What treatment approach is recommended for a 58-year-old male with HIV, Hepatitis B, and Hepatitis C presenting with pruritus and xerosis?

Management of Pruritus and Xerosis in HIV/Hepatitis B/Hepatitis C Coinfection

For this 58-year-old male with HIV, Hepatitis B, and Hepatitis C presenting with pruritus and dry skin, initiate aggressive emollient therapy combined with indomethacin 25 mg three times daily orally, while simultaneously investigating whether antiviral medications are contributing to symptoms. 1

Immediate Assessment Priorities

Determine if the patient is currently on antiviral therapy for HIV or hepatitis, as this directly impacts both the cause and management approach. 1

• If on interferon/ribavirin-based hepatitis C treatment, xerosis and pruritus occur in 30% of cases and represent expected medication side effects rather than treatment-stopping events 1
• If on protease inhibitor triple therapy (telaprevir), skin problems occur in 54% of cases, with over 90% being eczematous dermatitis 1
• HIV-associated pruritus correlates directly with viral load and can be associated with eosinophilia 1

Rule out severe cutaneous adverse reactions (SCAR) immediately by examining for mucosal involvement, blistering, skin detachment, or involvement of >50% body surface area, which would require hospitalization and immediate drug discontinuation. 1, 2

Specific Etiologic Considerations

Xerosis is the most common cause of pruritus in HIV patients and should be addressed first with aggressive moisturization. 1, 3, 4

• Xerosis occurs in HIV due to immune dysregulation and is exacerbated by antiviral medications 3, 5
• Pruritus from cholestasis is associated with hepatitis A, B, C, and E infections 1
• Drug-induced pruritus from antiretroviral therapy or hepatitis medications must be distinguished from disease-related symptoms 1, 3

Always exclude scabies, which presents with severe pruritus and minimal skin signs, particularly in HIV patients. 1

First-Line Treatment Algorithm

Step 1: Topical Management

• Apply emollients/moisturizers liberally and frequently to all affected areas, as this addresses the xerosis component present in both HIV and hepatitis C treatment 1, 6
• Use topical corticosteroids for eczematous areas, particularly in skin folds where ribavirin-associated dermatitis commonly occurs 1

Step 2: Systemic Therapy

• Prescribe indomethacin 25 mg three times daily orally, which proved more effective than sedating antihistamines for HIV-associated pruritus in case-control studies 1, 2
• Monitor for gastric intolerance, which was observed in several patients in clinical studies 1
• Non-sedating antihistamines (cetirizine 10 mg daily or loratadine 10 mg daily) can be added but are less effective than indomethacin for HIV-related pruritus 2

Step 3: Dermatology Consultation Timing

• For Grade 1 (localized) or Grade 2 (diffuse <50% body surface) eczematous dermatitis in patients on hepatitis C treatment, dermatology consultation is recommended but not urgent 1
• Regular dermatology follow-up throughout hepatitis C treatment course is appropriate, as symptoms can be managed while continuing antiviral therapy in the majority of cases 1

Critical Management Decisions for Antiviral Therapy

If on Hepatitis C Treatment (Interferon/Ribavirin/Protease Inhibitors):

Do NOT discontinue treatment for Grade 1 or 2 dermatological side effects, as these can be managed symptomatically and treatment can continue in the large majority of cases. 1, 6

• Grade 1 (localized) or Grade 2 (diffuse <50% body surface): Continue all medications with symptomatic management 1
• Grade 3 (>50% body surface involvement): Stop protease inhibitor immediately; discontinue ribavirin if no improvement after 1 week 1
• Suspected SCAR/DRESS/Stevens-Johnson syndrome: Stop all medications immediately and hospitalize 1, 6

If on HIV Antiretroviral Therapy:

Continue current ART regimen unless there is evidence of severe cutaneous adverse reaction with systemic involvement. 2

• HIV-associated xerosis and pruritus are disease manifestations, not necessarily drug reactions 3, 4, 5
• Antiretroviral hypersensitivity typically occurs within 1-6 weeks of starting therapy, not during stable treatment 2

Laboratory Workup

Obtain the following baseline studies to assess for systemic involvement and guide management:

• Complete blood count with differential (assess for eosinophilia associated with HIV pruritus) 1, 2
• Comprehensive metabolic panel including liver function tests (evaluate cholestatic component from hepatitis) 1, 2
• HIV viral load (degree of pruritus correlates with viral load) 1, 5
• Hepatitis B and C viral loads (assess disease activity) 7

Alternative Therapeutic Options

If standard therapy fails after 2 weeks, consider:

• Phototherapy, which is safe and effective for HIV-associated dermatoses and idiopathic pruritus 1, 3, 4
• Hypnosis, which significantly reduced HIV-related itch in case series 1
• Psychosocial and behavioral interventions including relaxation techniques and habit reversal training 1

Common Pitfalls to Avoid

Do not label as "idiopathic HIV pruritus" until all specific causes are excluded, including xerosis, seborrheic dermatitis, eczema, drug reactions, scabies, and systemic causes. 3, 4

Do not discontinue hepatitis C treatment prematurely for manageable dermatological side effects, as xerosis and pruritus resolve progressively once treatment is stopped but should not prevent treatment completion. 1

Do not overlook the temporal relationship between symptom onset and medication initiation, as this distinguishes drug-induced from disease-related pruritus. 2, 3

Do not use sedating antihistamines as first-line for HIV-associated pruritus, as indomethacin has superior efficacy. 1

Monitoring and Follow-Up

Monitor weekly until symptoms stabilize, with instructions to return immediately if:

• Fever develops 2
• Mucosal involvement appears 1, 2
• Blistering occurs 1, 2
• Body surface involvement exceeds 50% 1
• Systemic symptoms emerge 2

If no improvement after 2 weeks of appropriate treatment, refer to dermatology for specialized management. 2