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Cutaneous Manifestations of HIV Infection

Monika Kaniszewska, MD, MS, and Kelly Park, MD, MSL

CD4+ count > 500 cells/mm3

Dermatologic Disease
Oral Hairy Leukoplakia
Seborrheic Dermatitis
Scabies
Acute Retroviral Syndrome
Oropharyngeal candidiasis
Cutaneous findings Diagnosis
EBV-associated mucosal plaques early in HIV infection. Clinical diagnosis – lesions will not
Asymptomatic white corrugated plaques on the lateral scrape off in contrast to Candida.
tongue. No progression to malignancy.
Associated with Pityrosporum infection. Erythematous Clinical diagnosis
macules with overlying greasy scale in sebaceous skin. Biopsy shows neutrophils at follicular
Refractory as CD4+ count declines. ostia.
Sarcoptes scabiei mite. Highly contagious, face and scalp KOH or mineral oil mount of skin
involvement can be seen as well as crusted scabies due scrapings will show mites, eggs or
to large mite burden. feces.
Biopsy will show mite particles in cor-
neum.
Morbiliform exanthem with systemic symptoms. Occurs Seroconversion takes 6 weeks. Labs
2-4 weeks after HIV exposure. May go unnoticed. may be negative. Check viral antigens
Exanthem may last 4-5 days, most pronounced on face/ or nucleic acid.
trunk sparing extremities.
CD4+ count 250 - 500 cells/mm3
Most commonly caused by ubiquitous yeast Candida Clinical diagnosis
albicans. Thrush is a very common presentation causing Culture
characteristic white plaques on the tongue with friable Microscopic visualization of hyphae
surface. Other: esophageal disease, vaginal candidiasis, and yeast forms
paronychia and cutaneous candidiasis.

Herpes Zoster Caused by Varicella zoster virus transmitted via aerosol Tzanck prep
droplets. 7-15 times greater relative risk in HIV-infected Viral Culture
individuals. Reactivation and severe disease can occur. DFA
Classic dermatomal form or multidermatomal, ulcerative Skin biopsy (if previous are negative)
or verrucous lesions with potential dissemination.

Psoriasis More severe and refractory in HIV patients. Increased Clinical diagnosis
incidence of psoriatic arthritis. May be seen as part of Biopsy
reactive arthritis (Reiter’s syndrome – arthritis, urethritis,
conjunctivitis and plaque-type psoriasis/keratoderma blen-
norrhagica).

Kaposi’s Sarcoma Caused by HHV-8, most common AIDS-associated can- Biopsy

cer. Lesions are red to violaceous vascular-like plaques to
Monika Kaniszewska, nodules with variable distribution. Can occur at any stage
MD, MS, is a PGY- of HIV.
4 dermatology resident
at Loyola University Cervical/anal intraepithelial neo- Associated with high-risk HPV subtypes (16, 18, 31, 33). Pap smear
Medical Center in plasia and cancer Lesions present as non-resolving erythematous plaques Acetowhite test on colposcopy
that progress. Biopsy
Maywood, Illinois.

CD4+ count <250 cells/mm3

HSV infection Oral, labial and genital infections similar to immunocom- Tzanck smear
petent individuals, deep ulcerations occur with immu- DFA
nosuppression. Increased frequency with CD4+ count HSV PCR
<100. Viral culture
Skin biopsy (if previous are negative)
Bacillary angiomatosis Red to violaceous vascular-like papulonodules and ulcer- Characteristic histology:
ations. Vascular proliferation
Numerous bacilli on
Causative organism: Warthin-Starry stain
Bartonella henselae
Kelly K. Park, MD, MSL, Associated with cat scratches/fleas
is a PGY-3 dermatology Visceral disease common
Bartonella quintana
resident at Loyola Transmitted by human body louse,
University Medical Pediculus humanus var. corporis,
Center in Maywood, subcutaneous and osseous involvement
Illinois.
Botryomycosis Caused by Staphylococcus aureus. Other presentations Culture
common: impetigo, folliculitis etc. Unusual presentations Gram stain
like botryomycosis may be difficult to treat.

D­Rirections
in
esidency p. 1 • Fall 2014
 boards’ fodder
Cutaneous Manifestations of HIV Infection
Monika Kaniszewska, MD, MS, and Kelly Park, MD, MSL

CD4+ count <250 cells/mm3 (cont.)

Systemic fungal infection
Eosinophilic folliculitis
Non-Hodgkin lymphoma
Giant mollusca
HSV/CMV with large non-healing
ulcerations (perianal)
Papular pruritic eruption
Acquired ichthyosis
Mycobacterium avium complex
Major aphthae
Any dimorphic fungal infection: Skin biopsy
Crytococcosis* Tissue culture
Dome-shaped papules resembling
molluscum +/- CNS involvement For cryptooccus:
Histoplasmosis* Serum or CSF Ag
Coccidiodomycosis*
Sporotrichosis
Blastomycosis
Presentations vary from papulonodules, crusted or verru-
cous plaques to ulcerations
Idiopathic eruption causing pruritic papules with increased Biopsy shows intrafollicular eosinophils
IgE and eosinophilia. Lesions favor the trunk. Pruritus
leads to secondary changes.
B-cell most common type. Younger age of onset associ- Biopsy
ated with more advanced stage at presentation. 50%
associated with EBV.
CD4+ count <50 cells/mm3
Caused by poxvirus. Classic umbilicated lesions and larg- Clinical
er coalescent plaques over face, neck and intertriginous Biopsy
areas. Often treatment resistant.
Mucosal ulcers of anogenital areas, usually a sign of dis- Intranuclear CMV inclusions in endo-
ease dissemination. thelial cells seen on biopsy or Tzanck
smear.
Viral culture
Symmetric, non-follicular pruritic papules favoring extremi- Clinical
ties. Can result in secondary changes.
Large plate-like scales on the legs that often spread. Clinical
Variable (papules, nodules, verrucous plaques, ulcer- Culture
ations, etc.). Biopsy
Acid-fast staining
CXR
Mucosal erosions without infectious etiology. Refractory to Biopsy
therapy, treated with thalidomide. Culture

EBV, Epstein-Barr virus; HHV-8, human herpesvirus 8; AIDS, acquired immunodeficiency syndrome; HPV, human papillomavirus; KOH,
potassium hydroxide; DFA, direct fluorescent antigen; PCR, polymerase chain reaction; CNS, central nervous system; CSF, cerebral spinal
fluid; Ag, antigen;
HSV, herpes simplex virus; CMV, cytomegalovirus; CXR, chest x-ray.
*Cutaneous lesions can present as molluscum contagiosum-like lesions

References
1. Jung A, Paauw D. Diagnosing HIV-Releated Disease. Journal of General Internal Medicine. 1998;13:131-36.
2. Nnoruka E, Chukwuka J, Anisuiba B. Correlation of mucocutaneous manifestations of HIV/AIDS infection with CD4 counts and disease progression.
International Journal of Dermatology. 2007;46(suppl. 2):14-18.
3. Bolognia JL, Jorizzo JL, Schaffer JV, editors. Bolognia Textbook of Dermatology. 3rd ed. Spain: Mosby Elsevier publishing; 2012: chapter 78.

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