This article is more than 5 years old. Information may no longer be current.
Cutaneous manifestations of HIV
At the beginning of the AIDS epidemic, Kaposi’s sarcoma was identified as a major sign of HIV infection. In the movie Philadelphia, Tom Hanks’ character was thin, drawn, with dark lesions that he tried to hide. HIV and Kaposi’s sarcoma became synonymous with death, becoming known as the “gay man’s cancer.” Throughout the first years of the AIDS era, cutaneous manifestations of the disease were one of the major facets of the disease.
With the advent of newer antiretroviral therapy options, patients with HIV infection have higher CD4 counts and lower viral loads. With a more functional immune system, we are less likely to see many of the cutaneous manifestations of the disease (see Table). I am certainly happy to see fewer of these skin findings, but it is always important to recognize possible signs of HIV infection, as there may be clues of undiagnosed infection. I will discuss some of the more common and interesting entities, including acute seroconversion syndrome, Molluscum contagiosum, varicella zoster, Candida infections, oral hairy leukoplakia and others.
Jeffrey M.
Weinberg
Primary HIV infection
Two to 4 weeks after inoculation with HIV, with high levels of circulating infectious virions, a symptomatic seroconversion reaction occurs in 50% to 70% of individuals. Arthralgia, myalgia, fever, weight loss, nausea, vomiting and diarrhea and lymphadenopathy are present. A cutaneous eruption is present in approximately 75% of cases, characterized by a widespread morbilliform rash, which typically fades within 1 to 2 weeks. Urticarial and vesicular lesions have been described. Alopecia may develop. Mucocutaneous ulceration involving the oropharynx, oesophagus or anogenital area is common. Severe primary HIV infection, also known as acute seroconversion syndrome, may be associated with oropharyngeal or esophageal candidiasis.
Molluscum contagiosum
Typically, the primary skin lesion is white or red papules or small nodules with or without umbilication. Atypical presentations include large and multiple lesions on the face in adults. The diagnosis is mainly by clinical exam, but histopathology may be required for confirmation in atypical cases. Spontaneous resolution after ART has been reported.
Varicella zoster
The cutaneous presentation of primary and secondary varicella-zoster virus infection in patients with HIV generally follows a typical course with crops of pruritic vesicles that become generalized in primary varicella and are dermatomal in herpes zoster.
In the setting of HIV, varicella is often more florid with a pronounced systemic prodrome (malaise, headache, fever, myalgia), a prolonged course, and a greater incidence of complications such as encephalitis, pneumonitis and hepatitis.
Human papillomavirus
HPV infection results in varied presentations, including common warts (verruca vulgaris), plantar warts, filiform, condylomata accuminata and mucocutaneous warts, which can occur in the oral, ocular and anogenital mucosa. Although they may be large, multiple, recalcitrant to therapy and disfiguring, with a significant psychological burden, warts in the setting of HIV generally resemble those found in the general population.
Candida infections
Candidiasis can affect the mucosal surface of the oral, vaginal and gastrointestinal tract. Oral candidiasis is the most common form associated with HIV. It usually presents as white, exudative, mucosal plaques on the tongue and oral mucosa. There is also an erythematous/atrophic erythematous presentation without white plaques.
Additional manifestations include angular cheilitis with erythema and white scale, and chronic hyperplastic candidiasis with discrete leukoplakia. Recurrent episodes of vulvovaginal candidiasis also can be seen in patients with HIV.
Psoriasis
The association between psoriasis and HIV infection appears paradoxical, but insights into the role of T-cell subsets, autoimmunity, genetic susceptibility and infections associated with immune dysregulation explain the pathogenesis of psoriasis with HIV in general. Psoriasis may present as the first clinical manifestation of HIV or, less commonly, may appear in the advanced stages of HIV when it has progressed to AIDS. A substantial proportion of patients with HIV-associated psoriasis have a pattern of acral involvement, often with pustules and sometimes with severe destructive nail changes.
Kaposi’s sarcoma
This condition usually manifests as pigmented macules, plaques, papules or nodules. However, subcutaneous nodules may present with no skin pigmentation. Lesions range in size from a few millimeters to large confluent areas many centimeters in diameter. The color ranges from pink to red or purple. In darker-skinned individuals, Kaposi’s sarcoma lesions may appear dark brown or black. Lymphedema is a frequent complication of AIDS-associated Kaposi’s sarcoma, and its severity may be disproportionate to the extent of cutaneous Kaposi’s sarcoma. This condition can manifest at any time in the course of HIV infection, but becomes more common as immunocompetence declines.
Dermatophytosis and onychomycosis
Tinea infections and onychomycosis also are common in the setting of HIV. The features are generally similar to those seen in immunocompetent individuals. Tinea unguium (nail fungus) frequently is found in association with tinea pedis and produces subungual hyperkeratosis, onycholysis (separation of the nail plate from the nail bed) and nail discoloration. Proximal white subungual onychomycosis is a less common presentation overall and is more specific to HIV infection.
Oral hairy leukoplakia
Oral hairy leukoplakia is a condition characterized by irregular white patches on the side of the tongue and less commonly elsewhere on the tongue or in the mouth. These lesions occur primarily in HIV-positive patients, and patches resemble oral candidiasis, except that oral hairy leukoplakia lesions cannot be dislodged.
Although this is a brief review of conditions seen in association with HIV, it is important to keep vigilant for all signs of the condition, as it may aid in early diagnosis and treatment.
Jeffrey M. Weinberg, MD, FAAD, is an associate clinical professor of dermatology at Columbia University College of Physicians and Surgeons in New York City. In addition, he is director of the Clinical Research Center/Dermatopharmacology at St. Luke’s and Roosevelt Hospitals and acting director of the Division of Dermatology at Jamaica Hospital Medical Center, both in New York City. Weinberg can be reached at: foresthillsdermatology@gmail.com.
Disclosure: Weinberg reports no relevant financial disclosures.