eMedicine Specialties > Dermatology > Viral Infections

Cutaneous Manifestations of HIV Disease

Emel Erdal, MD, Associate Professor of Dermatology, Mesa Hospital, Turkey
Anna Zalewska, MD, PhD, Assistant Professor, Adjunct Professor, Department of Dermatology and Venereology, Medical University of Lodz, Poland; Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School

Updated: Aug 12, 2009

Introduction

Background

Human immunodeficiency virus (HIV) infection continues to represent a major challenge and health problem worldwide. Two types of HIV have been identified. HIV-1 is the main cause of HIV infection throughout the world. HIV-2 is a prevalent cause of HIV infection in West Africa and is increasingly being identified in other areas. HIV-2 is less virulent than HIV-1.

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.

Pathophysiology

HIV produces cellular immune deficiency characterized by the depletion of helper T lymphocytes (CD4⁺ cells). Most infections and neoplastic processes in the skin of a patient who is infected with HIV are altered or facilitated by the loss of CD4⁺ cells of the immune system.

Animal models show that Langerhans cells are the first cellular targets of the virus, which fuse with CD4⁺ lymphocytes and spread into deeper tissues. In studies with human subjects, glycoprotein 120, the viral-envelope protein, binds to the CD4⁺ molecule; however, the entrance of glycoprotein 120 into the cell requires a coreceptor, CCR5, which is a surface chemokine receptor. A rapid occurrence of plasma viremia with widespread dissemination of the virus is observed after the virus inoculation.

In humans, this viremia appears 4-11 days after mucosal entrance of the virus. The replication rate of the virus decreases with the virus-specific immune response in the host mediated by the cytotoxic lymphocytes that are specially targeted against the virus. Some soluble factors secreted by CD8⁺ cells may contribute to the reduction of the viral load. After this event, a viral set point is developed.

Frequency

United States

In 2001, approximately 5 million new HIV infections were reported, and 3 million deaths occurred due to HIV/AIDS. The risk of HIV infection within 3 high-risk groups, including young men who have multiple male sexual partners, persons who use drugs via injection, and persons who use crack cocaine, has increased as much as 4-5% per year.

International

Worldwide, more than 30 million persons are estimated to be infected with HIV-1, with 16,000 new cases daily.

Mortality/Morbidity

Cutaneous manifestations are frequently observed in patients with HIV infection. An autopsy analysis of HIV-seropositive patients revealed that 72% had opportunistic viral infections. Most patients were infected with cytomegalovirus (CMV) and herpes simplex virus (HSV).

The prevalence of clinically apparent molluscum contagiosum (MC) infection varies from 5-18% in different study series.

Cutaneous manifestations of HIV disease may be less responsive to usual treatment modalities. Patients with HIV have been found to have increased rates of cutaneous colonization by Staphylococcus aureus, and, in patients with advanced disease, sepsis and deep tissue infection can be common. In patients with bacteremia, S aureus has been isolated as much as 25% of the time. In one series of 646 patients with HIV, S aureus sepsis developed in 14 patients, and 10 of them later died. Risk factors for sepsis include intravenous catheter use, intravenous drug use, and trauma. AIDS-related neoplastic diseases also contribute to morbidity and mortality.

Race

In the United States, persons of color, including African Americans and Hispanics, are disproportionately infected.

Sex

HIV-1 infection frequently occurs in homosexual men. However, the spectrum of prevalence of dermatologic disease in women who are infected with HIV versus men who are infected with HIV differs only in a higher frequency of Kaposi sarcoma (KS) and oral hairy leukoplakia in men; men possibly have a higher frequency of onychomycosis. Women are at an increased risk for gynecologic infections, including recurrent candidiasis and human papillomavirus (HPV). Women most commonly acquire HIV infection through sexual intercourse.

Age

HIV infection commonly occurs in young adults. The virus may infect children by transplacental transmission or by breastfeeding. Some rare cases of children infected after sexual abuse by adults with HIV-1 have also been reported.

Clinical

History

The cutaneous manifestations occurring in HIV infection are mostly due to the alterations in the immune system.

• Acute primary HIV infection may lead to a transient, generalized, morbilliform eruption on the trunk and the arms.
• In the early asymptomatic stage of HIV disease, no signs of infection other than lymphadenopathy are present. This stage may last for 10 years or longer.
• With the onset of immunosuppression, nonspecific skin changes occur such as common disorders with atypical clinical features, including recurrent varicella zoster, numerous hyperkeratotic warts, treatment-resistant seborrheic dermatitis, and oral hairy leukoplakia.
• In the later stages of HIV disease, chronic HSV, MC, and CMV appear.
• Mycobacterial infections and mucocutaneous candidiasis occur.
• KS can occur prior to the onset of immunosuppression.
• According to Smith et al¹ (who examined 912 patients infected with HIV-1) condylomata acuminata and verrucae are observed early, without an increase in occurrence as the disease progresses; whereas the incidence of HSV infections, MC, and oral hairy leukoplakia increases as the disease advances.
• Verrucous herpes infection, leprosy, condylomalike molluscum contagiosum, and AIDS-associated pigmented or nonpigmented erythroderma may be seen.^2,3,4,5 Leishmaniasis and miliary tuberculosis are also concerns.^6,7

Physical

Cutaneous manifestations of HIV disease can present as neoplastic, infectious, and noninfectious diseases.

• Kaposi sarcoma
  • KS was 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.
  • 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 8–associated malignancies.
  • 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.

Man who has HIV infection and Kaposi sarcoma.

Man who has HIV infection and Kaposi sarcoma (same patient as in Media File 2).

• Other HIV-associated malignancies
  • AIDS-related B-cell non-Hodgkin lymphomas may lead to skin nodules.
  • Anal carcinoma and cervical intraepithelial neoplasia are papillomavirus-associated tumors associated with HIV disease. These tumors tend to be more progressive and aggressive.
  • An increase in squamous cell carcinoma of the anal mucosa has been reported, especially in young homosexual men with HIV infection.
  • Intraoral or multiple squamous cell carcinoma, Bowen disease, and metastatic basal cell carcinoma have occasionally been reported in patients infected with HIV.
  • 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.
  • Children with AIDS have a higher risk of developing leiomyosarcoma, although the incidence is still low in this population.
  • 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 non–AIDS-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.⁸
• 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), and 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, and chronic VZV infection mimicking basal cell carcinoma, have also been described. According to Leibovitz et al,^9,10 chronic VZV infections associated with HIV-1 infection begin as vesicles and progress into necrotic, nonhealing ulcers.
• Epstein-Barr virus (EBV) has been implicated in the pathogenesis of oral hairy leukoplakia. Oral hairy leukoplakia, which is characterized by filiform white papules localized on the sides of the tongue, may develop in patients infected with HIV. Oral hairy leukoplakia 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.
• CMV 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.
  • Bournerias et al¹¹ reported epidermal involvement in 2 patients infected with HIV.
  • CMV infection of the eccrine ducts resulting in squamous metaplasia has been described in a patient 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.
• Widespread or recalcitrant warts may be observed on the oral mucosa, the face, the perianal region, and the female genital tract in patients infected with HIV. The perianal and cervical lesions may be difficult to treat. Large plantar warts caused by HPV-66 and an epidermodysplasia verruciformislike eruption, which is believed to be associated with HPV infection, have also been reported in patients infected with HIV.
• 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.

Young man with HIV disease and molluscum contagiosum on the lateral part of the eyebrow.

Molluscum contagiosum on the penile shaft in a patient with HIV disease.

• 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 by Trichophyton 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.
• Mycobacterial infections
  • Mycobacterium tuberculosis; Mycobacterium avium-intracellulare complex; and, rarely, Mycobacterium kansasii may present as acneiform papules and indurated crusted plaques.
  • 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 sporotrichosislike lesions was described in a patient with AIDS.
  • In patients with HIV, Mycobacterium haemophilum can also present as violaceous draining nodules and superficial ulcers on the extremities, trunk, head, and genitalia.
  • Rarely, B quintana coinfection with M avium complex and CMV has been reported in AIDS patients.
• 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.
  • 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, which is characterized by widespread hyperkeratotic, scaly maculopapular eruptions or crusted plaques, can occur in patients with HIV infection.
• Leishmaniasis: Atypical disseminated leishmaniasis 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
  • According to Mathes et al,¹² seborrheic dermatitislike eruptions are 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.
  • Seborrheic dermatitis may be increased in patients with AIDS-associated dementia or CNS disease.
  • 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.
  • The typical skin lesions of pityriasis rosea may accompany HIV disease.
  • 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
  • PPE 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.
  • The cause is not known. According to Boonchai et al,¹³ 81.25% of patients with PPE have advanced immunosuppression.

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

• 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.
  • 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.
• Drug eruptions
  • Morbilliform drug eruptions can occur in as many as 65-70% of patients who are treated by trimethoprim-sulfamethoxazole (TMP-SMZ) for Pneumocystis carinii pneumonia within 7 days of starting the therapy. Reddish macules and papules may be generalized and can become permanent after the discontinuation of the therapy. Sulfonamides may cause urticaria; erythema multiforme; toxic epidermal necrolysis; and systemic reactions, including fever, leukopenia, thrombocytopenia, hepatitis, and nephritis. Toxic epidermal necrolysis has been reported with antibiotics, fluconazole, clindamycin, phenobarbital, and chlormezanone in patients with HIV.
  • Fixed drug eruption has been reported in 2 patients receiving saquinavir, an HIV-1 protease inhibitor.
  • Drug eruptions have been reported as the most common cause of erythroderma in patients infected with HIV.
• Aphthosis: Severe aphthous stomatitis may be associated with HIV disease.
• Autoimmunity, atopic disease, and urticaria
  • Thrombocytopenic purpura, vitiligo, alopecia areata, sicca syndrome, 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. In a study by Vin-Christian et al,¹⁴ patients with HIV were sensitive to UV-B light. Vin-Christian et al¹⁴ also showed that the 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.

Causes

• HIV infection frequently occurs in men who have multiple male partners and in individuals who use illicit intravenous drugs.
• Children may be infected by transplacental transmission and rarely by sexual abuse from adults infected with HIV.
• Health care workers are another group at risk for HIV disease.

Differential Diagnoses

Other Problems to Be Considered

Ashy dermatosis
Normolipemic xanthomas
Multiple dermatofibromas
Recurrent neutrophilic eccrine hidradenitis
Pemphigus vegetans
Lichen scrofulosorum
Cutaneous mucinosis
Papulonecrotic tuberculide
Kawasaki disease
Eruptive dysplastic nevi
Dissemination of vaccinia
Ofuji disease
Angiomyolipomas
Glucan-induced keratoderma
Disseminated superficial porokeratosis

Workup

Laboratory Studies

• Acute primary HIV infection
  • Enzyme-linked immunosorbent assay (ELISA) can be used to screen for HIV infection. Western blot or immunofluorescent assay can be used to confirm the diagnosis.
  • In the asymptomatic period, the patient can be tested for antibodies against p24 and gp41.
  • Symptomatic disease
    • Anti–HIV-1 and anti–HIV-2 can be checked by using ELISA, Western blot, or latex agglutination. HIV may be diagnosed in most patients with the help of ELISA. Western blot assay is expensive, more specific, and can be used as the confirmation test. Latex agglutination, which detects gp120, is rapid and easy to use.
    • Viral load assays can be used to evaluate the effectiveness of the antiviral treatment.
    • Polymerase chain reaction and viral culturing are highly sensitive tests, but they are expensive and technically more difficult to perform.
    • The ratio of CD4⁺ to CD8⁺ T cells is decreased.
• Viral infections associated with HIV infection
  • Direct microscopic examination for HSV infection should be performed. Multinuclear cells with intranuclear inclusions may be present; however, these assays do not distinguish HSV from VZV.
  • Immunofluorescence can be used to detect monoclonal antibodies against HSV-1 and HSV-2.
  • Serology can be used to detect antibodies to type-specific glycoproteins of HSV, VZV, CMV, or EBV.

Imaging Studies

• Imaging studies may be helpful in evaluating extracutaneous manifestations of KS, lymphoma, and systemic infections.

Other Tests

• Culturing can be used to detect HIV and HIV-associated opportunistic infections, such as viral, bacterial, atypical mycobacterial, or fungal infections.
• Electron microscopy can be used to detect HIV-related infections.

Histologic Findings

Histopathologic examination is useful to diagnose cutaneous manifestations of HIV disease with atypical clinical features and KS. Routine hematoxylin and eosin and periodic acid-Schiff stainings may demonstrate multinuclear cells with intracytoplasmic inclusions of HSV infection. Other special stains may identify additional pathogens, or they may confirm malignancies, such as KS.

Treatment

Medical Care

• Viruses
  • HSV and HZV infections: The treatment of choice for HSV and HZV diseases in patients infected with HIV is acyclovir and other members of this class. These agents are activated by viral thymidine kinase. In some disseminated cases, the virus may be resistant to acyclovir because of the deficiency in viral thymidine kinase activity. Prolonged therapy and chronic suppressive therapy with subtherapeutic doses have also been implicated in the development of acyclovir resistance. In the presence of acyclovir resistance, other viral therapies, including cidofovir, foscarnet, and vidarabine, may be necessary.
  • EBV infection: Treatment is usually not necessary for patients with oral hairy leukoplakia. When the patient experiences significant discomfort, systemic (1200 mg/d) and topical acyclovir, ganciclovir, or foscarnet may be recommended.
  • CMV infection, warts, and molluscum contagiosum: Aldara (imiquimod) is curative of MC in most cases. Response to AZT therapy has been reported in patients infected with HIV associated with MC. Reports of the efficacy of cidofovir in several viral infections (eg, MC, warts, CMV infection) frequently observed in patients infected with HIV are limited. However, extensive studies of both the safety and the efficacy of cidofovir have not been conducted to date.
• Superficial fungal infections
  • Mucocutaneous candidiasis is usually difficult to treat, and oral azole treatment may be required.
  • Generalized dermatophytosis may be resistant to topical antifungal creams and may require systemic antifungal therapy.
• Bacillary angiomatosis: Oral erythromycin is usually effective for the treatment of bacillary angiomatosis.
• Treatment of noninfectious cutaneous manifestations of HIV infection other than KS
  • Xerosis: Emollients and dry skin care regimens are effective in the management of this condition.
  • Seborrheic dermatitis: Therapies with coal tar, sulfur, and salicylic acid shampoos; topical corticosteroids; topical tacrolimus; and 2% ketoconazole cream may be effective.
  • Psoriasis and Reiter syndrome: UV-B and psoralen UV-A (PUVA) may be useful in patients with psoriasis or Reiter syndrome. Systemic corticosteroids, methotrexate, and cyclosporine may increase the immune suppression and must be considered only with careful monitoring. Zidovudine is also reported to be useful in the treatment of HIV-associated psoriasis.
  • Pruritic papular eruption: Treatment with topical steroids, UV-B, PUVA, and pentoxifylline has been reported to be effective.
  • Eosinophilic folliculitis: This may respond to UV-B, isotretinoin, or zidovudine treatment.
  • Aphthosis: Tacrolimus is reported to be effective in the treatment of severe aphthous stomatitis in HIV disease.
• Kaposi sarcoma
  • For patients with limited disease, local therapy with liquid nitrogen, alitretinoin, or intralesional vincristine may be effective. Surgery, radiotherapy, and systemic chemotherapy usually with a single agent (eg, vinblastine, vincristine, bleomycin, doxorubicin, etoposide) may be useful in the treatment of KS; however, systemic chemotherapy has not been shown to improve the long-term survival rates. Patients treated with antiretroviral agents who recover immune response have had remission of KS.
  • Interferon (IFN)-alpha and IFN-beta photodynamic therapy and systemic hyperthermia have also been used.

Surgical Care

• Ablation and curettage may be useful in the treatment of MC.
• Cryotherapy, laser irradiation, and electrodesiccation can be useful for localized solitary lesions of KS.

Consultations

A primary care practitioner familiar with the manifestations of HIV should monitor patients with HIV. Patients confronting this chronic and debilitating disease may require additional support services. Infectious disease consultants are typically involved in the care of these patients.

• Ophthalmologist for CMV retinitis
• Neurologist and anesthesiologist for postherpetic neuralgia and neurologic symptoms
• Nephrologist to adjust the doses of antiviral agents
• Psychiatrist to encourage the expression of deep emotions, such as grief, guilt, and anger

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Antivirals

Acyclovir or famciclovir are usually recommended in HSV-1, HSV-2, and VZV infections. Cidofovir may be recommended for infections associated with HIV infection, including cutaneous CMV infection and retinitis, MC, warts, and HSV infections. Ganciclovir is recommended for CMV retinitis. Foscarnet is recommended for CMV infections. Aldara is used in the treatment of MC. Vidarabine is recommended for keratoconjuctivitis.

Acyclovir (Zovirax)

Inhibits activity of both HSV-1 and HSV-2. Has affinity for viral thymidine kinase, and once phosphorylated, it causes DNA chain termination when acted on by DNA polymerase. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative. In some disseminated cases, the virus may be resistant to acyclovir because of deficiency in viral thymidine kinase activity. Prolonged therapy and chronic immunosuppressive therapy may result in resistance when acyclovir is administered at subtherapeutic doses.

Dosing

Adult

Recurrent herpes stomatitis or genitalis: 200 mg PO 5 times/d or 400 mg tid for 5 d or until lesions have healed
Primary or disseminated herpes infection: 5 mg/kg IV q8h for 7-10 d; 200-400 mg 5 times/d for 10 d if only primary
Uncomplicated cases of varicella-zona: 800 mg PO 5 times/d for 7-10 d or 10 mg/kg IV q8h for 10 d may be recommended for primary, recurrent, severe, or disseminated HZV

Pediatric

Herpes: 250 mg/m² PO q8h or 5 mg (10 mg)/kg IV q8h for 7 d
Primary, recurrent, severe, or disseminated HZV infection: 10 mg/kg IV q8h for 7-10 d

Interactions

Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal failure or when using nephrotoxic drugs; in renal failure, adjust dose according to CrCl (CrCl >50 mL, IV q8h; CrCl 25-50 mL, IV q12h; CrCl 10-25 mL, IV qd; CrCl 0-10 mL, half the dose recommended IV qd); recommend contraception

Cidofovir (Vistide)

Nucleoside analog of deoxycytidine monophosphate. Inhibits viral DNA polymerase more avidly than human polymerase. Cidofovir is independent of thymidine kinase activation. IV and topical formulation available. Cidofovir 3% cream or gel has been used for HSV infections, MC, and warts associated with HIV infection.

Dosing

Adult

Initial: 5 mg/kg IV over 1 h once every other wk
Maintenance: 5 mg/kg IV over 1 h once every other wk
Topical: Apply thinly qd to bid until resolved

Pediatric

IV: Not established
Topical: Apply as in adults

Interactions

Coadministration of aminoglycosides, amphotericin B, IV pentamidine, and foscarnet may increase nephrotoxicity

Contraindications

Documented hypersensitivity; coadministration with other nephrotoxic agents; serum creatinine level >1.5 mg/dL; CrCl <55 mL/min; urine protein level >100 mg/dL

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor neutrophil counts; renal toxicity is major adverse effect; prehydrate with isotonic sodium chloride solution IV and coadminister probenecid with each infusion to minimize nephrotoxicity (monitor renal function); monitor serum creatinine and urine protein levels 48 h prior to treatment (adjust dose accordingly); granulocytopenia may occur; with topical application, local irritation, pain, paresthesia, or ulceration may occur

Ganciclovir (Cytovene, Vitrasert)

Synthetic guanine derivative active against CMV. Acyclic nucleoside analog of 2-deoxyguanosine that inhibits replication of herpes viruses in vitro and in vivo. Levels of ganciclovir-triphosphate are as much as 100-fold greater in CMV-infected cells than in uninfected cells, possibly because of preferential phosphorylation of ganciclovir in virus-infected cells.

Dosing

Adult

Induction: 5 mg/kg IV over 1 h q12h for 14-21 d (do not use PO ganciclovir for induction treatment)
Maintenance: 500 mg PO q4h for life; 5 mg/kg IV qd for 5-7 d per wk

Pediatric

<3 months: Not established
>3 months: Administer as in adults

Interactions

Concomitant administration with cytotoxic drugs, such as dapsone, vinblastine, Adriamycin, pentamidine, flucytosine, vincristine, amphotericin B, TMP-SMZ combinations, or other nucleoside analogs, may result in additive toxicity in bone marrow, spermatogonia, and germinal layers of skin and GI mucosa (coadminister only if potential benefits outweigh risks); coadministration with imipenem-cilastatin may cause generalized seizures (use only if potential benefits outweigh risks); serum creatinine may increase following concurrent use of ganciclovir with either cyclosporine or amphotericin B; in the presence of probenecid, renal clearance of ganciclovir is reduced; bioavailability may increase when didanosine is administered either 2 h prior to or simultaneously with ganciclovir; bioavailability may decrease in the presence of zidovudine, while bioavailability of zidovudine is increased in the presence of ganciclovir

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Clinical toxicity of ganciclovir includes granulocytopenia, anemia, and thrombocytopenia; use only when benefits outweigh risks (eg, in advanced HIV disease) because oral ganciclovir is associated with higher rate of CMV retinitis progression compared with IV formulation; half-life and plasma/serum concentrations may be increased because of reduced renal clearance; dosages >6 mg/kg IV may result in increased toxicity; rapid infusions may result in increased toxicity; initially, reconstituted solutions of IV ganciclovir have a high pH (11); phlebitis or pain may occur at site of IV infusion despite further dilution in IV fluids; administration should be accompanied by adequate hydration; photosensitization (photoallergy or phototoxicity) may occur

Foscarnet (Foscavir)

Organic analog of inorganic pyrophosphate that inhibits replication of known herpesviruses, including CMV, HSV-1, and HSV-2. Inhibits viral replication at pyrophosphate-binding site on virus-specific DNA polymerases. Poor clinical response or persistent viral excretion during therapy may be due to viral resistance.
Patients who can tolerate foscarnet well may benefit from initiation of maintenance treatment at 120 mg/kg/d early in treatment. Individualize dosing based on renal function status.

Dosing

Adult

Induction: 60 mg/kg/dose IV q8h or 100 mg/kg IV q12h for 14-21 d
Maintenance: 90-120 mg/kg/d IV as single infusion for life

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Coadministration with potentially nephrotoxic drugs (eg, aminoglycosides, amphotericin B, IV pentamidine) may increase nephrotoxicity (do not administer unless potential benefits outweigh risks); coadministration with IV pentamidine may cause hypocalcemia

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May cause decline in renal function; for correct dosing, obtain 24-h serum creatinine level at baseline and continue to monitor (discontinue if serum creatinine <0.4 mL/min/kg); hydration may reduce nephrotoxicity; carefully monitor electrolytes (eg, calcium, magnesium); assess for electrolyte and mineral level abnormalities if mild perioral numbness, paresthesias symptoms, or seizures occur; granulocytopenia and anemia may occur (regularly monitor CBC); infuse solutions into veins with adequate blood flow to avoid local irritation; to avoid toxicity, do not administer by rapid or bolus IV injection

Vidarabine (Vira-A)

Topical idoxuridine that interferes with early steps of viral DNA synthesis. If no signs of improvement after 7 d or incomplete reepithelialization in 21 d, consider alternative therapy. Severe cases may require longer treatment. After reepithelialization occurs, treat bid for another 7 d to prevent recurrence.

Dosing

Adult

Apply 0.5-inch ribbon into lower conjunctival sac 5 times/d q3h

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Viral resistance is possible but none reported

Imiquimod (Aldara)

Used for the treatment of warts and MC; induces secretion of interferon alpha and other cytokines; mechanisms of action are unknown.

Dosing

Adult

Apply 3 times/wk prior hs; leave on skin for 6-10 h

Pediatric

Not established

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not recommended for treatment of rectal, cervical, intravaginal, urethral, and intra-anal human papilloma infection; after surgery or drug treatment, do not use topical imiquimod until genital/perianal tissue is healed

Antifungals

Mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

Ketoconazole systemic (Nizoral)

Fungistatic activity. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Dosing

Adult

200 mg/d PO; increase to 400 mg/d PO if clinically indicated

Pediatric

<2 years: Not established
>2 years: 3.3-6.6 mg/kg/d PO once

Interactions

Isoniazid may decrease bioavailability; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels

Contraindications

Documented hypersensitivity; fungal meningitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacid, anticholinergics, or H2-blockers at least 2 h after administration

Ketoconazole topical (Nizoral)

Fungistatic activity. Imidazole broad-spectrum antifungal agent; inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Dosing

Adult

Rub gently into affected area qd or bid for 2-4 wk

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes

Retinoids

Vitamin A derivatives have many roles. They encourage cellular differentiation, they are antiproliferative, and they serve as immunomodulators.

Alitretinoin (Panretin)

Naturally occurring endogenous retinoid. Inhibits growth of KS by binding to retinoid receptors

Dosing

Adult

0.1% gel; apply topically to affected cutaneous lesions bid/qid

Pediatric

Not established

Interactions

Increases toxicity of DEET if used concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Preexisting cutaneous T-cell lymphoma; do not use occlusive dressing; avoid UV light exposure of treated areas

Follow-up

Deterrence/Prevention

• The education of the public and of health care workers concerning HIV transmission is important.
• Sexual contacts should be tested. Protection of sexual partners of patients infected with HIV is necessary.

Prognosis

• The long-term prognosis is poor. Treatment with highly active antiretroviral therapy is initially effective.

Patient Education

• The education of patients, their spouses, their partners, and their families is part of the physician's responsibility.
• For excellent patient education resources, visit eMedicine's Immune System Center, Sexually Transmitted Diseases Center, Teeth and Mouth Center, and Yeast and Fungal Infections Center. Also, see eMedicine's patient education articles HIV/AIDS, Canker Sores, Candidiasis (Yeast Infection), and Syphilis.

Miscellaneous

Special Concerns

• Children with HIV infection
  • The most common cutaneous infections in children with HIV disease are impetigo and cellulitis caused by S aureus.
  • Common cutaneous manifestations in children with HIV infection are mucocutaneous candidiasis, including recurrent and widespread diaper dermatitis and chronic paronychia. Recurrent herpetic gingivostomatitis, scabies, severe atopic dermatitis, drug eruptions, and leukocytoclastic vasculitis are other cutaneous manifestations of HIV infection in the pediatric age group.

Multimedia

Media file 1: Dull red, violaceous, maculopapular lesions on the upper part of the trunk in a 49-year-old man with primary HIV-1 infection.

Media file 2: Man who has HIV infection and Kaposi sarcoma.

Media file 3: Man who has HIV infection and Kaposi sarcoma (same patient as in Media File 2).

Media file 4: Young man with HIV disease and molluscum contagiosum on the lateral part of the eyebrow.

Media file 5: Molluscum contagiosum on the penile shaft in a patient with HIV disease.

Media file 6: Old herpes zoster and Kaposi sarcoma in a patient with HIV disease.

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Keywords

Kaposi sarcoma, Kaposi's sarcoma, KS, human immunodeficiency virus, HIV, HIV-associated malignancy, viral infection, herpes simplex virus, herpes zoster virus, HSV, HZV, Epstein-Barr virus, EBV, cytomegalovirus, CMV, warts, molluscum contagiosum, MC, fungal infections, candidiasis, dermatophytosis, cryptococcosis, histoplasmosis, North American blastomycosis, coccidioidomycosis, bacterial infections, impetigo, folliculitis, bacillary angiomatosis, mycobacterial infections, syphilis, scabies, papulosquamous dermatoses, seborrheic dermatitis, drug eruptions, hair and nail disorders, cutaneous vasculitis, autoimmunity, atopic disease, urticaria, aphthous stomatitis, pruritic papular eruption, PPE, eosinophilic folliculitis, EF

Contributor Information and Disclosures

Author

Emel Erdal, MD, Associate Professor of Dermatology, Mesa Hospital, Turkey
Disclosure: Nothing to disclose.

Coauthor(s)

Anna Zalewska, MD, PhD, Assistant Professor, Adjunct Professor, Department of Dermatology and Venereology, Medical University of Lodz, Poland
Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Ronald A Greenfield, MD, Professor, Department of Internal Medicine, Section of Infectious Diseases, University of Oklahoma College of Medicine
Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology
Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist  Speaking and teaching

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Julia R Nunley, MD, Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center
Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society
Disclosure: Johnson and Johnson stock holder dividends; Amgen stock holder dividends; Forest Lab, Inc stock holder dividends; Galaxo Smith Klein stock holder dividends; Covidien stock holder dividends; Novartis Grant/research funds Consulting; Biolex  sub-investigator

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, and previous author, Randa M. Hamadeh, MD, to the development and writing of this article.

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