There are many cutaneous manifestations of HIV disease, due to both infectious and non-infectious conditions. With the introduction of the protease inhibitor group of drugs and the advent of early treatment with triple therapy regimens, it is likely that some of the conditions described below will become less common in the HIV positive population.
Infections: HIV
positive individuals are more prone not only to infections common in the general population but also to infections with organisms which do not usually cause disease in immunocompetent individuals (commensal organisms). In an HIV positive patient, any new lesion should be considered as possibly due to infection with an unusual organism.
HIV
Seroconversion is associated with an acute mononucleosis type illness, usually accompanied by a non-specific maculopapular eruption affecting the upper trunk, associated with lymphadenopathy, malaise, headache, and fever.
Thrush may be severe, disseminated, treatment-resistant, involving the posterior pharynx and oesophagus. [prescription take]: Topical nystatin; systemic imidazoles.
Molluscum contagiosum
Lesions tend to develop on the face and genitals. Management can be difficult: cryotherapy, topical retinoids, cautery, and curettage may be tried. Differential diagnosis: Disseminated cryptococcosis.
Herpes simplex virus infection
This can be increasingly troublesome as HIV progresses. Painful ulcers and erosions develop, particularly around the mouth and genitals. Any ulcerated or eroded area should be considered as HSV until proven otherwise. Management: High-dose aciclovir (oral or IV). Aciclovir resistance may develop and foscarnet is an alternate treatment.
Varicella zoster
This may occur early in HIV, with atypical presentation. Complications such as ulceration and post-herpetic neuralgia appear to be more frequent and severe. In advanced disease, disseminated infection occurs. Treatment: High-dose aciclovir (IV if systemic disease).
Cryptococcosis
Looks like facial molluscum contagiosum. [prescription take]: Fluconazole.
Scabies
Severe variants, eg crusted scabies are more common in advanced HIV disease. Paradoxically, patients may not complain of severe itch. A widespread scaly, crusted eruption occurs (highly infectious). Treatment: Permethrin lotion. Ivermectin may also be of benefit (but side-effects may be serious).
Oral hairy leukoplakia
(Epstein-Barr virus infection of oral mucosa) Adherent white plaques are seen on the lateral aspects of the tongue. Treatment: Systemic aciclovir.
Inflammatory disorders
Despite the immunosuppression associated with HIV disease, inflammatory cutaneous conditions occur frequently.
Seborrhoeic dermatitis
Common in later stages of HIV, it may be widespread and severe. Red scaly patches typically affect hair-bearing areas, eg the nasolabial folds, scalp and flexures. [prescription take]: Topical (or systemic) imidazoles.
Psoriasis
Treatment: Standard therapies (dithranol; calcipotriol; UV). Treatment of HIV will often improve psoriasis.
Eosinophilic folliculitis
The cause of this condition is unknown and it occurs frequently as HIV progresses. Itchy follicular papules and pustules affect the face, chest, and back. Treatments are often unsatisfactory but include topical steroids; phototherapy; antihistamines.
Drug reactions
These occur more commonly in HIV patients and particular culprits include co-trimoxazole (maculopapular eruptions; erythema multiforme; toxic epidermal necrolysis); dapsone; foscarnet (ulceration); zidovudine (nail + mucosal pigmentation).
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