Skin Manifestations of HIV

Disease
By Lucero

Skin Manifestations of HIV Disease

Cutaneous manifestations, which may be the initial

signs of virus-related immunosuppression, frequently

occur in patients who are infected with HIV.
Recognizing HIV-related skin changes may lead to the

diagnosis of HIV infection in the early stages, which

allows initiation of appropriate antiretroviral therapy.

Kaposi sarcoma

It is the first reported malignancy

associated with HIV infection.
The worldwide prevalence of KS
in patients with AIDS may approach
34%. In the United States, the
prevalence of KS is less than 5% in
patients with HIV. Most of the
patients are homosexual men, with
some increase in patients who
acquire HIV infection through sexual
contact.

Kaposi sarcoma
KS is an abnormally vascularized tumorlike lesion affecting

skin, lymph nodes, and viscera.

It is believed to be a proliferation of endothelial cells induced

by human herpesvirus type 8.

KS is promoted by various angiogenic and proinflammatory

factors including HIV-Tat.

In addition, the latency-associated nuclear antigen type 1

(LANA-1) protein is highly expressed in spindle cells, which is

considered important in the maintenance of human herpesvirus
type 8associated malignancies.

Kaposi sarcoma
KS begins as pink macules that become disseminated and

palpable. Purplish or brown macules and plaques may become

nodular. Mucosal involvement is common.
The clinical progression of KS in patients infected with HIV is

more aggressive than the other clinical types of KS.

HIV-associated
malignancies:
AIDS-related B-cell non-Hodgkin

lymphomas may lead to skin nodules.

An increase in squamous cell carcinoma

has been reported, especially in young

homosexual men with HIV infection.
Malignant melanoma in patients with

HIV appears to be more aggressive than

in individuals without HIV. One study
reported shorter disease-free and overall
survival rates in patients with melanoma
and HIV compared with patients with
melanoma who did not have HIV.

 Since the advent of highly active antiretroviral therapy (HAART), the

incidence of non AIDS-defining cutaneous cancers in particular basal cell

carcinoma among HIV-infected persons has exceeded that of AIDS-defining
cutaneous cancers such as KS.
In a prospective study, Crum-Cianflone et al found that 6% of HIV-infected

persons developed a cutaneous malignancy over a mean follow-up period of

7.5 years.
The development of cutaneous nonAIDS-defining cancers in this cohort

proved to be associated with the traditional risk factors of increasing age and
lighter skin color, rather than with CD4 lymphocyte counts, HIV RNA levels,
or receipt of HAART.

Viral infections
In patients infected with HIV, several viruses of the

Herpesviridae family may lead to cutaneous disease,

including:
- Chronic perianal and perioral herpetic
ulcers caused by HSV
- Recurrent typical dermatomal zoster
caused by herpes zoster virus (HZV)
- Disseminated CMV infection.
- Recurrent oral and anogenital HSV is
common in patients infected with HIV, and it
may lead to chronic ulcerations.
In pediatric patients, herpes simplex stomatitis is more

common than varicella zoster virus (VZV) and may

become chronic and ulcerative. Patients with VZV may
develop chronic ecthymatous VZV.

Old herpes zoster

and Kaposi
sarcoma in a
patient with HIV
disease.

Acute disseminated HZV infection

and atypical manifestations,
including:
- Hyperkeratotic papules
Folliculitis
Verrucous lesions
Chronic ulcerations
Disseminated ecthymatous lesions
Chronic VZV infection mimicking basal cell carcinoma

According to Leibovitz et al, chronic VZV infections

associated with HIV-1 infection begin as vesicles and
progress into necrotic, nonhealing ulcers.

Epstein-Barr Virus
It has been implicated in the
pathogenesis of oral hairy leukoplakia.
Oral hairy leukoplakia It is characterized by filiform white
papules localized on the sides of the
tongue, may develop in patients
infected with HIV.
Has no malignant potential, but it
may be the initial sign of progressive
immunosuppression.
White plaques may be confused
with oral candidiasis, lichen planus,
and geographic tongue.

Cytomegalovirus Infection
CMV is a DNA virus in the Herpesviridae family. Ulcers in the
perineal region are the most common presentation for CMV
infection in patients infected with HIV-1. The concurrent
involvement of other infectious agents, such as HSV, in the
same lesions confounds the role of CMV in cutaneous lesions.
HSV is proposed to be the initiating infection leading to ulcer
formation, with CMV secondarily localizing in the granulation
tissue.
Nonspecific maculopapular eruptions similar to those
affecting patients with EBV or papulovesicular, nodular,
purpuric, and ulcerative lesions of CMV infection are observed
in patients who are immunocompromised. However, cutaneous
lesions are rarely observed in patients infected with HIV.
Diagnosing skin CMV infection in individuals infected with HIV
is important. The presence of CMV infection is considered a
poor prognostic sign in HIV disease.

Molluscum Contagiosum
The MC virus is a DNA virus in the Poxviridae

family.
It replicates in the cytoplasm of epidermal cells.
MC lesions are small papules with central

umbilication. In HIV infection, MC may be

widespread and atypical.
The lesions may be observed on unusual sites, such as

the face, neck, and scalp, and the lesions may be of

unusual morphology and size.
Such unusual forms include solitary, endophytic,

aggregated, inflamed, and giant MCs. MCs mimicking

sebaceous nevus of Jadassohn, ecthyma, and giant
condylomata acuminata have been reported.

Superficial Fungal Infections

Recurrent and persistent

mucocutaneous candidiasis is
common in patients with HIV
infection. In the United States,
recurrent vaginal candidiasis is the
most common presentation of HIV
infection in women.
In adults, generalized

dermatophytosis, or tinea capitis,

which is typically caused
byTrichophyton rubrum,may suggest
HIV infection.
Pityriasis versicolor may be

persistent and recurrent in patients

with HIV infection.

Deep fungal infections

Rarely, cutaneous cryptococcosis may be observed

in patients with HIV infection. Clinical

manifestations include cellulitis; papules; plaques;
ulcers; or translucent dome-shaped papules with
central umbilication, resembling MC.
Cutaneous histoplasmosis may lead to red papules, a

cellulitislike eruption, ulcerations, acneiform papules,

or molluscumlike lesions in patients infected with
HIV.
North American blastomycosis may present as a

disseminated maculopapular eruption in HIV disease.

Systemic coccidioidomycosis may disseminate to the

skin, usually as hemorrhagic papules or nodules.

Bacterial infections

Impetigo and folliculitis may be

recurrent and persistent in HIV

disease, particularly in children.
Disseminated furunculosis,

gingivitis, gangrenous stomatitis,

and abscess formation can occur
in patients with HIV infection.
Bacillary angiomatosis, which

is caused by Bartonella henselae

and rarely by Bartonella
quintana, usually manifests as
red papules and nodules.

Dermatologic Manifestations of StaphylococcusAureus

Staphylococcus aureus is the most common cutaneous bacterial infection in

persons with HIV disease.

Morphologic patterns that may occur include: bullous impetigo, ecthyma,
folliculitis, hidradenitis-like plaques, abscesses, cellulitis, and pyomyositis.
Bullous impetigo is most common in hot, humid weather, presenting as
very superficial blisters or erosions, most commonly seen in the groin or
axilla. Because the blisters are flaccid, they are short-lived; often only
erosions or yellow crusts are present. These lesions closely mimic cutaneous
candidiasis.
Ecthyma is an eroded or superficially ulcerated lesion with an adherent
crust. Under this crust is often a plane of purulent material teeming with
staphylococci. Removal of this crust is necessary to treat the lesion topically.

Mycobacterial infections
Mycobacterium tuberculosis;

Mycobacterium avium-intracellulare
complex; and, rarely, Mycobacterium
kansasii may present as acneiform
papules and indurated crusted plaques.
In patients with HIV, Mycobacterium

haemophilum can also present as

violaceous draining nodules and
superficial ulcers on the extremities, trunk,
head, and genitalia.

Mycobacterial infections
M. avium complex, a common opportunistic

pathogen among patients with AIDS, usually

manifests as disseminated disease involving the
lungs, lymph nodes, and gastrointestinal tract.
Primary cutaneous infections with M. avium

complex are extremely rare, and most cutaneous

lesions are caused by dissemination.
Cutaneous manifestations thus far reported

include scaling plaques, crusted ulcers, ecthymalike lesions, verrucous ulcers, inflammatory
nodules, panniculitis, pustular lesions, and
draining sinuses. Localized skin involvement
resembling sporotrichosis is unusual.
Primary cutaneous M avium complex infection

manifesting as sporotrichosis-like lesions was

described in a patient with AIDS.

Syphilis
Syphilis presents more frequently in patients who

are either homosexual or bisexual or in those who

use illicit drugs.
A high prevalence of HIV seropositivity, as well as
other sexually transmitted diseases, exists in
patients with syphilis.
Syphilitic ulcers are believed to increase HIV
transmission.
Most cases of syphilis that occur in HIV disease
are clinically and serologically typical.
Patients with HIV infection with primary syphilis
tend to present more frequently with multiple
ulcers compared with patients who are not
infected with HIV.

Syphilis
Rapid progression of secondary

syphilis to tertiary syphilis and

syphilis maligna has been reported
in patients infected with HIV.
Syphilis seroconversion may be

delayed, and standard serologic

tests that aid in diagnosing syphilis
may be unreliable.
Appropriate serologic follow-up to

ensure an adequate response to

treatment is important in patients
infected with HIV.

Scabies : Atypical or

Norwegian scabies
- It is characterized
by widespread
hyperkeratotic, scaly
maculopapular eruptions or
crusted plaques, can occur
in patients with HIV
infection.
Leishmaniasis : Atypical

disseminated
leishmaniasis
- It has been
reported in an HIV-infected
patient

Demodicidosis: Demodex

folliculorum
- Folliculitis may lead to a
pruritic papular eruption (PPE) on
the face and the upper part of the
trunk in patients with HIV disease.
Papulosquamous dermatoses of

AIDS
- Generalized dry skin
syndrome is frequently observed in
patients with HIV infection. Xerosis
may be the initial clinical
manifestation of AIDS and is often a
cause of pruritus.
- In the United States,
pruritus has been reported in 4.5%
of patients with AIDS.

Seborrheic dermatitis
It is observed in 83% of patients

with AIDS.
Seborrheic dermatitis may be the

initial cutaneous manifestation of

HIV disease.
The eruption, which is

characterized by widespread
inflammatory and hyperkeratotic
lesions, may progress to
erythroderma in some patients.
The typical skin lesions of

pityriasis rosea may accompany

HIV disease.

Seborrheic Dermatitis
The immune alterations caused by

HIV infection may lead to psoriasis

and Reiter syndrome. In some
instances, preexisting psoriasis may
become more severe with disseminated
plaques and pustules.
Acquired ichthyosis may begin on the

lower extremities and disseminate in

advanced HIV disease.
Acquired ichthyosis may be a marker

of concomitant infection with HIV-1

and human lymphotropic virus II in
persons who use intravenous drugs and
have profound helper T-cell depletion.

Eosinophilic folliculitis manifests

as an idiopathic, highly pruritic,
papulopustular eruption of sterile
pustules involving the face, neck, trunk,
and extremities.
- The serum immunoglobulin E
(IgE) level and blood eosinophil count
may be increased.
Pruritic papular eruption
It is a common cutaneous
manifestation in patients infected with
HIV. It manifests as small, itchy, red or
skin-colored papules on the head, neck,
and upper part of the trunk. Occurs in
advanced immunosuppressed patient.

Dull red, violaceous,

maculopapular lesions on
the upper part of the
trunk in a 49-year-old
man with primary HIV-1
infection.

Autoimmunity, atopic disease,

and urticaria:
Thrombocytopenic purpura, vitiligo, pemphigoid, and other

autoimmune blistering diseases have been reported in

association with HIV disease.
Atopic disease may be reactivated by HIV disease. Atopic
eczema may be severe in children infected with HIV.
Increased serum IgE levels have been found in these
children; however, increased IgE levels were not correlated
with atopic symptoms.
Urticaria may occur primarily or as a drug eruption in HIV
disease. Cold urticaria has also been associated with HIV
disease.

Cutaneous Vasculitis
Cutaneous vasculitis has

been reported with HIV

disease.
CMV and parvovirus B19

have been discussed in the

etiology of HIV-associated
cutaneous vasculitis.
Leukocytoclastic vasculitis

has been reported with

indinavir treatment.

Photosensitivity has been reported in patients with

advanced HIV disease. Patients with HIV were

sensitive to UV-B light.
Patients who were most severely affected were

sensitive to both UV-B and UV-A light.

Photo-induced lichenoid drug reactions may be

seen, particularly in dark-skinned patients.

In patients infected with HIV, drug-induced

pigmentation can occur on skin exposed to light.

Hair and nail disorders

Diffuse alopecia or alopecia areata may be associated with

HIV disease and may be inflammatory and permanent. The

apoptotic follicular stem cell population in higher proportion
may represent a hair cycle disturbance in patients with diffuse
alopecia related to HIV-1 infection.
Generalized alopecia can occur in patients with HIV who are

treated with indinavir, an antiretroviral protease inhibitor.

Elongation of the eyelashes and softening and straightening

of the scalp hair may be observed in HIV disease.

Hair and nail disorders

Beau lines, telogen effluvium, and pallor of

the nail beds are the general effects of the

chronic illness.
Zidovudine is associated with longitudinal,

transverse, or diffuse melanin pigmentation of

the nails; however, nail pigmentation has also
been observed in patients with HIV who have
never received zidovudine.
Proximal subungual onychomycosis is usually

a sign of HIV disease.

QUESTIONS:
1) What is the most common and
the first reported malignancy
associated with HIV infection?

2) Pruritic papular eruption occurs?

A) Early manifestation
B) Coinfection
C) Advanced immunosuppresion
D) Premalignant manifestaion