Can I Catch Hiv From A Person With Dry Cracked Skin?

AIDS. Writer manuscript; available in PMC 2011 Sep 3.

Published in terminal edited grade as:

PMCID: PMC3166536

NIHMSID: NIHMS319910

Prevalence and factors associated with dry peel in HIV infection: the FRAM study

Daniel Lee

^aDepartment of Medicine, University of California, San Diego, California, USA

Constance A. Benson

^aDepartment of Medicine, University of California, San Diego, California, USA

Cora East. Lewis

^bDivision of Preventive Medicine, Academy of Alabama, Birmingham, Alabama, Usa

Carl Grunfeld

^cDepartment of Medicine, Academy of California, San Francisco, California, USA

^dMetabolism Section, San Francisco Veterans Affairs Medical Middle, San Francisco, California, USA

Rebecca Scherzer

^dMetabolism Section, San Francisco Veterans Affairs Medical Center, San Francisco, California, United states

Abstract

Objective

Complaints of dry pare in HIV-infected individuals were reported after the appearance of HAART. The objective of the written report was to evaluate the prevalence of dry pare and associated factors in HIV-infected and command subjects.

Methods

A total of 1026 HIV-infected subjects and 274 controls [from the Coronary Artery Run a risk Development in Young Adults (CARDIA) study, a population-based study of cardiovascular risk assessment] in the Study of Fat Redistribution and Metabolic Modify in HIV infection (FRAM) had skin assessed past self-report and examination. Multivariable logistic regression identified factors associated with dry skin.

Results

Cocky-reported dry skin was more than prevalent in HIV-infected subjects than controls. In multivariable assay, HIV infection was associated with cocky-reported dry skin. In HIV-infected men, electric current indinavir use, CD4 cell count less than 200 cells/μl and recent opportunistic infections were associated with dry out skin. Indinavir employ had an elevated hazard in men with CD4 jail cell counts of 200 cells/μl or greater but non with CD4 prison cell counts less than 200 cells/μl. In HIV-infected women, a CD4 cell count less than 200 cells/μl was associated with dry skin; indinavir use did non reach statistical significance but, as in men, indinavir apply had an elevated risk in those with college CD4 cell counts than in those with CD4 cell counts less than 200 cells/μl.

Conclusion

Dry skin is more mutual in HIV-infected individuals than controls. In HIV-infected individuals, low CD4 cell counts and indinavir utilise in those with higher CD4 cell counts are associated with dry skin.

Keywords: complexity, dermatology, opportunistic infection, protease inhibitors, retinoid

Introduction

HIV infection is associated with a number of common dermatological disorders [1,ii]. As many as 30% of HIV-infected individuals reported dry pare or ichthyosis in the pre-HAART era [3], whereas more recent HAART-era studies have reported the prevalence of dry skin to range from nineteen to 28% [iv–6]. Although some researchers take reported a refuse in infectious dermatological conditions in the HAART era, probably as a outcome of a low incidence of opportunistic infections (OI) [6], complaints of dry pare and other non-infectious conditions persist.

Nosotros evaluated the prevalence of dry skin in the Fatty Redistribution and Metabolic Change in HIV infection (FRAM) cohort, a representative sample of HIV-infected subjects and controls in the United States using both self-assessed and examiner-rated measures of skin dryness. To our knowledge, this is the outset paper to compare the prevalence of dry skin in a big national study among HIV-infected United states adults with a control population. In addition, nosotros examined predictors of self-assessed dry skin amidst HIV-infected participants.

Methods

Written report population

The FRAM Study enrolled 1183 HIV-infected and 297 controls between 2000 and 2002. FRAM was designed to evaluate the prevalence and correlates of changes in fat distribution, insulin resistance, and dyslipidemia in a representative sample of HIV-infected subjects and HIV-seronegative controls in the United States. The methods accept been described in particular previously [7]. HIV-infected subjects were recruited from xvi HIV or communicable diseases clinics or cohorts from June 2000 to Septemebr 2002. Control subjects were recruited from 2 centers from the Coronary Artery Risk Development in Young Adults (CARDIA) report [viii]. CARDIA participants were originally recruited in 1985–1986 as a population-based sample of healthy 18–thirty-year-one-time Caucasian and African-American women and men to study cardiovascular adventure factors longitudinally. The protocol was approved past institutional review boards at all sites.

Dry skin cess

Dry skin was assessed in 1172 HIV-infected and 297 control men and women. Self-reported questionnaires were administered to appraise for changes in skin over the past 5 years (the fourth dimension since the introduction of HAART) with bidirectional scales including dry, no modify and moist. Clinicians also performed an overall cess of pare (current) using a like bidirectional calibration (dry, normal, moist). Results were dichotomized for analysis every bit dry compared with unchanged or normal. Subjects with moist skin were uncommon (n =xxx or 2% of self-report; and n =133 or ix% of examinations) and were excluded (27% of those excluded were controls and 73% were HIV infected), leaving a total of 1026 HIV infected and 274 controls in the analysis. Those excluded as a result of cocky-reported moist skin were similar in about demographic and clinical characteristics, except they were somewhat more than probable to be African-American (57 versus 41%, P = 0.048), to be physically inactive (63 versus 41%, P = 0.011), and to have current CD4 cell counts beneath 200 cells/μl (42 versus 23%, P = 0.047).

Other measurements

Age, sex, race, medical history, and adventure factors for HIV were determined by self-report, and alcohol, tobacco, and illicit drug use were assessed by standardized questionnaire. A single laboratory measured claret CD4 lymphocyte count and percent, and plasma HIV RNA in HIV-infected participants (Covance, Indianapolis, Indiana, U.s.a.). Trained research assembly performed standardized medical chart abstraction of medications and medical history at HIV sites.

Statistical assay

Analyses that compared HIV-infected subjects with controls excluded HIV-infected individuals with recent OI, and were restricted to those between the ages of 33 and 45 years (Due north =551), considering the control population did not include subjects outside this historic period range. Characteristics of HIV-infected participants and controls were compared and tested for statistical significance using the Mann–Whitney U-test for continuous variables, and Fisher'southward verbal test for categorical variables.

Multivariable logistic regression analysis was used to investigate whether there was an independent association of HIV infection compared with controls in self-reported dry out skin. Dry skin past examination was not farther investigated in multivariable analysis because information technology was felt that factors such as the use of skin moisturizers and cosmetics could confound the rating, leading to a less reliable assessment of dry skin. We observed a statistically meaning HIV past sex interaction (P = 0.008), so analysis was stratified past sex. Potential predictors in the combined HIV and control analysis included demographic information (sex, historic period, ethnicity), level of physical activity (quartiled), current smoking status, illicit drug utilize (electric current or e'er use of marijuana, speed, crack, cocaine, combination use of scissure and cocaine), less than acceptable food intake, torso mass index (BMI), homeless status (ever versus never), total number of alcohol drinks per week in the past year, menopause status (for women), and season (winter, spring, summer, or autumn).

Multivariable logistic regression models were built using stepwise regression, with P = 0.05 for entry and retention and with age (modeled per decade), ethnicity, and HIV status forced to be included in every model. We performed this past evaluating possible models one by one, rather than with an automated stepwise procedure, in lodge to avoid the exclusion of observations that had missing data only on unselected candidate variables. To account for possible differences between geographical sites, likelihood ratio testing was used to make up one's mind whether a random site effect should exist added to the model. For each model, tests were conducted for goodness of fit using the Hosmer–Lemeshow test.

A 2nd multivariable regression analysis was performed only amid HIV-infected subjects to determine the factors independently predictive of dry peel amid HIV-infected individuals. In add-on to the predictors listed above, these models included HIV-RNA level (detectable versus undetectable) and CD4 cell count (<200 versus ≥ 200 cells/μl) at the time of the study visit. Also tested for inclusion in the model were hepatitis C status (hepatitis C virus RNA >615), recent OI status, AIDS by CD4 jail cell count or OI, HIV duration, days since final OI, and HIV risk factors. In multivariable models decision-making for the to a higher place factors, we evaluated the current employ of each individual antiretroviral drug and antiretroviral class: nucleoside reverse transcriptase inhibitor, non-nucleoside reverse transcriptase inhibitor, protease inhibitor (PI), and HAART every bit previously defined [9]. The current use of each antiretroviral drug, antiretroviral class, and HAART was added to the adjusted model in a forward stepwise way.

All analyses were conducted using the SAS arrangement, version 9.one (SAS Institute, Inc., Cary, N Carolina, USA).

Results

The demographics and clinical characteristics of the FRAM participants have been described in detail previously [vii]. The demographics of the slightly smaller subset that had dry skin ratings by self-report or exam are shown in Table 1.

Tabular array i

Demographics and clinical characteristics of HIV-positive subjects versus controls

	HIV-positive (age-restricted)	Control	P value	HIV-positive (all)
n	551	274		1026
Sex
Female	31%	49%	<0.0001	31%
Age (years)
Median	40.0	xl.5	0.025	42.0
IQR	37.0–43.0	37.0–43.0		37.0–48.0
Ethnicity
Caucasian	l%	51%	0.095	49%
African-American	37%	49%		39%
Hispanic	11%			x%
Other	i%			3%
BMI
Median	24.5	27.two	<0.0001	24.vi
IQR	22.0–27.8	23.8–31.5		22.ane–27.8
Inadequate food intake	26%	13%	<0.0001	25%
Ever homeless	eight%		NA	viii%
Alcohol
None	28%	19%	0.002	29%
<1/calendar week	32%	27%		30%
1–7/week	28%	37%		27%
>vii/calendar week	12%	17%		xiii%
Current smoker	47%	17%	<0.0001	43%
Physical activity
1st Quartile	42%	24%	<0.0001	45%
2nd Quartile	20%	25%		21%
third Quartile	21%	25%		18%
4th Quartile	18%	26%		16%
Menopausal (% of women)	5%	five%	>0.99	23%
Current fissure	4%	i%	0.056	4%
Current CD4 cell count (cells/μl)
Median	368.0			350.0
IQR	217.0–542.0			215.0–541.0
CD4 cells <200	23%			23%
HIV RNA (1000 copies/ml)
Median	0.4			0.4
IQR	0.four–14.v			0.4–12.5
Undetectable HIV RNA	fifty%			51%
AIDS by CD4 cell count/OI	73%			72%
Recent OI	twoscore%			42%
Electric current HAART use	80%			77%
Duration (years)
Median	2.eight			2.eight
IQR	i.v–four.3			1.4–4.4
Current PI use	57%			55%
Duration (years)
Median	2.nine			2.nine
IQR	1.v–4.2			1.3–4.iii
Current indinavir employ	15%			16%
Duration (years)
Median	ii.8			ii.viii
IQR	one.v–iv.5			one.four–four.four

Dry skin in HIV-infected participants versus controls

The prevalence of self-reported dry skin was higher in HIV-infected subjects compared with controls in both men (42.1 versus 9.9%, P < 0.0001) and women (51.5 versus 31.vi%, P = 0.001, Fig. 1), with similar results seen for dry out pare by examination. The overall prevalence of dry out skin was greater in women than in men. No statistically pregnant associations were found between ethnicity and dry pare. Stratification by ethnicity revealed the same patterns in African-Americans and Caucasians (data not shown).

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Prevalence of dry skin in HIV-infected and control participants^a

^aAge-restricted analysis. Self-report excludes subjects with moist skin by self-report, Exam excludes subjects with moist skin by exam. HIV-infected (greyness bars); control subjects (open bars). CI, Confidence interval.

Being HIV infected was associated with higher odds of reporting dry peel (Tabular array 2). In multivariable analysis, being HIV infected remained associated with higher odds of self-reported dry skin, with larger differences seen in men [odds ratio (OR) 5.7, 95% confidence interval (CI) 3.1–ten.4, P <0.0001] than in women (OR 2.2, 95% CI 1.32–three.6, P = 0.002) probably caused by the higher prevalence of reported dry peel in control women.

Table 2

Multivariable analysis^a of self-reported dry skin in HIV-positive subjects versus controls

	Men		Women
	OR (95% CI)	P value	OR (95% CI)	P value
HIV versus control
Unadjusted	6.vi (3.7, xi.nine)	<0.0001	two.three (1.43, iii.7)	0.001
Adjusted^b	5.7 (3.1, 10.iv)	<0.0001	two.ii (1.32, three.half-dozen)	0.002

Factors associated with dry skin in HIV infection

As a result of the greater prevalence of dry skin in women and considering the HIV effect was larger in men than in women (P = 0.008, examination for HIV by sex interaction), nosotros elected to stratify the multivariable assay of factors associated with dry skin in HIV infection by sex.

A low CD4 cell count was associated with increased study of dry skin in both HIV-infected men (<200 versus >200 cells/μl, OR ane.58, 95% CI 1.06–2.4, P = 0.026) and women (<200 versus ≥ 200 cells/μl, OR 2.0, 95% CI 1.11–3.6, P = 0.021; Table 3). In HIV-infected men, current indinavir use was associated with increased odds of dry skin (OR ane.96, 95% CI one.30–3.0, P = 0.001). Although the indinavir by CD4 prison cell count interaction did not accomplish statistical significance (P = 0.12), we found that the association betwixt indinavir employ and dry skin was stronger in men with a highest CD4 cell count (OR ii.3, 95% CI 1.45–iii.6, P < 0.001) compared with those with CD4 cell counts less than 200 cells/μl (OR ane.02, 95% CI 0.40–2.6, P = 0.96). In women, indinavir utilise did not reach statistical significance (OR 1.12, 95% CI 0.57–2.2, P = 0.74) but, equally in men, higher odds of dry out skin on indinavir were seen in those with higher CD4 cell counts (OR 1.41, 95% CI 0.64–three.1, P = 0.39) than in those with CD4 cell counts less than 200 cells/μl (OR 0.52, 95% CI 0.12–2.ii, P = 0.37). The association of indinavir with dry skin was stronger than any other antiretroviral medication. We examined other PI (every bit well equally PI as a grade) and plant that their effects trended in the same direction as indinavir, simply merely indinavir reached statistical significance.

Table 3

Multivariable analysis^a of factors associated with self-reported dry out skin in HIV-positive subjects

	Men		Women
	OR (95% CI)	P value	OR (95% CI)	P value
Factors
African-American versus Caucasian	0.94 (0.66, ane.36)	0.76	0.98 (0.58, ane.63)	0.92
Hispanic versus Caucasian	1.07 (0.62, ane.82)	0.81	i.16 (0.46, 2.96)	0.75
Other versus Caucasian	1.85 (0.68, 5.04)	0.23	ii.07 (0.43, 9.95)	0.36
Age (per decade)	1.05 (0.88, 1.25)	0.61	1.23 (0.92, ane.64)	0.17
HIV-related
Current CD4 cell count (<200 versus ≥ 200 cells/μl)	1.58 (1.06, ii.36)	0.026	2.00 (ane.eleven, iii.61)	0.021
Electric current HIV viral load (<400 versus ≥ 400 cells/μl)	0.82 (0.58, 1.16)	0.26	1.50 (0.91, ii.48)	0.110
Recent OI (<100 versus ≥ 100 days)	one.80 (i.30, 2.48)	0.0004	1.47 (0.91, 2.36)	0.113
Electric current utilise of indinavir	1.96 (1.30, 2.95)	0.001	1.12 (0.57, 2.23)	0.74
CD4 cell count ≥ cells/μl	2.29 (1.45, iii.61)	0.0003	1.41 (0.64, 3.10)	0.39
CD4 prison cell count <200 cells/μl	1.02 (0.41, 2.55)	0.96	0.52 (0.12, 2.21)	0.37
Lifestyle
Food: inadequate versus adequate	1.80 (1.21, 2.69)	0.004	1.40 (0.86, 2.29)	0.18
Current crack	0.79 (0.31, ii.03)	0.63	0.30 (0.ten, 0.91)	0.034

Lacking acceptable food intake was also associated with the report of dry out pare in HIV-infected men (OR ane.80, 95% CI 1.21–two.7, P = 0.004). A similar tendency for inadequate food intake to be associated with dry skin appeared in HIV-infected women (OR i.40, 95% CI 0.86–2.3, P = 0.18). BMI did non appear to be associated with dry out pare in either men or women. Another factor associated with dry skin was recent OI in men (inside 100 days versus 100+ days ago or never, OR 1.80, 95% CI i.xxx–2.5, P <0.001). In women, electric current cleft cocaine use was associated with lower odds of dry skin (OR 0.30, 95% CI 0.10–0.91, P = 0.034).

Subjects with acne and atopic diseases may have a higher risk of developing dry skin, and therefore we analysed their prevalence and association with dry pare. Approximately eighteen% of the HIV-infected subjects were found to have acne or an atopic disease, of whom 52% of women and 39% of men reported dry peel, a prevalence similar to that seen in the full accomplice. In both unadjusted and adjusted models, acne/atopic illness status was institute to have little association with dry skin (data not shown).

Give-and-take

Using the FRAM cohort, we establish a higher prevalence of dry peel by both self-report and examination in HIV-infected men and women compared with controls. After multivariable aligning, we found that low CD4 jail cell count, indinavir use, recent OI condition, and inadequate food intake were associated with higher odds of self-reported dry out pare in HIV-infected men. Low CD4 cell count was besides associated with dry pare in HIV-infected women, whereas current fissure cocaine use was associated with lower odds of dry skin.

Our finding of an clan between the current apply of indinavir and dry skin is supported by other smaller studies that accept described PI-related severe dry skin. A prospective study of 332 HIV-infected patients found PI-related desquamative cheilitis and skin dryness in xv patients on indinavir (20% of patients receiving indinavir) and one patient on ritonavir [10]. They reported resolution of the dermatological disorders upon discontinuation of the medication. Other indinavir-related dermatological issues have been reported [xi–17].

A proposed mechanism for the induction of dry out pare by PI such every bit indinavir is the displacement of vitamin A from cytoplasmic retinoic acid bounden protein, enhancing its interaction with the retinoic acid receptor [18]. Other data likewise back up the concept that PI enhance the authorisation of retinoids [xix]. To date, plasma retinol levels have not been found to exist higher in individuals taking PI, although retinal dehydrogenase activity was college in a minor grouping of HIV-infected individuals administered PI, which could increase retinoic acid concentrations [20]. A contempo in-vitro investigation found that v HIV PI (amprenavir, indinavir, nelfinavir, ritonavir, and saquinavir) inhibited cytochrome P450 3A isoforms to varying degrees [21]. This inhibition may alter or disrupt the normal metabolism of retinoic acid, because cytochrome P450 3A enzymes are known to mediate the synthesis of retinoic acid [22].

Our finding that a low CD4 cell count is associated with higher odds of dry skin is likewise supported by previous reports before the common use of HAART. One report plant that cutaneous findings more than than doubled at CD4 prison cell counts less than 100 cells/μl [23]. A second report establish college rates of xerosis and other dermatological issues in those with CD4 jail cell counts below 200 cells/μl [24]. Some other study plant a mean CD4 cell count of only 179 cells/μl among HIV-infected patientswith xerosis [4]. Our findings thus support the concept that even in the era of constructive HAART, dry skin is associated with a low CD4 prison cell count.

The association between recent OI and dermatological problems is also supported by findings in the literature. For example, many viral, bacterial, and fungal infections can crusade OI in HIV-infected patients and are associated with cutaneous manifestations [16]. The clan of recent OI with dry skin, combined with the clan with low CD4 jail cell count, emphasize that avant-garde HIV disease is associated with dry out skin.

We besides found a potent clan betwixt the study of inadequate food intake and dry skin in HIV-infected men. A similar finding is seen in patients with anorexia nervosa, in whom low BMI is associated with xerosis, which oftentimes resolves when balanced diet or higher body weight are restored [25]. Nosotros found that those with and without adequate food intake had similar BMI (information not shown), and BMI itself showed no credible association with dry out peel in adjusted or unadjusted models. Information technology is possible that poorer diet per se may be associated with dry skin.

This report has several limitations. Virtually importantly, the cross-sectional pattern limits the power to determine causality. For example, we cannot determine whether having a recent OI causes dry skin, whether treatment regimens for OI cause cutaneous reactions, or whether the dry skin occurred before or independent of the OI. Individuals with acne or atopic disease may accept a college risk of developing dry skin, mayhap biasing the results. The prevalence of dry skin in such subjects was similar to the full cohort, nevertheless, so inclusion in our analysis of such subjects should not have biased the results. Furthermore, acne/atopic disease condition showed trivial clan with dry peel in adjusted and unadjusted models. Lifestyle variables such every bit nutrient intake and crevice cocaine use could too impact dry skin, although information technology may have existed already. Another limitation is the utilise of cocky-report, which may take problems of perception. Control men reported much less dry out skin compared with command women and HIV-infected men and women. Information technology is possible that control men do not notice their skin as much equally HIV-infected men. Although past studies have establish an association of other PI in addition to indinavir with dry skin, only indinavir reached statistical significance in our assay. As the other PI showed a weak trend in the same direction as indinavir, nosotros cannot rule out a class effect. Finally, there may take been incomplete or inadequate command for factors that confound the association of HIV infection and dry skin. It is likely that HIV infection, and in particular advanced HIV disease, is the primary predictor of dry out peel. To address the concerns of causality, a prospective study evaluating the evolution of dry pare in an HIV-infected population may be helpful.

Some factors associated with dry out peel, as identified in HIV-infected men, did not accomplish statistical significance in women. The results seen in women oft trended in the same management every bit for men, merely were of smaller magnitude.

In summary, dry out skin is more mutual in HIV-infected individuals compared with controls. In HIV-infected men and women, depression CD4 cell count is associated with dry skin. In HIV-infected men, indinavir utilise, recent OI and inadequate food intake were also found to exist associated with dry pare. Future enquiry may better elucidate the relationship of these factors to dry out skin in the setting of chronic HIV infection.

Acknowledgments

Sites and investigators: Academy Hospitals of Cleveland (Barbara Gripshover, Physician); Tufts University (Abby Shevitz, Doctor and Christine Wanke, Doc); Stanford University (Andrew Zolopa, Md and Lisa Gooze, MD); University of Alabama at Birmingham (Michael Saag, MD and Barbara Smith, PhD); John Hopkins University (Joseph Cofrancesco and Adrian Dobs); University of Colorado Heath Sciences Center (Constance Benson, Doc and Lisa Kosmiski, Md); University of Northward Carolina at Chapel Loma (Charles van der Horst, MD); Academy of California at San Diego (Due west. Christopher Mathews, MD and Daniel Lee, MD); Washington Academy (William Powderly, Physician and Kevin Yarasheski, PhD); VA Medical Center, Atlanta (David Rimland, MD); Academy of California at Los Angeles (Judith Currier, Medico and Matthew Leibowitz, Doc); VA Medical Center, New York (Michael Simberkoff, Doc and Juan Bandres, Doc); VA Medical Center, Washington DC (Cynthia Gibert, Medico and Fred Gordin, Md); St Luke'due south-Roosevelt Hospital Eye (Donald Kotler, Medico and Ellen Engelson, PhD); Academy of California at San Francisco (Morris Schambelan, Physician and Kathleen Mulligan, PhD); Indiana Academy (Michael Dube, Physician); Kaiser Permanente, Oakland (Stephen Sidney, MD); University of Alabama at Birmingham (Cora E. Lewis, MD).

Information Coordinating Center: University of Alabama, Birmingham (O. Dale Williams, PhD, Heather McCreath, PhD, Charles Katholi, PhD, George Howard, PhD, Tekeda Ferguson, and Anthony Goudie).

Epitome Reading Center: St Luke's-Roosevelt Infirmary Heart (Steven Heymsfield, MD, Jack Wang, MS and Mark Punyanitya).

Part of the Main Investigator: University of California, San Francisco, Veterans Affairs Medical Centre and the Northern California Plant for Research and Development (Carl Grunfeld, MD, PhD, Phyllis Tien, MD, Peter Bacchetti, PhD, Dennis Osmond, PhD, Andrew Avins, Dr., Michael Shlipak, MD, Rebecca Scherzer, PhD, Erin Madden, MPH, Mae Pang, RN, MSN, Heather Southwell, MS, RD, and Yong Kyoo Chang, MS).

Sponsorship: This study was supported past National Institutes of Health (NIH) grants RO1-DK57508, HL74814, and HL53359, and NIH GCRC grants MO1-RR00036, RR00051, RR00052, RR00054, RR00083, RR0636, and RR00865. The funding agency played no function in the collection or assay of the data.

Footnotes

Conflicts of involvement: None.

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