Is My Skin Telling Me Something? A Guide on HIV/AIDS-Related Skin Conditions

With the advancement of medical care in Singapore, HIV (human immunodeficiency virus) infection is no longer seen as a ‘death sentence’. Clinically effective treatment has shown that one with a HIV infection is able to have a near normal life expectancy as someone without HIV infection. The outlook of HIV infection has transformed from being a terminal illness to a chronic medical condition that is controllable. 

To achieve this, those who are found to be HIV infected are advised to start on anti-retroviral medication as soon as possible to decelerate, control the progression of disease, and improve long term quality of life of an infected person.

Dermatological manifestation of HIV infection is unique at various stages of HIV. Understanding possible association of certain dermatological conditions can facilitate picking up undiagnosed HIV, hence allowing commencement of anti-retroviral medication without further delay.

In this article, we want to highlight the common skin diseases that can be associated with people living with HIV. We want to encourage public social awareness and we encourage those who are at risk to consider HIV testing.  

Skin presentation during early acquisition of acute HIV infection

During acute HIV infection, when the body sero-converts HIV virus, one can present with a body eruption. It can be a red rash over the body that is generalised yet faint, subtle in appearance, and it is very easily missed. One may present concurrently with fever, flu symptoms or even unexplained lymph nodes on the body.

Picking up HIV infection at this stage is very beneficial as this allows early treatment of HIV and reduce the chance of progressive transmission of disease. One should consider HIV testing if there is concern of exposure to HIV infection.

Why does a person with HIV has tendency of skin disease?

As its name suggests, HIV is an infection associated with progressive deficit of the host’s immune system, hence predisposing the infected person with various skin conditions, such as infections and even cancer. 

Furthermore, anti-retroviral medication used for HIV management is commonly known to be associated with skin allergy and reactions.

Skin presentations that can be experienced by someone with HIV

Skin bacterial infections

• Staphlococcus aerues and Streptococcus spp — Patients with HIV infection can commonly present with skin bacterial infections in the form of abscess, boils, cellulitis, impetigo and etc.
  
• Syphilis — Treponema pallidum has been resurfacing in the past 2 decades, and can be seen concurrently in HIV infection patients. Due to the immunocompromised state of HIV patients, one can progress rapidly from primary syphilis infection to tertiary syphilis infection within months (rather than years).

• Mycobacterium tuberculosis —  Skin tuberculosis can occur during any stage of HIV infections. One can present with a myriad of skin lesions such as bumps (papules), deep-seated lumps (nodules), ulcers, blisters, or even necrotic (dead skin) lesions. This skin manifestation is becoming less common over the years with better medical management of HIV.

Skin viral infections

• Human papillomavirus infection (HPV) — HPV infection is more common in people living with HIV. Those who has HPV with concurrent HIV tends to have a more resistant infection, higher recurrence, higher chance of failure to treat and the presentation can be more prolific. One who has underlying HIV can present with larger multiple warts, oral or anal warts. One may also be more predisposed towards HPV related cancers such as cervical and anal cancer.

• Herpes Simplex virus infection (HSV) — Cold sores can be more frequent and present more aggressively in patients who has HIV infection. Sores can be seen over the genital region, mouth areas, fingers, or uncommon skin areas. Due to underlying low immunity, one may even have dissemination of HSV, or present with chronic ulcers, making clinical diagnosis and treatment difficult.

• Mollusucm contagiosum — This is a skin infection caused by poxvirus leading to presentation of small dimple-domed-like skin colored bumps. It can be seen in healthy adults and children. In HIV patients, the molluscum lesions can appear bigger in size and more extensive in numbers.
• Shingles/ Varicella Zoster virus (VZV) — Shingles can occur in 8% of those with HIV. In those HIV patients who are undiagnosed and untreated, one can develop shingles 2-7 years after acquiring the disease and just before a drastic drop of immune system due to progression of HIV infection/AIDS. It is important to consider screening for HIV in a person with shingles and one who has possible exposure to HIV.

Skin fungal infections

One living with HIV infection are predispose to fungal infection due to the constant immunocompromised state of the condition. Commonly, thrush (candidiasis), skin (tinea infections) or nail fungal infection can occur any part of the body areas. The fungal infection tends to be more aggressive and resistant to treatment in comparison with those without fungal infection.

When the HIV infection progresses with dwindling of the immune system of the infected person, one can develop fungal opportunistic infections that involve uncommon widespread skin appearance, mucosal (oral/ genital involvement) or in severe cases even disseminate and affect the blood stream, internal organs such as the lungs, liver etc.  

Skin inflammatory conditions

• Seborrheic dermatitis — Seborrheic dermatitis can present as an initial phase of untreated symptomatic HIV infection. Having said that, seborrheic dermatitis can occur at some point of the disease in 85% of HIV patients. It can also worsen when the immune system in HIV patients drops further.  It tends to run a more recalcitrant skin rash with typical scaly red patches over the oily/seborrheic areas of the scalp, eyebrows, nose, chest, genital areas.

• Psoriasis — With declining immune system in HIV, one may notice progressive worsening of psoriasis. Recalcitrant treatment of psoriasis should prompt HIV testing.

• Hair loss — Patients living with HIV may notice hair thinning and hair loss over time when the HIV progresses due to underlying chronic compromised immune system, poor nutritional state, fungal infection of the scalp, syphilis infection and etc

Skin malignancy/ cancer

Living with HIV increases a person’s risk of developing skin-related cancers due to impairment of the immune system. Skin cancers such as melanoma, basal cell carcinomas or squamous cells carcinoma can occur more rapidly in patients with HIV. Skin related lymphomas, Kaposi sarcoma can be seen associated with HIV patients.

Skin presentations when a person is having severe HIV infection/AIDS syndrome

Certain skin presentations tend to occur in advanced or severe compromised immune system state in HIV or AIDS. Picking up these conditions should warrant a screening for HIV.

• Cytomegalovirus skin infection
• Epstein-barr virus presenting as oral leukoplakia
• Mycobacterium skin infections
• Invasive deep fungal infections such as Cryptococcus infection
• Eosinophilic folliculitis, pruritic eruptons
• Kaposi sarcoma

These are some of the skin conditions that are associated with severe HIV infections/AIDS and will require a trained health care worker or further biopsy skin tests to confirm the diagnosis. Nonetheless, if there is any doubt or concern of a person’s skin condition, it is always advisable to seek medical advice and if need, consider HIV testing.

Important points to take home from the article: 

• People living with a HIV infection commonly experience skin diseases.

• One with HIV can develop various skin infections, inflammatory skin conditions, skin cancer that be more aggressive and recalcitrant to treatment.
  
• Common skin conditions such as HPV warts, herpes infection, psoriasis, seborrheic dermatitis can be seen in HIV patients.
  
• Recognising skin conditions that can be associated with HIV infection allows early HIV screening and diagnosis, thereafter prompt commencement of antiretroviral treatment and control the progression of HIV disease.
  
• Consider HIV screening if there is exposure risk to HIV and development of unexplained skin disease.

References:

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