• 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.
• 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.
• 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.
  • 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,^{8, 9} 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 al¹⁰ 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.
• 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,¹¹ 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,¹² 81.25% of patients with PPE have advanced immunosuppression.
• 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,¹³ patients with HIV were sensitive to UV-B light. Vin-Christian et al¹³ 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.

DIFFERENTIALS

Section 4 of 11  

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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

Section 5 of 11  

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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab 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

Section 6 of 11  

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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

Section 7 of 11  

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

Drug Category: 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.

Drug Category: 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.

Drug Category: Retinoids

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

FOLLOW-UP

Section 8 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 9 of 11  

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• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 10 of 11  

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• Workup
• Treatment
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• Follow-up
• Miscellaneous
• Multimedia
• References

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.
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Media file 2:  Man who has HIV infection and Kaposi sarcoma.
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Media file 3:  Man who has HIV infection and Kaposi sarcoma (same patient as in Media File 2).
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Media file 4:  Young man with HIV disease and molluscum contagiosum on the lateral part of the eyebrow.
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Media type:  Photo

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

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

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
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• Treatment
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• Follow-up
• Miscellaneous
• Multimedia
• References

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22. Boumis E, Chinello P, Della Rocca C, Paglia MG, Proietti MF, Petrosillo N. Atypical disseminated leishmaniasis resembling post-kala azar dermal leishmaniasis in a HIV-infected patient. Int J STD AIDS. May 2006;17(5):351-3. [Medline].
23. Calikoglu E, Soravia-Dunand VA, Perriard J, Saurat JH, Borradori L. Acute genitocrural intertrigo: a sign of primary human immunodeficiency virus type 1 infection. Dermatology. 2001;203(2):171-3. [Medline].
24. Chetty R, Bramdev A, Govender D. Cytomegalovirus-induced syringosquamous metaplasia. Am J Dermatopathol. Oct 1999;21(5):487-90. [Medline].
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