Dermal symptoms of HIV-infected patients

Author: Dr. Várkonyi Viktória

Lesions on the skin and mucous membranes are frequently occurring and significant concomitant symptoms of HIV infection, present in about 90% of patients and may indicate underlying HIV infection. Some of these are due to the development of unknown diseases, but in most cases, known skin diseases appear at an unusual age, in atypical form and localization.

The most frequently occurring are viral and fungal infections, various papular rashes and skin growths. The frequency of skin disease increases in parallel with a decrease in the absolute number of CD4+ lymphocytes, i.e., as weakness develops in the immune system. On the other hand, we have also observed that certain skin diseases appear much more frequently than in uninfected control groups of similar age in some HIV-positive patients with relatively strong immune systems, , and their appearance allows not only for the HIV to be identified, but also for a prognosis of the progression of the disease.

Symptoms appearing on the skin and mucous membranes therefore have diagnostic value in the case of unidentified HIV, and prognostic value in known HIV infections.

Without striving for completeness, those skin symptoms and diseases will be presented below which have known diagnostic or prognostic significance, and which can thereby lead the physician to identification of HIV infection.

Herpes Simplex

Symptoms are frequently persistent for lengthy periods, extensive, painful lesions and ulcers can be observed along with dermal necrosis and fever. These appear most frequently around the mouth, the genitals, as well as the anus in the case of patients belonging to the homosexual risk group; in this group, the mucous membrane inside the anus can also be affected (painful bowel movement).

It should be recalled that a significant percentage of HIV-infected patients are first positively diagnosed when they turn to their physicians because of skin and mucous membrane symptoms, which have diagnostic value for HIV. Persistent, necrotizing herpes simplex satisfies these criteria.

Herpes zoster (shingles)

In HIV patients, this skin disease is characterized by symptoms which signify the involvement of more than one neural path, without respect for a particular side of the body, and which also have a tendency for hemorrhaging , severe necrosis and dispersion. In some cases, it has been documented that in spite of high dosage antiviral therapy, herpes zoster recurred (in individuals with unimpaired immune systems, shingles usually develops only once).

Molluscum contagiosum

According to data, the typical dome-shaped lesions with dimpled centers appear in 8-10% of HIV-positive patients. While the infection in otherwise healthy adults tends to appear on the genital area as a sexually transferred disease, extragenital location (e.g., the face), and conspicuously large-sized growths – diameters of over 1 cm – can frequently develop in HIV patients, as well as a tendency for dispersion in late stages of the disease. As many as several hundred molluscum may be found on a single HIV patient.

In spite of surgical or cryosurgical removal the tendency for recurrence is extraordinarily high. The appearance of a large number of unusually large molluscum in young adults can be the first sign of HIV infection; this is therefore one of the symptoms of diagnostic value.

Human Papillomavirus (HPV) Infection

The most common forms are condyloma acuminatum (genital warts) and condyloma planum (flat condyloma). The former can be compared to a rooster’s comb, consisting of extremely large growths, while the latter is often simply a featureless stain, which can be only be seen by applying diluted acetic acid solution to the area.

Symptoms are localized in the genital, perinanal and intravaginal areas in both HIV-positive and HIV-negative individuals. Treatments tend to be ineffective, flare-ups can occur frequently. (It should be noted, however, that treatment of GWs in HIV-negative patients is also a test of both the patient’s and physician’s patience, and the number of subsequent outbreaks is significant.) A tendency to deteriorate into malignancies is also characteristic, especially if the lesions stem from HPV types 16 and18. In the case of perianal localization, it is expedient to rectoscopically determine the extent of the involvement of the rectal mucous membrane, and the possibility of development of carcinoma.

Oral hairy leukoplakia

These are white or grey patches that develop on the sides or back of the tongue, possibly on the mucous membrane of the inner cheek. They are raised, firm, unevenly textured (fuzzy) growths that cannot be scraped off. Subjective complaints may be disturbance in tasting and bad breath. Their appearance is usually linked to advanced impairment of the immune system and signals a poor prognosis.

Fungal infections

Fungal infection of the skin and mucous membranes occurs relatively frequently in HIV-infected individuals. The clinical picture of oral candidiasis (fungal inflammation of the oral mucous membrane) consists of multiple, whitish deposits which may involve the pharynx, proceeding toward the esophagus. Genital, anal and perianal candidiasis occurs relatively frequently in HIV-infected patients. Treatment is often ineffective. Extensive pityriasis versicolor and nail fungi which involve all of the nails is also not unusual.

Kaposi’s sarcoma

This is an opportunistic tumor of both diagnostic and prognostic value, and is indicative of AIDS. Livid, purplish, bruised-like skin symptoms at various stages (initially reddish stains, later flat and raised growths, and finally, outward growing tumors) which have a tendency to spread quickly, and which are characteristically found on the tip of the nose or the edge of the earlobe.

Seborrheic dermatitis

This is one of the most commonly occurring skin symptoms, which is mainly present on the midsection of the face in the early stages of the infection. As the status of the immune system deteriorates, the prevalence increases and the clinical symptoms become more explicit. Although the clinical picture is similar to that of seborrheic dermatitis occurring in the healthy (non-HIV) population, it should still be considered to be a separate entity since the infection is an early indicator of the expected development of the collection of AIDS symptoms.

Other skin symptoms

Other skin symptoms which can be frequently observed in HIV-infected individuals.

Pronounced dryness of the skin accompanied by itchiness, pimply rash and papular skin symptoms

Scratched nodules of 2-5 mm in diameter on the cheeks, the upper torso and the proximal area of the limbs, accompanied by intolerable itchiness in 50% of cases. Surging flare-ups are characteristic and if the symptoms appear in HIV-infected individuals, they will persist throughout their life.

Summary

Sexually active individuals, who change partners frequently are advised to undergo HIV screening. Although we frequently hear “I’m sure I wasn’t infected!”, we know this is not always the case. We are at your disposal with counselling services.