Dermatological Manifestation of HIV

AIDS Prurigo

• Refers to generalized pruritus without cutaneous signs.
• Common complaint.
• Occurs later in the course of HIV/AIDS.
• Signifies a decline in CD4 count (< 200 cells /mm³).

Secondary Prurigo Nodularis

• Arises following prolonged scratching.
• Characterized by discrete hemispherical nodules that are intensely pruritic.
• Treatment: antipruritic lotions, doxepin, corticosteroids, and oatmeal bath.
• Systemic antihistamines and corticosteroids.
• PUVA is used in treatment-resistant cases.

• A chronic eruption of multiple, sterile, usually pruritic follicular and non-follicular erythematous plaques and papulopustules.
• Commonly affects the face, trunk, and extremities.
• The erythematous component of the pigmented skin often appears coppery red or hyperpigmented.
• Histology reveals follicular spongiosis and infiltration of the hair follicles and sebaceous glands by eosinophils.
• Believed to be due to hypersensitivity to Demodex folliculosum mite.
• May last for days to years.
• Treatment: topical steroids and antihistamines, PUVA, or itraconazole.
• Note: a marker of deteriorated immunity.
• Application of permethrin 48 hourly for 6 weeks.
• Isotretinoin at 0.5 mg/kg/day.

• Is a unique manifestation of HIV.
• Has not been found in HIV seronegative individuals.
• Clinically, they are discrete, fleshy or slightly erythematous, symmetrically disseminated non-follicular papules on the trunk, buttocks, and the extremities.
• Highly pruritic, leaving excoriated papules that heal to post-inflammatory hypopigmented spots surrounded by a hyperpigmented halo.
• Eruption waxes and wanes.
• The etiology is unknown; a hypersensitivity reaction to an antigen (e.g., arthropod salivary gland products) or a direct effect of HIV has been considered.
• Others consider it to be a variant of Eosinophilic Folliculitis.

• Xerosis refers to dry skin.
• Ichthyosis is a disorder of keratinization characterized by dry, scaly skin.
• They are associated with reduced eccrine sweating.
• The extensor aspects of the limbs are severely affected.
• It is postulated that secondary vitamin A deficiency may be a precipitant.
• Treatment: Emollients (e.g., petrolatum), improved diet, and multivitamin supplements may lead to clinical improvement.

• AZT-pigmented nail bands
• Foscarnet-painful, penile ulceration in 30% of treated patients
• Liposomal doxorubicin-hand-foot syndrome which is associated with distal paresthesias, erythema, and marked tenderness of the palms and soles, may develop into erosion and ulcers.
• Thiacetazone-Steven Johnson's syndrome

Seborrheic Dermatitis

• Affects 5% of the general population.
• Occurs in 40-83% of HIV patients.
• Differs from the classic type, as it is widespread and contains parakeratosis, keratinocyte necrosis, abundant plasma cells, and leukocytes.

Staphylococcal Infection

• Superficial: impetigo and folliculitis
• Deep: ecthyma, abscesses, cellulitis, botryomycosis

Botryomycosis

• Is a chronic suppurating granulomatous lesion
• Presents clinically as inflammatory nodules, discharging ulcers, sinuses, and fistulae
• Can affect the skin, bone, liver, etc.
• Pin-head size whitish granules are grossly seen on the skin
• Tightly packed club-like projections are seen microscopically.

Treatment: Surgical excision

Ecthyma Gangrenosum

• It is a necrotic bullous skin disorder often affecting the apocrine areas
• Pseudomonas aeruginosa is implicated
• Direct effect of the bacilli, immune complexes, and/or the exo/endotoxins on the vascular endothelium have been proposed to be responsible
• Clinically, it begins with bullae or hemorrhagic pustules which eventually evolve into necrotic ulcerations
• The lesions are usually round, indurated, painless, with a necrotic center and surrounding erythema
• Commonly affected sites are the axilla and the perineum
• Treatment is with antibiotics

Herpes Zoster

• It is due to the reactivation of the Varicella zoster virus
• It is often preceded by pain, followed by blisters which appear in a band-like pattern asymmetrically
• It usually involves one side of the body

Herpes Simplex

• Herpes simplex 1 - herpes labialis
• Herpes simplex 2 - herpes genitalis

The lesion usually resolves within 1-2 weeks and may recur.

The rate of recurrence is more in HIV patients and takes a longer time to heal. The lesion is more severe and involves a larger surface area of the body.

It is often preceded by a stinging sensation and later followed by blisters which break down and crust over before healing.

Oral Hairy Leukoplakia

It is an unusual condition characterized by small, light fuzzy patches which are often seen on the side of the tongue.

It is believed to be due to EBV.

Molluscum Contagiosum

Common in children and less frequently affects young adults.

It is caused by VZV.

Appear as smooth, waxy, skin-colored bumps ranging from the size of a pin-head to about 0.5 cm with a central core filled with a white cheese-like material.

They are not painful and usually not itchy.

An itchy type undergoes koebner phenomenon.

Viral Wart

It is caused by HPV.

It is a painless growth that can occur on any part of the body, particularly affecting the face, hands, and the feet.

Also seen on the genital and the anal regions in 75% of sexually active individuals.

Associated with cervical and anal cancer.

A notable example is Kaposi Sarcoma:

• Is a tumor of the cells that make up the blood vessels.
• More common in individuals who have contracted HIV via MSM (Men who have Sex with Men).
• HUMAN HERPES VIRUS-8 (HHV8) is the causal agent.
• Can occur on any part of the body but has a predilection for the legs, feet, and the perineum.
• Lesions vary in color, ranging from pink, dark-red, purple to brown, and they may be raised with varying sizes.