Transcript Related Guidelines

What Are the Cutaneous Manifestations of HIV?

Sarah A. Wolfe, MD · Duke University


October 30, 2020

Key Takeaways:

  • HIV-related skin changes are common in patients with HIV and can include Kaposi sarcoma, diffuse candidiasis, and diffuse molluscum contagiosum. 

  • Atopic dermatitis (xerosis, pruritus, eczema), seborrhoeic dermatitis, and skin infections frequently occur in patients with HIV.

  • Other cutaneous manifestations of HIV include epidermal dysplasia verruciformis, hypertrophic herpes, and secondary syphilis.

This transcript has been edited for clarity.

Persons with HIV commonly experience HIV-related skin changes.[1] Common AIDS-related skin changes include Kaposi sarcoma, diffuse candidiasis, and diffuse molluscum contagiosum.[1,2] Pruritus and dermatitis are among the skin manifestations we see more in those who have chronic HIV and have access to antiretrovirals in this era.[3] It has been shown that HIV can be associated with immunoprofile changes to a T-helper profile, which means that patients exhibit skin manifestations in line with intrinsic atopic dermatitis. What we see on the skin can be variable—it can be xerosis, pruritus, or frank eczema changes. This may be erythematous or hyperpigmented plaques and patches that are diffuse or symmetrical. Treatment is with topical steroids such as triamcinolone on the torso and extremities, or hydrocortisone on the face or skin folds. When the pruritus is severe, antihistamines like hydroxyzine or less sedating cetirizine or fexofenadine can be helpful. 

It's worth noting that drug reactions are more prevalent in individuals with HIV.[4] Notable culprits include trimethoprim and sulfamethoxazole, which can be a common cutaneous eruption or be on the more severe end with toxic epidermal necrolysis. Antiretrovirals, such as abacavir, can trigger hypersensitivity reactions in those who are genetically susceptible. 

Seborrhoeic dermatitis is a common skin change seen in individuals with HIV and commonly appears as dandruff on the scalp, or when on the face, can be in the eyebrows, glabella, nasal labial folds, or around the ears as greasy scaling on an erythematous space.[5,6] First-line treatment is with ketoconazole shampoo or cream or on the face with a mild topical steroid, such as hydrocortisone. 

A number of skin infections are more common in the setting of HIV.[7] Notably, with human papillomavirus (HPV), warts are more prevalent and stubborn in the setting of HIV. The concern with warts, particularly genital warts, is the risk for transformation to squamous cell carcinoma. Characteristic findings of dysplasia or frank squamous cell carcinoma are signs of induration, ulceration, or a lack of response to typical treatment of warts. A skin biopsy is required to make this diagnosis. This is also known as anal cancer when it's present in the perianal area or found elsewhere in the genital area. This poses risk of metastasis when near the mucosal surfaces, such as the anal area. 

Another HPV-related dermatosis seen in HIV is called acquired epidermal dysplasia verruciformis.[1] This is similar to flat warts and can appear as hyperpigmented or hypopigmented papules on the extremities or torso and can be disfiguring. We unfortunately don't have great treatments for this. The HPV type for this type of wart change tends to be HPV 5, and fortunately, we don't usually see transformation to skin cancer with this. 

Another finding in the setting of HIV is hypertrophic herpes.[8] This is a unique manifestation of herpes simplex and appears as genital involvement with ulcerated painful nodules that can also be present on the face. There's no relationship with low CD4 count. We're unclear as to why this manifestation is so prominent. A biopsy is required for diagnosis and also to rule out skin cancer. This is an excessive inflammatory response to herpes simplex virus that doesn't respond to typical antivirals, such as acyclovir, valacyclovir, or famciclovir. Treatment has been successful with medication such as topical imiquimod, surgical removal with thalidomide, and more recently, with intralesional cidofovir. 

Finally, I'll comment about secondary syphilis, which is on the rise in the United States.[9] There is a large portion of patients with HIV who develop co-infection with syphilis, so it's definitely worth screening and observing for this. How do you know when syphilis is present? It's called the great mimicker in dermatology because it can manifest in different ways—very isolated localized lesions or it can be diffuse. Typically it's asymptomatic. Involvement in particular areas, such as the palms and soles, and also in the mouth as slick patches called mucus patches can be a tip-off and warrants a rapid plasma reagin (RPR) test or venereal disease research laboratory (VDRL) test.


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