Seborrhoeic Dermatitis and HIV

What is seborrhoeic dermatitis?

Seborrhoeic dermatitis is a chronic, recurring, benign skin inflammation that mainly affects the skin area with more oil glands (sebaceous glands). The rash presentation is frequently seen over the face, scalp, body, or the folds of the body – such as the armpit or groin. The rash manifests as dry, desquamated (flaky), greasy red patches seen over the greasy region of the face or body.

While the actual cause of seborrhoeic dermatitis remains unknown, it is an inflammatory skin condition associated with changes in a person’s hormone, neurological system, skin barrier and skin microbial environment. 

To explain in simple terms, the skin's surface is an environment of its own with various microbes, including bacteria such as Staphylococcus spp, and fungi such as yeast (Malassezia spp). Malassezia spp thrives on the lipids and fatty acids present in the sebum produced by sebaceous glands. In seborrhoeic dermatitis, Malassezia spp feeding on sebum on the skin surface causes skin microbial alteration, skin barrier defects, and an inflammatory response. 

Facial seborrhoeic dermatitis occurs when the skin presentation of flakes, scales, and redness occurs over the oily (seborrhoeic) region of the face – in particular over the brows, nasolabial fold (the fold between the nose and the cheek), over the hairline and the ears.

What do you understand about HIV infections?

• HIV stands for Human Immunodeficiency Virus.
• HIV is a virus that attacks a person's immune system. If the HIV condition is not treated, a person's immune system will deteriorate progressively over time, leading to a condition known as AIDS (acquired immunodeficiency syndrome).
• It is a viral condition that can be transmitted through intercourse, body fluid, and blood product needle sticks (sharing needles, syringes).
• There is currently no cure for HIV infection.
• Once a person acquires HIV, they will have the infection for life.
• However, there are effective antiretroviral medications to control the progression of HIV disease, allowing a person with HIV to live a long life with comparable quality of life and able to protect their partners effectively.

As most patients have no symptoms or very mild symptoms when having HIV, the only way to know of a person's HIV status is via HIV screening tests. 

Correlation between Seborrhoeic Dermatitis and an HIV infection

Medical literature reveals the frequency of seborrhoeic dermatitis in HIV-positive patients is higher and ranges between 30-80% of the general population, in comparison to 1-3% of seborrhoeic dermatitis in people without HIV. 

The presentation of seborrhoeic dermatitis in HIV-positive patients tends to be more severe, with more striking redness and extensive scaling with a broader spread affected region of the face or body. Although the condition is typically seen over the face and scalp region, it can also affect other body parts, such as the umbilicus, groin, and armpit region. Both patients and clinicians can commonly misdiagnose the rash as a fungus infection or even other autoimmune skin conditions.

Seborrhoeic dermatitis can occur during any stage of an HIV infection. It can happen during the early course of HIV disease when the CD4+ (a type of immune cell) count is between 400-500 cells/μL. Due to this reason, a sudden occurrence of severe seborrhoeic dermatitis in a person who has no previous history of similar skin rash warrants further screening for HIV in those with possible exposure risks of HIV.

Role of HIV screening in frequent flare up/un-resolving seborrhoeic dermatitis

While no clinical tests are required in most cases of seborrhoeic dermatitis, in severe or recalcitrant seborrhoeic dermatitis with an acute onset, an HIV test should be considered as part of the clinical investigations if there is a possible risk of exposure. 

Antiretroviral medications facilitate the resolution of the symptoms and reduce flare-ups and seborrhoeic dermatitis. 

Early screening, detection, and confirmation of HIV ensures a significantly better long-term prognosis of the condition. 

Do reach out to your trusted physician if you are concerned about possible exposure to HIV infection or have a skin rash that is unresolved.

Why should I get tested for HIV infection?

Getting HIV test results allows you to obtain treatment for HIV (if needed) without further delay. Importantly, knowing a person’s HIV status allows one to make proper conscientious decisions to avoid further spreading of HIV to other loved ones.

Although HIV infection is not reversible, there are antiretroviral medications in the pipeline to effectively control the progression of the disease, allowing a person to live a good quality long life.

What is the treatment of seborrhoeic dermatitis?

The goal of managing seborrhoeic dermatitis is to re-establish the skin microbial equilibrium and maintain a good skin barrier to minimise or prevent skin inflammation.

This can be achieved with a combination treatment of:

• Low-dose topical steroid
• Topical antifungal
• Topical calcineurin inhibitors such as tacrolimus or pimecrolimus topicals
• Antifungal wash
• Oral antifungal may be offered (for severe or recalcitrant cases)

For patients with HIV and seborrhoeic dermatitis, the fundamental core treatment remains similar to a person without HIV.

• First-line treatment involves a combination of topical antifungal and steroid.
• Treatment failure and recurring flare-ups of seborrhoeic dermatitis are more frequent in HIV patients as they tend to have a more extensive and severe form of seborrhoeic dermatitis. As there is a possible correlation between CD4+ counts and the severity of seborrhoeic dermatitis, antiretroviral medications can control, reduce relapse, and aid in the resolution of seborrhoeic dermatitis in HIV patients.

What have I learnt so far?

• Seborrhoeic dermatitis can be a skin clue to underlying HIV disease.
• There is no way to find out a person’s HIV status unless they are screened for HIV.
• There is no cure for HIV.
• There are antiretroviral medications to control the disease progression of HIV and alleviate and manage the symptoms of seborrheic dermatitis.

References

1. Cortés-Correa C, Piquero-Casals J, Chaparro-Reyes D, Garré Contreras A, Granger C, Peñaranda-Contreras E. Facial Seborrheic Dermatitis in HIV-Seropositive Patients: Evaluation of the Efficacy and Safety of a Non-Steroidal Cream Containing Piroctone Olamine, Biosaccharide Gum-2 and Stearyl Glycyrrhetinate - A Case Series. Clin Cosmet Investig Dermatol. 2022 Mar 18;15:483-488.
2. Ippolito F, Passi D, Di Carlo A. Is seborrhoeic dermatitis a clinical marker of HIV disease? Minerva Ginecol 2000;25 (Suppl 1):54-8
3. Paraskevi Chatzikokkinou , Konstantinos Sotiropoulos , Alexandros Katoulis , Roberto Luzzati , Giusto Trevisan. Seborrheic Dermatitis – An Early and Common Skin Manifestation in HIV Patients. Acta Dermatovenerol Croat 2008;16(4):226-230 
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5. Berrey MM, Schacker T, Collier AC, Shea T, Brodie SJ, Mayers D, et al. Treatment of primary human immunodeficiency virus type 1 infection with potent antiretroviral therapy reduces frequency of rapid progression to AIDS. J Infect Dis. 2001;183(10):1466–75.
6. Dunic I, Vesic S, Jevtovic DJ. Oral candidiasis and seborrheic dermatitis in HIV-infected. HIV Medicine. 2004;5:50–4
7. Hengge UR, Franz B, Goos M. Decline of infectious skin manifestations in the era of highly active antiretroviral therapy. AIDS. 2000;14(8):1069–70.
8. Forrestel AK, Kovarik CL, Mosam A, Gupta D, Maurer TA, Micheletti RG. Diffuse HIV-associated seborrheic dermatitis—a case series. Int J STD AIDS 2016; 27(14):1342–1345. 
9. Borda LJ, Wikramanayake TC.  Seborrheic dermatitis and dandruff: a comprehensive review. J Clin Investig Dermatol 2015; 3(2):10.13188/23731044.1000019.