Cutaneous signs and symptoms associated with acquired immunodeficiency syndrome (AIDS) increase in frequency and severity as the disease advances. However, infection by human immunodeficiency virus (HIV) may produce a transient macular roseola-like eruption. As HIV infection progresses, infectious processes and neoplastic disease are most often seen. Patients also may have symptoms such as pruritus without visible skin lesions.

Cutaneous infections are a common feature of AIDS. Superficial infections such as dermatophytosis, candidiasis, and scabies may be extensive and have altered appearances. Superficial fungal infections may coexist with other pathogens such as herpesvirus or cytomegalovirus to produce unusual complex cutaneous infections.

Cutaneous viral infections also may have unpredictable presentations. Molluscum contagiosum occurs commonly and is persistent; lesions may become quite large. Human papillomavirus-induced lesions may occur, ranging from persistent verrucae to severe anogenital condyloma.

Molluscum contagiosum and human papillomavirus lesions frequently occur in cosmetically sensitive areas. Locally destructive treatments such as curettage and cryotherapy are effective, but lesions almost always recur or new lesions develop, particularly as CD4 counts decrease.

Herpes zoster may be a reliable sign of the presence or progression of HIV infection in an otherwise asymptomatic person. With the diminishing immune response, the usually self-limited herpetic infections become chronic and fail to heal. Chronic herpetic lesions may not have the characteristic morphologic characteristics of acute lesions in immunocompetent individuals. Both herpes simplex and herpes zoster viruses may produce disseminated skin lesions in HIV-infected individuals. The diagnosis of herpetic infections can be made by morphologic features of the clinical lesion, examination of a Tzanck preparation (Wright’s stain of a scraping taken from the base of a lesion), skin biopsy, or viral culture and/or molecular diagnostic methods. For chronic or recurrent herpetic infection and for long-term suppression, oral antiviral therapy is helpful.

Unusual primary and disseminated infections occur in the skin in the context of HIV infection. Mucosal and cutaneous lesions of histoplasmosis, cryptococcosis, and other systemic fungal disorders can be signs of disseminated infection in AIDS patients. Mycobacterial infections produced by M. tuberculosis, M. avium-intracellulare, M. haemophilum, and others affect the skin in patients with AIDS. A long list of unusual or unique infections has been observed, including disseminated amebiasis, Trichosporon beigelei, sporotrichosis, Strongyloides infection, alternariosis, and superficial pheohyphomycosis. A new entity, bacillary angiomatosis caused by Bartonella henselae/quintana, produces vascular proliferations in the skin as well as in other sites. Reiter’s syndrome, with typical cutaneous findings, is found with increased frequency in patients with AIDS. It is safe to predict that unusual presentations of disseminated infectious diseases will continue to be described in the skin of AIDS patients.

Mucous membranes are commonly affected by infectious processes in patients with HIV infection. Oral candidiasis may be present and is one harbinger of the progression of HIV infection. Human papillomavirus and herpesvirus can produce lesions in the oral cavity. Oral hairy leukoplakia, a mixed infectious process, produces a characteristic “hairy” appearance to the sides of the tongue. Severe necrotizing gingivitis and recurrent oral ulcers are common. Lastly, disseminated infectious disease and malignant lymphoma can affect the mucous membranes.

The most common neoplasm in the context of AIDS is Kaposi’s sarcoma (see Color Plate 11 D) a proliferation now associated with the presence of human herpesvirus 8. In AIDS, however, Kaposi’s lesions may be solitary or disseminated; vary in color from light tan to deep purple; vary in appearance from macules to tumor nodules; or be arranged in a follicular, zosteriform, or linear pattern; they are generally atypical when compared with the lesions of Kaposi’s sarcoma occurring in non-HIV-infected individuals. Kaposi’s sarcoma found in AIDS patients frequently affects the mucosae. Other malignant tumors have an increased incidence in the setting of HIV infection, including squamous cell carcinoma and a variety of lymphomas, and all may have cutaneous involvement.

A number of poorly classified eruptions occur in AIDS patients. Best known is seborrheic dermatitis, which occurs in the usual locations but can be persistent and difficult to treat. Patients with AIDS also may have persistent pruritic eruptions, annular eruptions that resemble granuloma annulare, folliculitis, vasculitis, alopecia areata, vitiligo, porphyria cutanea tarda, eosinophilic folliculitis, and others. Certain well-characterized dermatoses such as psoriasis and atopic dermatitis appear to be worsened by the presence of HIV infection. Many AIDS patients receive a panoply of therapeutic agents that in turn produce a spectrum of cutaneous reactions including certain recognizable reactions, such as discolored nails from azidothymidine therapy.

References:
_{Penneys NS: Skin Manifestations of AIDS, 2nd ed. London, Martin Dunitz, 1995. This reference is the easiest way to see the most common skin changes associated with HIV infection; has primary references.}

Neal S. Penneys