Cutaneous manifestations are common in HIV patients, occurring in over 90% of cases. They can represent the first signs of HIV infection and have prognostic significance. Skin conditions in HIV patients often present atypically with lesions in unusual sites, atypical morphology, being more extensive or not responding to conventional treatments. Common manifestations include generalized rashes, oral/genital ulcers, seborrheic dermatitis, psoriasis, papulopruritic eruptions, eosinophilic folliculitis, granuloma annulare and various infections like herpes, molluscum, Kaposi sarcoma and non-Hodgkin's lymphoma. Dermatologists must have a high index of

1. CUTANEOUS
MANIFESTATIONS OF
HIV

2. Human Immunodeficiency Virus
▶Derived from SIV
▶Lymphotropic virus ,affects CD4+ T
cells and CD 4+ cells of monocytic
lineage

3. HIV
HIV 1 HIV 2
M N O P
STRAINS
GROUPS
A to K except E and I
SUBGROUPS
OR CLADES

4. ▶Genus- Lentivirus
▶Family- Retroviridae
▶120 nm icosahedral single stranded
positive sense enveloped RNA virus
STRUCTURE OF HIV

5. ▶ Cutaneous manifestations, may be the earliest signs
▶ Have prognostic significance
▶ >90% -some cutaneous manifestation
HIV IN DERMATOLOGY

6. ◦Generalized maculo-papular rash
on face, palms and soles
◦Non itchy
◦Oral ulcers, genital ulcers
Acute retroviral syndrome

7. ▶Pruritis and xerosis
▶Pigmentation disorders-
hyperpigmentation
hypopigmentation
▶Inflammatory disorders-
seborrheic dermatitis
psoriasis
granuloma annulare
eosinophilic folliculitis
PPE
Classification

8. ▶Infections
Bacterial –Staph, strep, TB, syphilis, bacillary
angiomatosis
Viral- HSV HZV HPV Molluscum
Fungal- superficial and deep
Parasitic- scabies
▶Malignancy
▶Drug induced- drug rash

9. ▶ENUMARATE THESE DISORDERS AND WRITE
▶ATYPICAL SITE
▶ATYPICAL MORPHOLOGY
▶EXTENSIVE LESIONS
▶DONOT RESPOND TO CONVENTIONAL
TREATMENT
▶LONGER DURATION OF TREATMENT
REQUIRED

10. ▶Commonly found in HIV
▶May develop prurigo nodularis
PRURITIS, XEROSIS

11. ▶Both hyperpigmentation and hypopigmentation
disorders
▶Hyperpigmentation of skin nails mucosa
PIGMENTATION DISORDERS

12. ▶Persistent serpentine supravenous
hyperpigmentation
▶Acanthosis nigricans
▶Generalised hyperpigmentation
▶Oral and anal hyperpigmentation

13. ▶Hypopigmentation disorders –rare
▶Vitiligo
▶Extensive hypopigmentation (drug photosensitivity)

14. ▶Seborrheic Dermatitis
▶Psoriasis
▶Eosiniphilic Folliculitis
▶PPE
▶Granuloma Annulare
INFLAMMATORY
DERMATOSES

15. ▶May occur at ANY CD4
▶HIV- more disseminated ,erythroderma can be presenting
feature
SEBORRHEIC DERMATITIS

16. ▶Presentation may be atypical
▶2 subgroups
▶1) Pre-existing psoriasis patients developing HIV – develop
typical plaque psoriasis
▶2) HIV patients going on to develop Psoriasis –
◦ Inverse psoriasis
◦ Palmoplantar psoriasis
◦ Psoriatic arthritis
PSORIASIS

17. ▶Pruritic
▶skin-colored to erythematous
▶papules
▶on the mainly extremities, trunk,
▶mucous membranes (mouth, nostrils, eyes, genitals), palms,
spared.
PAPULOPRURITIC ERUPTION

18. ▶PPE is a diagnosis of exclusion
▶a/w CD4 100-200

19. ▶a/w CD4 cell counts‹ 250 - 300
▶Very rare nowadays- due to ART
▶M>>F
▶highly Pruritic
▶Edematous
▶papulopustular eruption of sterile pustules.
▶Centripetal distribution , above nipple line
EOSINOPHILIC FOLLICULITIS

20. ▶Generalized (59%) ,
▶atypical (including oral and perforating) occur in HIV
GRANULOMAANNULARE

21. BACTERIAL INFECTIONS
INFECTIONS

22. ▶Staphylococcus aureus > Pseudomonas> E.coli >
Streptococcus
▶Cellulitis,soft tissue infection, bullous impetigo,
ecthyma, SSSS, TSS, abscesses,folliculitis,
pyomyositis, botryomycosis

23. ▶Psedomonas aeruginosa-
Ecthyma gangrenosum, panniculitis, septicemia
▶Group A streptococcus- erysipelas, lymphadenitis

24. SYPHILIS
■May present atypically
■Primary : genital ulcers can be mutiple, larger and
deeper
■Secondary : lues maligna
False negative serology

25. ▶Bartonella henselae
▶Red to violaceous, soft to firm papules, nodules or
plaques, few mm to 2-3cm
BACILLARY ANGIOMATOSIS

26. MYCOBACTERIUM TUBERCULOSIS
▶Extrapulmonary, including cutaneous is common-
AIDS
defining illness

27. Atypical mycobacterial infections common-

28. FUNGAL INFECTIONS
■SUPERFICIAL
FUNGAL INFECTIONS
■DERMATOPHYTOSES
■CANDIDIASIS
■SYSTEMIC MYCOSIS
■CRYPTOCOCCOSIS
■HISTOPLASMOSIS
■PENICILLIOSIS
■PNEUMOCYSTIS
JIROVECI
DEEP FUNGAL
INFECTIONS- AIDS
DEFINING ILLNESS

29. DERMATOPHYTOSES
▶Common in HIV , More prevalent in MSM-even
without HIV
▶Tinea cruris , Tinea corporis, Tinea pedis ,
onychomycosis
▶Widespread dermatophytoses NOT common in HIV

30. ➢Atypical morphology
➢Lesions have little inflammation and often lack the
elevated border
➢Atypical presentations like deep , invasive
dermatophytosis , Majocchi’s granuloma
➢Atypical sites
➢Penis scrotum
➢Tinea capitis in adults –could be a sign of HIV

31. ▶Esophageal candidiasis ,candidiasis of trachea
bronchi lungs- AIDS defining illness
CANDIDIASIS

32. VIRAL INFECTIONS

33. ▶Both HSV 1 and 2 are common
▶Atypical, extensive ,respond poorly to conventional
treatment
▶Large deep ulcers
▶Chronic herpetic ulcers of longer than 1 month
duration- AIDS defining illness
HERPES SIMPLEX VIRUS

34. ▶Varicella / chicken pox
↖Prolonged course
↖Lesions may be Verrucous
↖Complications- pneumonitis, meningitis,bacterial
infections
VARICELLA ZOSTER INFECTION

35. ➢ Herpes zoster
-occurs in younger age group in HIV patients
-Can present as atypical forms
Multidermatomal HZ
Disseminated HZ
Verrucous lesion
necrotic or ulcerative lesions
-systemic complications like fulminant hepatitis and acute
meningoencephalitis
-recurrences are common

36. ▶Atypical in location, morphology, and size
▶Extensive ,giant , warty , Extragenital sites(FACE)
MOLLUSCUM CONTAGIOSUM

37. ORAL HAIRY LEUKOPLAKIA
-EBV
-Asymptomatic raised corrugated white lesion on the
lateral tongue .
-D/d -oral candidiasis

38. HUMAN PAPILLOMA VIRUS
➢Common warts ,anogenital warts, oral lesions
-diffuse
-occur at multiple sites
-vegetating types
➢ Increased risk of premalignant and malignant
conditions

39. PARASITIC INFECTIONS

40. ➢Norwegian scabies
SCABIES

41. NEOPLASMS

42. KAPOSI SARCOMA
▶Caused by HHV 8
▶AIDS DEFINING
▶ purple to brown patch,
plaque or nodule, which
may ulcerate
▶Lower extremities ,face
and oral cavity
▶In HIV -multicentric

43. ▶Primary skin malignancies are most common NADCs
▶SCC: BCC in HIV infected individuals is 1 : 7
▶SCC may present atypically, at a younger age, at
unusual sites (e.g. the nail fold) and be multifocal and
aggressive
NON AIDS DEFINING CANCERS

44. ➢Melanoma- present atypically and behave more
aggressively. May occur as benign macules or multiple
naevoid lesions.

45. DRUG REACTIONS

46. ▶Commonly used drugs
◦ATT
◦ART
◦Antibiotics esp Septran

47. ▶Therefore, a prior drug reaction does not constitute
an absolute contraindication to continued or further
treatment with a particular drug.
▶ART
◦Pruritis
◦Rash
◦SJS/TEN

48. IRIS (IMMUNE RECONSTITUTION
INFLAMMATORY SYNDROME)

49. TAKE HOME MESSAGE
ALL skin diseases in HIV patients in general
have
▶Unusual sites
▶Unusual presentations
▶Refractory to conventional therapy
▶Longer duration of treatment required
▶Continue ART

50. Skin manifestations may be due
to
▶Disease
OR
▶Drug

51. In patients presenting with
▶Unusual/rare diseases
▶Unusual presentations of common
diseases
▶Not responding to Conventional
therapy
Think of HIV

52. ▶K/C/O HIV presenting with skin
manifestation
▶Infection
▶Inflammatory
▶Neoplastic
▶Drug associated
▶Plan skin biopsy, culture, PCR etc.
▶Specific therapy + Continue ART