HIV infection/AIDS is a pandemic that still
poses one of the greatest
challenges in global public health.
Approximately 40 million people in the
world are currently living with
HIV infection and 25 million have died since
Thirteen million children have been
HIV is an enveloped RNA virus.
The incubation period ranges from 3 to 6 weeks.
Upon initial infection, the virion
binds to CD4 + T lymphocytes, monocyte-macrophages and dendritic cells.
Changes in conformation induce fusion of the viral envelope with
the plasma membrane.
Next, its outer coat is removed and the virus
particle is internalized.
The DNA copy is then integrated
into the host DNA and can be expressed as a cellular gene.
there is transcription of viral RNA into DNA
Cleavage of some of viral genome into the structural
components of the
virus is accomplished by proteases.
Intact viruses are then produced and host cells are
• Up to 92% of HIV/AIDS patient will have one
or more skin disorders during the course their
• Recognizing HIV-related skin changes may
lead to the diagnosis of HIV infection in the
early stages &clincal staging of HIV/AIDS
which allows initiation of antiretroviral
• Dermatological manifestations are seen
at every stage of HIV/AIDS
• Some of the conditions are unique and
virtually pathognomonic for HIV disease
like bacillary angiomatosis and oral hairy
Acute Retroviral Syndrome
• 80 percent of cases
• Occurs during seroconversion .
• IP 3 to 6 weeks
• Constitutional symptoms are followed by
• Some recommend initiation HAART .
•Commonest inflammatory dermatosis seen
• affects 32-83% of HIV/AIDS patients
•usually present as sever or atypical forms.
•Atypical forms: erythroderma, secondary bacterial
• Generalized dry skin is more frequently
observed in patients with HIV infection.
• It is often accompanied by severe generalized
generalized acquired ichthyosis with large plate-like
scales on the legs.
Severe form of Atopic dermatitis is a frequent
problem in children or adults with HIV/AIDS and is
often difficult to control with conventional therapy.
It may develop at any stage of HIV infection .
Like seborrheic dermatitis, a rapid onset of 'eruptive'
can serve as an important clue to an underlying HIV
The psoriasis is often severe and may be associated
significant nail dystrophy, arthritis and Reiter's disease.
It tends to worsen with declining immune status.
Pruritic Papular eruption
(PPE) of AIDS is characterized by marked
pruritus and a greater involvement of the extremities than the trunk or face.
It is more prevalent in Africa as compared to North America or Europe.
Propsed possibility that it is an exaggerated response to arthropod
Clinically, the lesions are symmetrically distributed, non-follicular papules
often with secondary change(excoriation,prurigo nodularis)
Pruritic papular eruption (PPE)
• Common and relatively specific manifestation,
60% have advanced immunosuppression.
• The cause is not known.
• Emollients, steroid and antihistamines give
• Pyodermas are very common in HIV/AIDS
Recurrent Staph &streptococal infections
3 .Bacillary angiomatosis
is a bacterial infection that may involve virtually
any body site, but it favors the skin and subcutaneous tissue.
Lesions of variable size and shape may be seen, including red to purple
'vascular appearing‘ papules or nodules & ulcers.
The number of lesions ranges from one to more than hundreds.
Gram-negative bacilli in the genus Bartonella are responsible for this
Diagnosis is usually based
on histologic features
i.e. characteristic vascular proliferation
numerous bacilli visualized by Warthin-
• TTC 500mg QID for 2m.
• Doxacycilline 100mg BID until it resolve.
• Wide spread &extensive fungal
infections which are resistant to
treatment can be related to
• Recurrent and severe oropharyngeal
candidiasis, usually extending to the
esophagus is the presenting
symptom and indicates
• Deep and rare fungal infections like
cryptococcosis, coccidiomycosis, and
histoplasmosis affecting the systemic organs
and the skin are unique features of advanced
Systemic fungal infection
• Indicates Profound immunodeficiency
• Histoplasmosis, Cryptococcosis
•high index of suspicion is very important
•treat with Systemic antifungals for longer periods.
Common viral skin infections in
• Herpes simplex virus 1,2
• Varicella zooster
• Human papilloma virus
• Epistein bar virus
• Hepes simplex virus 8.
Herpes Simplex Virus
• Chronic persistent infection with herpes
simplex virus (HSV) is AIDS defining illness.
• Ulceration is the usual finding with or with
out prior history of blisters.
• Dissiminated forms with meningitis may
occur in advanced immunosupression.
• Once significant immune suppression
develops, lesions may progress
to chronic, non-healing, deep ulcerations
The genitalia and tongue.
frequent recurrences are usually seen.
Treatment of HSV
• Acyclovir 200mg po q5hrs for 7 to 10days
• Topical treatments for herpes are much
• Prolonged treatment with intravenous
acyclovir is needed for HSV Encephalitis.
Varicella zoster virus
primary varicella infection (chicken pox )occur during
it may be subclinical.
In HIV-infected individuals, primary varicella may be
severe,prolonged &complicated by pnumonia
,hepatitis ,encephalitis &death.
HIV infected pts.have a 10 times risk of developing
• Commonly seen early in the course of HIV
infection, particularly in healthy-appearing
• It is due to reactivation of the latent virus that
resides in the dorsal ganglion in
• The lesions starts as painful grouped vesicles
which follows dermatomal distribution.
• Recurrences and multidermatomal involvement
Treatment of herpes zoster
• Acyclovir 800mg po 5 times daily for 7days.
• The drug is effective only during the active
stage of the disease.
Oral Hairy Leukoplakia
• Very specific manifestation of HIV infection
• presenting as filiform white papules usually on
the edge of the tongue.
• it is due to Epstein-Bar virus infection.
• May be the initial sign of progressive
• Caused by poxvirus.
• It Affects
Sexualy active adult
• Involvment of oral and genital mucosa indicate
• Occurrence of MC on the face of an adult is an
indication to screen for HIV
• The character of the lesions are Centrally
umbilicated skin coloured papules.
• Spontaneous healing is rare
• No hematogenous spread
• Cryotherapy/ electrocautery
• 50 % trichloraceticacid
• Saliycilic acid
• 10%Potassium hydroxide solution
•usually it Will recur but resolves with continuing ART.
HPV is transmitted by close, repeated contact from infected individual.
HPV-induced lesions are common in the general population
more prevalent in HIV-infected individuals
Lesions may be
• widespread with multiple verrucated papules on the face,
• limbs and genitalia that may coalesce into large plaques.
In addition, HIV-infected patients have
• Higher risk of developing cervical intraepithelial neoplasia (CIN) and
• anal intraepithelial neoplasia (AIN).
human papilloma virus
human papilloma virus
With increasing immunodeficiency, cutaneous
and/or mucosal HPV infection recur
from latency, presenting clinically as verruca,
condyloma acumintatum,insitu or invasive
squamous cell cancer.
human papilloma virus
The increased prevalence of HPV-induced
lesions in HIV disease is related to
deficient cell mediated immunity .
Increased HPV replication of the more
oncogenic HPV types occurs with more
human papilloma virus
The degree of immunosuppression correlates with the presence of
HPV DNA,extent of HPV inf.& potential for malignent
Individuals with CD4 cell counts <200/mL being at greatest risk.
Potential for malignant transformation varies considerably
according to the type& site of HPV-infected epithelium
being greatest for the transitional epithelium of the cervix and
lesser for vulvar epithelium,
And least for the epithelium of the male genitalia, perineum,
inguinal folds, and perianal rigion.
• Lesions may be extensive and resistant to therapy.
• warts usually look like those seen in
nonimmunosuppressed patients, but are more
• Flat warts on adult face are typical features of HIV
• Condyloma acuminata are of special
significance in persons with HIV infection.
• They are very difficult to eradicate.
• Cervical dysplasia and carcinoma are more
frequent and invasive cervical ca is AIDS
Oropharyngeal HPV-induced lesions resemble
anogenital condylomata, pink or whit in color.
Extensive intraoral condyloma acuminatum (oral
presents as multiple large plaques, analogous to
anogenital giant C.acuminata of Buschke-
Lowensten >>> verrucous carcinoma.
Monitoring should include serial physical
proctoscopy, cervical and anal HPV
determination and cytology.
confirmation when indicated.
Human papiloma virus treatment
Treatment decisions are based upon the size and
location of the lesions as well as histologic grade.
Treatment options are
podophyllin , podophyllotoxin, trichloroacetic acid,
cryotherapy, electro desiccation,
CO2 laser and surgical excision.
• The first reported malignancy in association
with HIV infection
• Appears as red-to-brown flat macules in any
site, mainly above the trunk
• Prognosis is poor and kills the patient unless
HAART is instituted immediately
The choice of treatment of KS depends on the extent and the
It often improves with HAART.
Certain patients with rapidly progressive
(poly)chemotherapy with cytotoxic drugs.
In addition to the vinca alcaloids
vinblastin and vincristin, which are
administered by the intravenous.
HIV-associated leishmaniasis may occur in both endemic
and nonendemic regions of the world.
Diffuse cutaneous leishmaniasis can be significantly
associatied with hiv infection.
• Frequency the same
• Norwegian (crusted) scabies, which is
characterized by wide spread
hyperkeratotic plaque occurs on palms and
• Prolonged treatment with repeated course
of scabicides is needed
Crusted scabies, in particular, is extremely contagious.
In any itchy HIV-infected patient, there should be a high index of
suspicion for scabies.
HIV-infected individuals with scabies are usually
treated initially with standard therapies but they may
require multiple courses.
Permethrin 5% cream
Ivermectin 250to 400microgram/kg single dose.
• The immune dysregulation associated with
AIDS has made these patients to react
abnormally for any exogenous stimuli like
arthropod bite, drugs, and UV radiation
Hair and Nail Disorders
• Diffuse alopecia or alopecia areata
• Elongation of the eyelashes and softening and
straightening of the scalp hair
• Yellow or white
• Blue nails
• Proximal subungal onychomycosis
Adverse Cutaneous Drug Eruptions
Adverse cutaneous drug eruptions can range from extremely mild to
life-threatening and may be caused by either a single drug or drug
They are quite common in HIV-infectcd Individuals.
Mechnisms underlying these reactions are unknown likely related to:
•Increased 100 times in patients with HIV
•12-16% skin rash is due to Bactrim
•Commonest type is maculopapular(morbiliform) rash
•8-10 days within Bactrim intake.
•Resolves with discontinuation of the drug
Common Drug reaction
• Steven Johnson Syndrome (SJS)
•Toxic epidermal necrolysis(TEN)
•Fixed drug eruption
• targetoid lesions and mucosal lesions
Patients may also present with:
urticaria, pruritus, vasculitis, photodermatitis
An adverse drug reaction should be high on the
differential diagnosis list when a patient taking
several medications develops cutaneous