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Patients who develop Pneumocystis infection on a particular prophylactic regimen should be switched to a different one Prophylaxis against M avium complex infection should be given to patients whose CD4 counts fall below 75 100 cells/ mcL Clarithromycin (500 mg orally twice daily) and azithromycin (1200 mg orally weekly) have both been shown to decrease the incidence of disseminated disease by approximately 75%, with a low rate of breakthrough of resistant disease The latter regimen is generally preferred on the basis of ease of compliance and cost Adding rifabutin increases the toxicity of the regimen but does not significantly increase its efficacy and is therefore not recommended As sole therapy, rifabutin (300 mg orally daily) is less effective and more toxic than clarithromycin or azithromycin Clinicians should make certain that patients do not have active M tuberculosis infection by examination of a chest radiograph prior to starting rifabutin because of concern about the development of resistance to rifabutin with cross-resistance to rifampin Similarly, before initiating prophylaxis, clinicians should establish with a blood culture that the patient does not have disseminated M avium complex infection Common side effects of both azithromycin and clarithromycin are nausea and diarrhea Two common side effects with rifabutin are rash and hepatic dysfunction Rifabutin may induce hepatic enzymes, thereby decreasing the activity of some drugs metabolized by the liver Prophylaxis against M avium complex infection may be discontinued among patients whose CD4 counts go above 100 cells/mcL in response to HAART and whose plasma viral load has been optimally suppressed to < 50 75 copies/mL Prophylaxis against M tuberculosis infection isoniazid 300 mg daily plus pyridoxine 50 mg orally daily for 9 months to a year should be given to all HIV-infected patients with positive PPD reactions (defined for HIV-infected patients as > 5 mm of induration) Toxoplasmosis prophylaxis is desirable in patients with positive IgG toxoplasma serology and CD4 counts below 100 cells/mcL Trimethoprim-sulfamethoxazole (one doublestrength tablet daily) offers good protection against toxoplasmosis, as does a combination of pyrimethamine, 25 mg orally.

Callosities and corns are caused by pressure and friction due to faulty weight-bearing, orthopedic deformities, improperly fitting shoes, or neuropathies Tenderness on pressure and after-pain are the only symptoms The hyperkeratotic well-localized overgrowths always occur at pressure points Fingerprint lines are preserved over the surface (not so in warts) When the surface is shaved with a 15 blade, a glassy core is found (which differentiates them from plantar warts, which have multiple capillary bleeding points or black dots when pared) Treatment consists of correcting mechanical abnormalities that cause friction and pressure Callosities may be removed by careful paring of the callus after a warm water soak or with keratolytic agents as found in various brands of corn pads Plantar hyperkeratosis of the heels can be treated successfully by using 20% urea (Ureacin 20) or 12% lactic acid (Lac-Hydrin) or combinations nightly and a pumice stone after soaking in water Callosities on diabetic feet, especially in the setting of hyposensate neuropathy, can be a major problem and the value of early management to prevent complications is very important

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Menz HB Footwear characteristics and foot problems in older people Gerontology 2005 Sep Oct;51(5):346 51 [PMID: 16110238]

Pearly papule, erythematous patch > 6 mm, or nonhealing ulcer, in sun exposed areas (face, trunk, lower legs) (Plate 22) History of bleeding Fair-skinned person with a history of sun exposure (often intense, intermittent)

Basal cell carcinomas are the most common form of cancer They occur on sun-exposed skin in otherwise normal fairskinned individuals; ultraviolet light is the cause The most common presentation is a papule or nodule that may have a central scab or erosion Occasionally the nodules have stippled pigment (pigmented basal cell carcinoma) Intradermal nevi without pigment on the face of older white individuals may resemble basal cell carcinomas Basal cell carcinomas grow slowly, attaining a size of 1 2 cm or more in diameter, often after years of growth There is a waxy, pearly appearance, with telangiectatic vessels easily visible It is the pearly or translucent quality of these lesions that is most diagnostic, a feature best appreciated if the skin is stretched On the back and chest, basal cell carcinomas appear as reddish, somewhat shiny, scaly patches Clinicians should examine the skin routinely, looking for bumps, patches, and scabbed lesions When examining

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