What are the cutaneous manifestations of HIV by disease stage?

Updated: Mar 26, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD  more...
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During acute primary HIV infection, a transient, generalized, morbilliform eruption may develop on the trunk and the arms. In the early asymptomatic stage of HIV disease, which may last from a few years to a decade or longer, no signs of infection other than lymphadenopathy are present. In a survey of 165 children in India with HIV infection, cutaneous manifestations were evident in 100 (61%) of them. Papular pruritic eruptions were evident in 16%, the most common condition, with highest prevalence in severe CD4 category. [5]  In one survey of 106 West African patients, the pruritic papular eruptions of HIV infection were mainly on the exposed parts of the body, especially the upper and lower limbs. [6]

Kaposi sarcoma can occur prior to the onset of immunosuppression. 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. However, Kaposi sarcoma of skin and/or oral cavity may develop in HIV patients with well-controlled HIV disease and may be a significant factor in their morbidity and mortality. [7]

In the later stages of HIV disease, chronic herpes simplex virus (HSV), molluscum contagiosum (MC), and cytomegalovirus (CMV) infections appear. An autopsy analysis of HIV-seropositive patients revealed that 72% had opportunistic viral infections; most patients were infected with CMV and HSV. The prevalence of clinically apparent MC infection varies from 5-18% in different series. Mycobacterial infections and mucocutaneous candidiasis occur.

A 42-month prospective study by Smith et al in 912 HIV-1–infected patients found that condylomata acuminata and verrucae are observed early, and their frequency does not increase as the disease progresses, whereas the incidence of HSV infections, MC, and oral hairy leukoplakia increases as the disease advances. [8, 9]

Verrucous herpes infection, leprosy, condylomalike molluscum contagiosum, and AIDS-associated pigmented or nonpigmented erythroderma may be seen in early HIV disease or as part of immune restoration syndrome after the initiation of antiretroviral therapy. [10, 11, 12, 13, 14] Leishmaniasis and miliary tuberculosis may be a concern in advanced HIV disease. [15, 16, 17] Diffuse or disseminated leishmaniasis may occur with HIV disease, [18, 19] including in association with the immune reconstitution inflammatory syndrome. [19]

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