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CutaneousManifestationsofHIV
Updated:Jun08,2016
Author:RobertASchwartz,MD,MPHChiefEditor:WilliamDJames,MDmore...

OVERVIEW

Overview
Cutaneousmanifestationsofhumanimmunodeficiencyvirus(HIV)diseasemayresultfromHIV
infectionitselforfromopportunisticdisorderssecondarytothedeclineinimmunocompetencefrom
thedisease.[1]CutaneousdisordersmaybetheinitialsignsofHIVrelatedimmunosuppression.
RecognizingHIVrelatedskinchangesmayleadtothediagnosisofHIVinfectionintheearlystages,
allowinginitiationofappropriateantiretroviraltherapy.Manyassociatedskindiseasesaremore
severeinthisgroup.Withtheuseofantiretroviraltherapy,theincidenceofsomeoftheseskin
disordershasdeclined,buttheincidenceofdrugreactionsandothernoninfectiousskineruptionshas
beenenhanced.[2]
Avarietyofneoplastic,infectious,andnoninfectiousdiseasescanproducecutaneousmanifestations
throughoutthecourseofHIVdisease.Thesemanifestationsmayoccurmorefrequentlythanin
personswithoutHIVinfectionandmaybelessresponsivetousualtreatmentmodalities.
ForotherdiscussionsofHIVinfection,seeHIVDisease,PediatricHIVInfection,andAntiretroviral
TherapyforHIVInfection.
Forpatienteducationinformation,seetheImmuneSystemCenter,SexuallyTransmittedDiseases
Center,TeethandMouthCenter,andYeastandFungalInfectionsCenter,aswellasHIV/AIDS,
CankerSores,Candidiasis(YeastInfection),andSyphilis.

ManifestationsbyHIVDiseaseStage
DuringacuteprimaryHIVinfection,atransient,generalized,morbilliformeruptionmaydeveloponthe
trunkandthearms.IntheearlyasymptomaticstageofHIVdisease,whichmaylastfromafewyears
toadecadeorlonger,nosignsofinfectionotherthanlymphadenopathyarepresent.
Kaposisarcomacanoccurpriortotheonsetofimmunosuppression.Withtheonsetof
immunosuppression,nonspecificskinchangesoccur,suchascommondisorderswithatypicalclinical
features,includingrecurrentvaricellazoster,numeroushyperkeratoticwarts,treatmentresistant
seborrheicdermatitis,andoralhairyleukoplakia.
InthelaterstagesofHIVdisease,chronicherpessimplexvirus(HSV),molluscumcontagiosum(MC),
andcytomegalovirus(CMV)infectionsappear.AnautopsyanalysisofHIVseropositivepatients
revealedthat72%hadopportunisticviralinfectionsmostpatientswereinfectedwithCMVandHSV.
TheprevalenceofclinicallyapparentMCinfectionvariesfrom518%indifferentseries.Mycobacterial
infectionsandmucocutaneouscandidiasisoccur.

A42monthprospectivestudybySmithetalin912HIV1infectedpatientsfoundthatcondylomata
acuminataandverrucaeareobservedearly,andtheirfrequencydoesnotincreaseasthedisease
progresses,whereastheincidenceofHSVinfections,MC,andoralhairyleukoplakiaincreasesasthe
diseaseadvances.[3,4]
Verrucousherpesinfection,leprosy,condylomalikemolluscumcontagiosum,andAIDSassociated
pigmentedornonpigmentederythrodermamaybeseeninearlyHIVdiseaseoraspartofimmune
restorationsyndromeaftertheinitiationofantiretroviraltherapy.[5,6,7,8,9]Leishmaniasisandmiliary
tuberculosismaybeaconcerninadvancedHIVdisease.[10,11,12]Diffuseordisseminated
leishmaniasismayoccurwithHIVdisease,[13,14]includinginassociationwiththeimmune
reconstitutioninflammatorysyndrome.[14]

ManifestationsinHIVInfectedChildren
Mucocutaneouscandidiasis,includingrecurrentandwidespreaddiaperdermatitisandchronic
paronychia,isacommoncutaneousmanifestationinchildrenwithHIVinfection.Themostcommon
cutaneousinfectionsinchildrenwithHIVdiseaseareimpetigoandcellulitiscausedby
Staphylococcusaureus.
OthercutaneousmanifestationsofHIVinfectioninthepediatricagegroupareasfollows:
Recurrentherpeticgingivostomatitis
Scabies
Severeatopicdermatitis
Drugeruptions
Leukocytoclasticvasculitis

Malignancies
Kaposisarcoma(KS)wasthefirstreportedmalignancyassociatedwithHIVinfectionandwasfirst
documentedin1981fromreportsinNewYork,LosAngeles,andSanFrancisco.[15]Theworldwide
prevalenceofKSinpatientswithAIDSmayapproach34%intheUnitedStateshowever,the
prevalenceofKSinpatientswithHIVdiseaseislessthan5%.Mostofthepatientsarehomosexual
men,althoughallpatientswhoacquireHIVinfectionthroughsexualcontactareatsomewhat
increasedrisk.
Sincetheadventofhighlyactiveantiretroviraltherapy(HAART),theincidenceofnonAIDSdefining
cutaneouscancersinparticular,basalcellcarcinomaamongHIVinfectedpersonshasexceeded
thatofAIDSdefiningcutaneouscancerssuchasKS.Inaprospectivestudy,CrumCianfloneetal
foundthat6%ofHIVinfectedpersonsdevelopedacutaneousmalignancyoverameanfollowup
periodof7.5years.[16]
ThedevelopmentofcutaneousnonAIDSdefiningcancersinthiscohortprovedtobeassociatedwith
thetraditionalriskfactorsofincreasingageandlighterskincolor,ratherthanwithCD4lymphocyte
counts,HIVRNAlevels,orreceiptofHAART.[16]
KSremainsthemostcommonHIVassociatedmalignancyinsubSaharanAfrica.[17]PediatricKSis
distinct,andlymphnodeinvolvementisacommonmanifestation.
AIDSrelatedBcellnonHodgkinlymphomasmaycauseskinnodules.

Analcarcinomaandcervicalintraepithelialneoplasiaarepapillomavirusassociatedtumorsassociated
withHIVdisease.Thesetumorstendtobemoreprogressiveandaggressive.Anincreasein
squamouscellcarcinomaoftheanalmucosahasbeenreported,especiallyinyounghomosexual
menwithHIVinfection.
Intraoralormultiplesquamouscellcarcinoma,Bowendisease,andmetastaticbasalcellcarcinoma
haveoccasionallybeenreportedinpatientsinfectedwithHIV.
MalignantmelanomaappearstobemoreaggressiveinpatientswithHIV.Onestudyreportedshorter
diseasefreeandoverallsurvivalratesinpatientswithmelanomawhohadHIVdisease,compared
withthosewhodidnothaveHIV.[18]
ChildrenwithAIDShaveahigherriskofdevelopingleiomyosarcoma,althoughtheincidenceisstill
lowinthispopulation.

Kaposisarcoma
KSisanabnormallyvascularizedtumorlikelesionaffectingskin,lymphnodes,andviscera.Itis
believedtobeaproliferationofendothelialcellsinducedbyhumanherpesvirustype8.KSis
promotedbyvariousangiogenicandproinflammatoryfactors,includingHIVTat.Inaddition,the
latencyassociatednuclearantigentype1(LANA1)proteinishighlyexpressedinspindlecells,which
isconsideredimportantinthemaintenanceofhumanherpesvirustype8associatedmalignancies.
KSbeginsaspinkmaculesthatbecomedisseminatedandpalpable.Purplishorbrownmaculesand
plaquesmaybecomenodular(seetheimagesbelow).Mucosalinvolvementiscommon.KS
demonstratesmoreaggressiveclinicalprogressioninpatientsinfectedwithHIVthaninother
populationswiththedisease.

KaposisarcomainamanwithHIVinfection.

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KaposisarcomainamanwithHIVinfection.

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ViralInfections
InpatientsinfectedwithHIV,severalvirusesoftheHerpesviridaefamilymayleadtocutaneous
disease,includingchronicperianalandperioralherpeticulcerscausedbyherpessimplexvirus(HSV),
recurrenttypicaldermatomalzostercausedbyherpeszostervirus(HZV),anddisseminated
cytomegalovirus(CMV)infection.

Herpessimplexandherpeszosterviruses
RecurrentoralandanogenitalHSVinfectioniscommoninpatientsinfectedwithHIV,anditmaylead
tochroniculcerations.Inpediatricpatients,HSVstomatitisismorecommonthanvaricellazostervirus
(VZV)andmaybecomechronicandulcerative.PatientswithVZVmaydevelopchronicecthymatous
VZV(seetheimagebelow).

OldherpeszosterandKaposisarcomainapatientwithHIVdisease.

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AcutedisseminatedHZVinfectionandthefollowingatypicalmanifestationshavealsobeendescribed:

Hyperkeratoticpapules
Folliculitis
Verrucouslesions
Chroniculcerations
Disseminatedecthymatouslesions
AccordingtoLeibovitzetal,chronicVZVinfectionsassociatedwithHIV1infectionbeginasvesicles
andprogressintonecrotic,nonhealingulcers.[19,20]ChronicVZVinfectionmaymimicbasalcell
carcinoma.[18]

EpsteinBarrvirus
EpsteinBarrvirus(EBV)hasbeenimplicatedinthepathogenesisoforalhairyleukoplakia,whichmay
developinpatientsinfectedwithHIV,particularlymen.Oralhairyleukoplakiaischaracterizedby
filiformwhitepapuleslocalizedonthesidesofthetongue.Thisconditionhasnomalignantpotential,
butitmaybetheinitialsignofprogressiveimmunosuppression.Whiteplaquesmaybeconfusedwith
oralcandidiasis,lichenplanus,andgeographictongue.

Cytomegalovirus
CMVisaDNAvirusintheHerpesviridaefamily.Ulcersintheperinealregionarethemostcommon
presentationofCMVinfectioninpatientsinfectedwithHIV1.Theconcurrentinvolvementofother
infectiousagents,suchasHSV,inthesamelesionsconfoundstheroleofCMVincutaneouslesions.
HSVisproposedtobetheinitiatinginfectionleadingtoulcerformation,withCMVsecondarily
localizinginthegranulationtissue.
NonspecificmaculopapulareruptionssimilartothoseaffectingpatientswithEBVorpapulovesicular,
nodular,purpuric,andulcerativelesionsofCMVinfectionareobservedinpatientswhoare
immunocompromised.However,cutaneouslesionsarerarelyobservedinpatientsinfectedwithHIV.
CMVinfectionoftheeccrineductsresultinginsquamousmetaplasiahasbeendescribedinapatient
withHIV.
DiagnosingskinCMVinfectioninindividualsinfectedwithHIVisimportant.ThepresenceofCMV
infectionisconsideredapoorprognosticsigninHIVdisease.

Warts
Widespreadorrecalcitrantwartsmaybeobservedontheoralmucosa,theface,theperianalregion,
andthefemalegenitaltractinpatientsinfectedwithHIV.Theperianalandcervicallesionsmaybe
difficulttotreat.Largeplantarwartscausedbyhumanpapillomoavirus66(HPV66)andan
epidermodysplasiaverruciformislikeeruption,whichisbelievedtobeassociatedwithHPVinfection,
havealsobeenreportedinpatientsinfectedwithHIV.[21]

Molluscumcontagiosum
Themolluscumcontagiosum(MC)virusisaDNAvirusinthePoxviridaefamily.Itreplicatesinthe
cytoplasmofepidermalcells.MClesionsaresmallpapuleswithcentralumbilication(seetheimages
below).

YoungmanwithHIVdiseaseandmolluscumcontagiosumonthelateralpartoftheeyebrow.

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MolluscumcontagiosumonthepenileshaftinapatientwithHIVdisease.

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InHIVinfection,MCmaybewidespreadandatypical.Thelesionsmaybeobservedonunusualsites,
suchastheface,neck,andscalp,andthelesionsmaybeofunusualmorphologyandsize.[22]Such
unusualformsincludesolitary,endophytic,aggregated,inflamed,andgiantMCs.MCsmimicking
sebaceousnevusofJadassohn,ecthyma,andgiantcondylomataacuminatahavebeenreported.

SuperficialFungalInfections
RecurrentandpersistentmucocutaneouscandidiasisiscommoninpatientswithHIVinfection.Inthe
UnitedStates,recurrentvaginalcandidiasisisthemostcommonpresentationofHIVinfectionin
women.
Inadults,generalizeddermatophytosis,ortineacapitis,whichistypicallycausedbyTrichophyton
rubrum,maysuggestHIVinfection.BourneriasetalreportedtineacapitisfromMicrosporumcanisin
2patientsinfectedwithHIV.[23]
PityriasisversicolormaybepersistentandrecurrentinpatientswithHIVinfection.

DeepFungalInfections

Rarely,cutaneouscryptococcosismaybeobservedinpatientswithHIVinfection.[24]Clinical
manifestationsincludethefollowing:
Cellulitis
Papules
Plaques
Ulcers
Translucentdomeshapedpapuleswithcentralumbilication,resemblingMC
Cutaneoushistoplasmosismayleadtoredpapules,acellulitislikeeruption,ulcerations,acneiform
papules,ormolluscumlikelesionsinpatientsinfectedwithHIV.[25,26]
NorthAmericanblastomycosismaypresentasadisseminatedmaculopapulareruptioninHIV
disease.
Systemiccoccidioidomycosismaydisseminatetotheskin,usuallyashemorrhagicpapulesor
nodules.Apositiveculture/stainingfrompusandcutaneouslesionsmaybeusedtodocumentthe
cryptococcosis.[27]

Bacterialinfections
ImpetigoandfolliculitismayberecurrentandpersistentinHIVdisease,particularlyinchildren.
Disseminatedfurunculosis,gingivitis,gangrenousstomatitis,andabscessformationcanoccurin
patientswithHIVinfection.Bacillaryangiomatosis,whichiscausedbyBartonellahenselaeandrarely
byBartonellaquintana,usuallymanifestsasredpapulesandnodules.[28]

Mycobacterialinfections
MycobacteriumtuberculosisMaviumintracellularecomplex(MAC)and,rarely,Mkansasiimay
presentasacneiformpapulesandinduratedcrustedplaques.
MAC,acommonopportunisticpathogenamongpatientswithAIDS,usuallycausesdisseminated
diseaseinvolvingthelungs,lymphnodes,andgastrointestinaltract.Primarycutaneousinfectionswith
MACareextremelyraremostcutaneouslesionsarecausedbydissemination.Cutaneous
manifestationsthusfarreportedincludethefollowing:
Scalingplaques
Crustedulcers
Ecthymalikelesions
Verrucousulcers
Inflammatorynodules
Panniculitis
Pustularlesions
Drainingsinuses
Localizedskininvolvementresemblingsporotrichosisisunusual.PrimarycutaneousMACinfection
manifestingassporotrichosislikelesionswasdescribedinapatientwithAIDS.[29]
Thepossibilityofcoinfections,whichmaybemultiple,shouldbekeptinmind.CoinfectionwithB
quintana,MAC,andCMVhasbeenreportedinanAIDSpatient.[30]

InpatientswithHIV,Mhaemophilumcanalsopresentasviolaceousdrainingnodulesandsuperficial
ulcersontheextremities,trunk,head,andgenitalia.

Syphilis
Coinfectionwithsyphilis(aswellasothersexuallytransmitteddiseases)maybefoundinHIV
infectedpatients,particularlythosewhoarehomosexualorbisexualorwhouseillicitdrugs.Syphilitic
ulcersarebelievedtoincreaseHIVtransmission.
MostcasesofsyphilisthatoccurinHIVdiseaseareclinicallyandserologicallytypical,[31]butsome
arenot.[32]AhighrateofreinfectionwasnotedinoneFrenchstudy,withlessseverecutaneous
manifestations.[31]However,syphilisseroconversionmaybedelayed,andstandardserologictests
thataidindiagnosingsyphilismaybeunreliable.Also,inprimarysyphilis,presentationwithmultiple
ulcersismorecommoninHIVinfectedpatients.Rapidprogressionofsecondarysyphilistotertiary
syphilisandsyphilismalignahasbeenreportedinpatientsinfectedwithHIV.
Appropriateserologicfollowuptoensureanadequateresponsetotreatmentisimportantinpatients
infectedwithHIV.

Staphylococcusaureusinfection
PatientswithHIVhavebeenfoundtohaveincreasedratesofcutaneouscolonizationby
Staphylococcusaureus,andinpatientswithadvanceddisease,sepsisanddeeptissueinfectioncan
becommon.MethicillinresistantSaureus(MRSA)softtissueinfectionisanincreasingproblem.[33]

ParasiticInfestations
AtypicalorNorwegianscabies,whichischaracterizedbywidespreadhyperkeratotic,scaly
maculopapulareruptionsorcrustedplaques,canoccurinpatientswithHIVinfection.
AtypicaldisseminatedleishmaniasishasbeenreportedinanHIVinfectedpatient.[34]
Demodexfolliculorumfolliculitismayleadtoapruriticpapulareruption(PPE)onthefaceandthe
upperpartofthetrunkinpatientswithHIVdisease.

PapulosquamousDermatosesofAIDS
GeneralizeddryskinsyndromeisfrequentlyobservedinpatientswithHIVinfection.Xerosismaybe
theinitialclinicalmanifestationofAIDSandisoftenacauseofpruritus.IntheUnitedStates,pruritus
hasbeenreportedin4.5%ofpatientswithAIDS.
SeborrheicdermatitismaybetheinitialcutaneousmanifestationofHIVdisease.AccordingtoMathes
etal,seborrheicdermatitislikeeruptionsareobservedin83%ofpatientswithAIDS.[35]Theeruption,
whichischaracterizedbywidespreadinflammatoryandhyperkeratoticlesions,mayprogressto
erythrodermainsomepatients.SeborrheicdermatitismaybeincreasedinpatientswithAIDS
associateddementiaorCNSdisease.
TheimmunealterationscausedbyHIVinfectionmayleadtopsoriasisandReitersyndrome.Insome
instances,preexistingpsoriasismaybecomemoreseverewithdisseminatedplaquesandpustules.
ThetypicalskinlesionsofpityriasisroseamayaccompanyHIVdisease.

AcquiredichthyosismaybeginonthelowerextremitiesanddisseminateinadvancedHIVdisease.
AcquiredichthyosismaybeamarkerofconcomitantinfectionwithHIV1andhumanlymphotropic
virusIIinpersonswhouseintravenousdrugsandhaveprofoundhelperTcelldepletion.[36]
Eosinophilicfolliculitismanifestsasanidiopathic,highlypruritic,papulopustulareruptionofsterile
pustulesinvolvingtheface,neck,trunk,andextremities.
Pruriticpapulareruption(PPE)isacommoncutaneousmanifestationinpatientsinfectedwithHIV.It
manifestsassmall,itchy,redorskincoloredpapulesonthehead,neck,andupperpartofthetrunk.
Thecauseisnotknown.AccordingtoBoonchaietal,81.25%ofpatientswithPPEhaveadvanced
immunosuppression.[37](Seetheimagebelow.)

Dullred,violaceous,maculopapularlesionsontheupperpartofthetrunkina49yearoldmanwithprimaryHIV1
infection.

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HairandNailDisorders
DiffusealopeciaoralopeciaareatamaybeassociatedwithHIVdiseaseandmaybeinflammatoryand
permanent.Theapoptoticfollicularstemcellpopulationinhigherproportionmayrepresentahair
cycledisturbanceinpatientswithdiffusealopeciarelatedtoHIV1infection.[38]
Beaulines,telogeneffluvium,andpallorofthenailbedsarethegeneraleffectsofthechronicillness.
ElongationoftheeyelashesandsofteningandstraighteningofthescalphairmaybeobservedinHIV
disease,andproximalsubungualonychomycosisisalsousuallyasignofHIVdisease.Thefrequency
ofonychomycosismaybehigherinmenthaninwomen.
GeneralizedalopeciacanoccurinpatientswithHIVwhoaretreatedwithindinavir,anantiretroviral
proteaseinhibitor.[39]Zidovudineisassociatedwithlongitudinal,transverse,ordiffusemelanin
pigmentationofthenailshowever,nailpigmentationhasalsobeenobservedinpatientswithHIVwho
havenevertakenzidovudine.

DrugEruptions
Drugeruptionshavebeenreportedasthemostcommoncauseoferythrodermainpatientsinfected
withHIV.Astudyidentified177casesofStevenJohnsonsyndrome/toxicepidermalnecrolysisfrom
20002010andfoundahighproportionofthepatientswereinfectedwithHIVinsubSaharanAfrica,
withahighfrequencyofantiretroviraldrugsasthecause.[40]ThiselevatedincidenceofHIVpatients

withanadversecutaneousdrugeruption,includingtoxicepidermalnecrolysis,maybeduetoaloss
ofskinprotectiveCD4+CD25+regulatoryTcells.[41]
Asmanyas6570%ofpatientstreatedwithtrimethoprimsulfamethoxazoleforPneumocystisjiroveci
pneumoniaexperiencemorbilliformeruptionswithin7daysofstartingthetherapy.Reddishmacules
andpapulesmaybegeneralizedandcanbecomepermanentafterthediscontinuationofthetherapy.
Sulfonamidesmaycausethefollowing:
Urticaria
Erythemamultiforme
Toxicepidermalnecrolysis
Systemicreactions,includingfever,leukopenia,thrombocytopenia,hepatitis,andnephritis
ToxicepidermalnecrolysishasbeenreportedwiththefollowingagentsinpatientswithHIV:
Fluconazole
Clindamycinandotherantibiotics
Phenobarbital
Chlormezanone
Fixeddrugeruptionhasbeenreportedin2patientsreceivingsaquinavir,anHIV1proteaseinhibitor.

PhotosensitivityandDrugInducedPigmentation
AstudybyVinChristianetalfoundthatphotosensitivityinHIVinfectedpatientsappearstobea
manifestationofadvanceddisease.[42]MostofthepatientsinthatstudyweresensitivetoultravioletB
(UVB)lighthowever,thepatientswhoweremostseverelyaffectedweresensitivetobothUVBand
UVAlight.[42]
PhotoinducedlichenoiddrugreactionsmayoccurinHIVinfectedpatients,particularlythosewithdark
skin.Inaddition,HIVinfectedpatientsmayexperiencedruginducedpigmentationofskinexposedto
light.

MiscellaneousDermatologicDisorders
ThefollowingdermatologicconditionsmaybeassociatedwithHIVdisease:
HIVrelatedCD8+cutaneouspseudolymphoma:Thisisaninflammatoryprocessthatresults
fromamassiveinfiltrationoftheskinbyactivated,oligoclonal,HIVspecific,cytotoxicT
lymphocytesandismostoftenseeninthosethataremarkedlyimmunosuppressed.[43]
Severeaphthousstomatitis
Cutaneousvasculitis(possiblycausedbyCMVorparvovirusB19)[44]
Leukocytoclasticvasculitiswithindinavirtreatment[45]
Thrombocytopenicpurpura,vitiligo,alopeciaareata,siccasyndrome,pemphigoid,andother
autoimmuneblisteringdiseaseshavebeenreportedinassociationwithHIVdisease.
AtopicdiseasemaybereactivatedbyHIVdisease.Atopiceczemamaybesevereinchildreninfected
withHIV.IncreasedserumIgElevelshavebeenfoundinthesechildrenhowever,increasedIgE
levelswerenotcorrelatedwithatopicsymptoms.[46]

UrticariamayoccurprimarilyorasadrugeruptioninHIVdisease.Coldurticariahasalsobeen
associatedwithHIVdisease.[47]

DifferentialDiagnosis
Thedifferentialdiagnosisincludesthefollowing:
Aspergillosis
Dermatofibroma
Ecthyma
GranulomaAnnulare
PityriasisRubraPilaris
PorphyriaCutaneaTarda
PyodermaGangrenosum
SebaceousCarcinoma
Sporotrichosis
Warts,Nongenital
OtherproblemstobeconsideredinHIVinfectedpatientswithdermatologicconditionsincludethe
following:
Ashydermatosis[48]
Normolipemicxanthomas
Multipledermatofibromas[49]
Recurrentneutrophiliceccrinehidradenitis
Pemphigusvegetans
Lichenscrofulosorum
Cutaneousmucinosis
Papulonecrotictuberculide
Kawasakidisease
Eruptivedysplasticnevi
Disseminationofvaccinia
Ofujidisease[50]
Angiomyolipomas
Glucaninducedkeratoderma[51]
Disseminatedsuperficialporokeratosis[52]

Workup
HistopathologicexaminationisusefultodiagnosecutaneousmanifestationsofHIVdiseasewith
atypicalclinicalfeaturesandKaposisarcoma(KS).Routinehematoxylinandeosinandperiodicacid
Schiffstainingsmaydemonstratemultinuclearcellswithintracytoplasmicinclusionsofherpessimplex
virusinfection.Otherspecialstainsmayidentifyadditionalpathogens,ortheymayconfirm
malignancies,suchasKS.HistologicassessmentoftheCXCL12axismaybeausefulbiomarkerfor
diagnosingKSandassessingitsprogression.[53]
ImagingstudiesmaybehelpfulinevaluatingextracutaneousmanifestationsofKS,lymphoma,and
systemicinfections.

Treatment

Viralinfections
Forherpessimplexvirus(HSV)andherpeszostervirus(HZV)infectionsinHIVinfectedpatients,the
treatmentofchoiceisacyclovirandothermembersofthisdrugclass.Theseagentsareactivatedby
viralthymidinekinase.Insomedisseminatedcases,thevirusmayberesistanttoacyclovirbecauseof
thedeficiencyinviralthymidinekinaseactivity.
Prolongedtherapyandchronicsuppressivetherapywithsubtherapeuticdoseshavealsobeen
implicatedinthedevelopmentofacyclovirresistance.Inthepresenceofacyclovirresistance,other
viraltherapies,includingcidofovir,foscarnet,andvidarabine,maybenecessary.
Treatmentisusuallynotnecessaryforpatientswithoralhairyleukoplakia.Ifthepatientis
experiencingsignificantdiscomfort,systemic(1200mg/day)andtopicalacyclovir,ganciclovir,or
foscarnetmayberecommended.
Inmostcasesofmolluscumcontagiosum,imiquimod(Aldara)iscurative.Resolutionwithzidovudine
therapyhasbeenreportedinHIVassociatedmolluscumcontagiosum.Thereareisolatedreportsof
theefficacyofcidofovirinseveralviralinfections(eg,molluscumcontagiosum,[54]warts,[21]CMV
infection)thatarefrequentlyobservedinHIVinfectedpatientsinfectedwithHIV,butextensivestudies
ofthesafetyandtheefficacyofcidofovirhavenotbeenconductedtodate.
Ablationandcurettagemaybeusefulinthetreatmentofmolluscumcontagiosum.

NoninfectiousandnonmalignantcutaneousmanifestationsofHIVinfection
Forxerosis,emollientsanddryskincareregimensareeffective.Forseborrheicdermatitis,coaltar,
sulfur,andsalicylicacidshampoostopicalcorticosteroidstopicaltacrolimusand2%ketoconazole
creammaybeeffective.
ForpsoriasisandReitersyndrome,ultravioletB(UVB)andpsoralenwithUVA(PUVA)maybe
useful.Systemiccorticosteroids,methotrexate,andcyclosporinemayincreasetheimmune
suppressionandmustbeconsideredonlywithcarefulmonitoring.Zidovudineisalsoreportedtobe
usefulinthetreatmentofHIVassociatedpsoriasis.
Forpruriticpapulareruption,topicalsteroids,UVB,PUVA,andpentoxifylline[55]havebeenreported
tobeeffective.EosinophilicfolliculitismayrespondtoUVB,[56]isotretinoin,orzidovudinetreatment.
Forsevereaphthousstomatitis,tacrolimusisreportedtobeeffective.

Kaposisarcoma
Forpatientswithlimiteddisease,localtherapywithliquidnitrogen,alitretinoin,orintralesional
vincristinemaybeeffective.Surgery,radiotherapy,andsystemicchemotherapyusuallywithasingle
agent(eg,vinblastine,vincristine,bleomycin,doxorubicin,etoposide)maybeusefulinthetreatment
ofKShowever,systemicchemotherapyhasnotbeenshowntoimprovethelongtermsurvivalrates.
PatientswhorecoverimmuneresponsewithantiretroviraltherapyhavehadremissionofKS.
Interferon(IFN)alphaandIFNbetaphotodynamictherapyandsystemichyperthermiahavealsobeen
used.Cryotherapy,laserirradiation,andelectrodesiccationcanbeusefulforlocalizedsolitarylesions
ofKS.

Miscellaneousconditions

Mucocutaneouscandidiasisisusuallydifficulttotreatoralazoletreatmentmayberequired.
Generalizeddermatophytosismayberesistanttotopicalantifungalcreamsandmayrequiresystemic
antifungaltherapy.Bacillaryangiomatosisusuallyrespondstooralerythromycin.

Consultations
OverallcareforpatientswithHIVshouldbeprovidedbyaprimarycarepractitionerwithexpertisein
managingthedisease.Infectiousdiseaseconsultantsaretypicallyinvolvedinthecareofthese
patients.Patientsconfrontingthischronicanddebilitatingdiseasemayrequireadditionalsupport
services.
Thefollowingareotherspecialiststhatmaybeconsulted:
OphthalmologistforCMVretinitis
Neurologistandanesthesiologistforpostherpeticneuralgiaandneurologicsymptoms
Nephrologisttoadjustthedosesofantiviralagents
Psychiatristtoencouragetheexpressionofdeepemotions,suchasgrief,guilt,andanger
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