Background: The global mortality from HIV and the cutaneous burden of infective, inflammatory and malignant diseases in the setting of AIDS have significantly declined following the advent of highly active antiretroviral therapy. Regrettably, there has been a contemporaneous escalation in the incidence of adverse cutaneous drug reactions (ACDR), with studies attesting that HIV-positive individuals are a hundred times more susceptible to drug reactions than the general population, and advanced immunodeficiency portending an even greater risk. Several variables are accountable for this amplified risk in HIV. Summary: Adverse reactions to trimethoprim-sulfamethoxazole are the most common, increasing from approximately 2–8% in the general population over to 43% amongst HIV-positive individuals to approximately 69% in subjects with AIDS. Antituberculosis drugs and antiretrovirals are also well-known instigators of ACDR. Cutaneous reactions range from mild morbilliform eruptions to severe, life-threatening manifestations in the form of Stevens-Johnson syndrome/toxic epidermal necrolysis. Histological features vary from vacuolar interface changes to full-thickness epidermal necrosis with subepidermal blister formation. A precipitous diagnosis of the ACDR, clinically and histologically if necessary, together with the isolation of the causative drug is critical. The identification process, however, is often complex and multifaceted due to polypharmacy and inconclusive data on which drugs are the most likely offending agents, especially against the background of tuberculosis co-infection. Key Messages: Whilst milder cutaneous reactions are treated symptomatically, severe reactions mandate immediate treatment discontinuation without rechallenge. Further studies are required to establish safe rechallenge guidelines in resource-limited settings with a high HIV and tuberculosis prevalence.

To the Editor: Skin diseases may have a severe effect on the quality of life (QOL) of affected individuals, [1,2] but their impact has rarely been investigated in the developing world. In South Africa, there have been no studies conducted on patients with sebor rhoeic dermatitis (SD). A crosssectional study was undertaken in the ILembe District, KwaZuluNatal Province, assessing the QOL of patients presenting with SD, correlating clinical severity and demographic parameters. Fortyfive consenting participants, with a clinical diagnosis of SD, were invited to participate. QOL was assessed using the Dermatology Life Quality Index (DLQI). [3] The severity of the condition was assessed by a dermatologist and graded at individual sites for erythema, thickness, scaling and pruritus on a threepoint scale. Body surface area involvement was calculated using the rule of nines and the sites of involvement were recorded. A detailed demographic profile was completed for each patient (Table 1). The median severity score was 24 and the median DLQI score was 17, which equates to a very large effect on the QOL. [3] The QOL varied depending on sex, educational level, ethnic origin, home language, marital status, residence, HIV status and site of involvement. Female patients were more negatively influenced by the disease, confirming the findings in three other studies. [46] Patients with no formal schooling were more adversely affected. The way the questions were interpreted and the perception of disability may explain the differences in DLQI between the groups. Visible body areas and groin involvement had a greater impact on a patient's QOL.

A 12-year-old African female presented with a 6-year history of relatively asymptomatic umbilical lesions. On clinical examination, the lesions were papillomatous, violaceous nodules and translucent papules with a serosanguineous discharge. The lesions emanated from the umbilicus and extended peri-umbilically. Histopathology confirmed a lymphangioma and MRI and CT imaging revealed multiple intra-abdominal lymphatic malformations. The patient was referred to plastic surgery for further management. Due to the extent of involvement, surgical resection was an option but currently the therapeutic approach is sclerotherapy with bleomycin.

An HIV-positive female on antiretroviral therapy (ART) presented with an annular eruption diagnosed as a drug reaction based on histology of a lichenoid dermatitis. She responded to oral steroid therapy and discontinuation, but progressed to develop features in keeping with cutaneous lupus. Although the antinuclear factor remained negative, her low serum complement levels, histology, and clinical features pointed to a diagnosis of subacute lupus in the setting of HIV infection. She responded well to antimalarial therapy and recommenced ART.