due to immune dysregulation, altered drug metabolism, and polypharmacy 5

Essential Baseline Evaluation

Obtain the following at presentation:

• CD4 count and HIV viral load to assess degree of immunosuppression and need for ART initiation or modification 1, 6
• Complete medication history including all antiretrovirals, prophylactic agents, and over-the-counter medications 2, 5
• Skin biopsy with histopathology when the diagnosis is unclear or to rule out infectious causes 3, 7
• Fungal and bacterial cultures if infection is suspected 4

Primary Management Strategy

Initiate or Optimize Antiretroviral Therapy

ART should be started immediately in all HIV-infected patients with dyschromatosis, regardless of CD4 count, as immune reconstitution often improves pigmentary disorders. 1

• Select a regimen with two nucleoside reverse transcriptase inhibitors (NRTIs) plus either a protease inhibitor or integrase inhibitor 1
• Avoid or discontinue zidovudine if it is the suspected causative agent of pigmentation, as this is the most common antiretroviral associated with hyperpigmentation 2, 3
• Monitor viral load at 4 weeks after ART initiation, then every 3-4 months to assess virologic response 1, 6
• CD4 counts should be monitored every 3-4 months during the first year of treatment 6

Drug-Induced Dyschromatosis Management

If antiretroviral medications are causing pigmentary changes:

• Do not discontinue HAART unless frank drug allergy is suspected, as the benefits of viral suppression outweigh cosmetic concerns 5
• Consider switching the offending agent to an alternative within the same class if pigmentation is severe or psychologically distressing 2
• Newer antiretrovirals (tipranavir, darunavir, etravirine, raltegravir, maraviroc) have varying cutaneous side effect profiles that may be preferable 2

Monitoring and Follow-Up

Regular Assessment Schedule

• Clinical evaluation every 3-4 months during the first year of ART to monitor both HIV disease and pigmentary changes 6
• Viral load and CD4 count every 3-4 months initially, then every 6 months once stable for over a year with sustained viral suppression 6
• Document progression or improvement of pigmentary changes with clinical photography 7

Long-Term Stable Patients

For patients with sustained viral suppression and stable CD4 counts >250 cells/μL for over a year:

• Reduce monitoring frequency to every 6 months 6
• CD4 monitoring may be discontinued if consistently above threshold for over 5 years 6

Common Pitfalls and Caveats

The most critical error is attributing all pigmentary changes to benign drug effects without ruling out serious underlying conditions such as opportunistic infections or systemic disease 5, 4:

• Always perform a thorough skin examination including hair, nails, and mucous membranes 5
• Consider systemic causes (chronic renal failure, liver disease, lymphoma) if no dermatologic diagnosis is established 5
• Remember that HIV-associated skin diseases present atypically due to immunosuppression, particularly in pigmented skin types 4
• Some dermatoses may temporarily flare when HAART is initiated due to immune reconstitution 5

Never delay ART initiation due to concerns about pigmentary side effects, as untreated HIV disease itself causes pigmentation and the benefits of viral suppression are paramount 1, 5