Rashes and Skin Conditions Associated with HIV and AIDS: Symptoms and More

HIV usually progresses through three stages:

A person is most likely to experience skin conditions during stage 1 and stage 3 of HIV.

Fungal infections are especially common when the immune system is at its weakest, in the third stage. Infections that appear during this stage are often called opportunistic infections.

Dermatitis is the most common symptom of HIV. Treatments normally include one or more of the following:

• antihistamines
• antiretroviral medications
• steroids
• topical moisturizers

Some types of dermatitis include:

Xerosis

Xerosis is skin dryness, which often appears as itchy, scaly patches on the arms and legs. This condition is extremely common, even in people without HIV. It can be caused by dry or hot weather, overexposure to the sun, or even hot showers.

Xerosis can be treated with moisturizers and lifestyle changes, such as avoiding long, hot showers or baths. More serious cases may require prescription ointments or creams.

Atopic dermatitis

Atopic dermatitis is a chronic inflammatory condition that often causes red, scaly, and itchy rashes. It can appear on many parts of the body, including the:

• feet
• ankles
• hands
• wrists
• neck
• eyelids
• inside of the knees and elbows

It affects about 30 percent of people in the United States, and it appears to be more common in dry or urban environments.

Atopic dermatitis can be treated with corticosteroid creams, skin-repairing creams known as calcineurin inhibitors, or anti-itch medications. Antibiotics may be prescribed for infections. However, recurrence is common in people with HIV.

Seborrheic dermatitis

Seborrheic dermatitis mostly affects the face and scalp, resulting in redness, scales, and dandruff. The condition is also known as seborrheic eczema.

While it occurs in around 5 percent of the general population, the condition is seen in 85 to 90 percent of people with HIV.

Treatment helps to relieve symptoms and typically consists of topical methods, such as antidandruff shampoos and barrier repair creams.

Photodermatitis

Photodermatitis occurs when UV rays from sunlight cause rashes, blisters, or dry patches on the skin. In addition to skin outbreaks, a person with photodermatitis might also experience pain, headaches, nausea, or fever.

This condition is common during antiretroviral therapy, when the immune system becomes hyperactive, as well as during severe immunodeficiency.

Eosinophillic folliculitis

Eosinophillic folliculitis is characterized by itchy, red bumps centered on hair follicles on the scalp and upper body. This form of dermatitis is found most frequently in people in later stages of HIV.

Oral medications, creams, and medicated shampoos may be used to help manage symptoms, but the condition is typically difficult to treat.

Prurigo nodularis

Prurigo nodularis is a condition in which lumps on the skin cause itchiness and a scab-like appearance. It mostly appears on the legs and arms.

This type of dermatitis affects people with extremely compromised immune systems. Itching can become so severe that repeated scratching causes bleeding, open wounds, and further infection.

Prurigo nodularis can be treated with steroid creams or antihistamines. In severe cases, a healthcare provider may recommend cryotherapy (freezing the lumps). Antibiotics may also be prescribed for infections caused by intense scratching.

DID YOU KNOW?

Photodermatitis is most common in people of color. People of color are also more likely to develop prurigo nodularis.

A number of bacterial, fungal, viral, and parasitic infections affect people with HIV. The most commonly reported infections include:

Syphilis

Syphilis is caused by the bacterium Treponema pallidum. It leads to painless sores, or chancres, on the genitalia or inside the mouth. The secondary stage of syphilis also results in sore throat, swollen lymph nodes, and rash. The rash won’t itch and typically appears on the palms or soles.

A person can only contract syphilis through direct contact, such as sexual contact, with syphilitic sores. Syphilis is usually treated with an injection of penicillin. In the case of a penicillin allergy, another antibiotic will be used.

Because syphilis and HIV share the same risk factors, people who receive a syphilis diagnosis may want to consider an HIV screening test as well.

Candidiasis

HIV can lead to oral thrush, a type of skin infection caused by the fungus Candida albicans (C. albicans). This recurrent infection causes painful cracks at the corners of the mouth (known as angular cheilitis) or a thick white layer on the tongue.

It occurs at lower CD4 cell counts. The preferred treatment method is antiretroviral therapy and an increase in the CD4 count.

Other fungal infections seen in people with HIV include:

• intertriginous infections, which are found in moist skin folds such as the groin or armpit; they lead to pain and redness
• nail infections, which can cause thickened nails
• foot infections in the areas surrounding the nails, which can cause pain and swelling
• vaginal yeast infections

A variety of antifungal medications can be used to treat these infections.

Other treatments for thrush include oral rinses and oral lozenges. Vaginal yeast infections can also be treated with alternative remedies such as boric acid and tea tree oil. Tea tree oil is a popular remedy for nail fungus as well.

Herpes zoster virus (shingles)

Herpes zoster virus is also known as shingles. It’s caused by the varicella-zoster virus, the same underlying virus as chickenpox. Shingles can lead to painful skin rashes and blisters appearing. It may appear when a person is in the early or late stages of HIV.

A person diagnosed with shingles may want to consider an HIV screening test if their HIV status is unknown. Shingles is more common and more severe in people living with HIV, especially those with more advanced forms of HIV.

Treatment often involves antiviral drug regimens. However, pain related to the lesions may persist long after the lesions heal.

People at high risk for shingles may want to discuss the vaccine with their medical provider. Since the risk of shingles increases with age, the vaccine is also strongly recommended for adults over 50.

Herpes simplex virus (HSV)

Chronic and persistent herpes simplex virus (HSV) is an AIDS-defining condition. Its presence indicates that a person has reached this most advanced stage of HIV.

HSV causes cold sores on the mouth and face as well as genital lesions. Lesions from HSV are more severe and persistent in people with advanced, untreated HIV.

Treatment may be administered episodically — as outbreaks occur — or on a daily basis. Daily treatment is known as suppressive therapy.

Molluscum contagiosum

Molluscum contagiosum is characterized by pink or flesh-colored bumps on the skin. This highly contagious skin virus often affects people with HIV. Repetitive treatments may be necessary to completely rid the body of these unwanted bumps.

Bumps caused by molluscum contagiosum are usually painless and tend to appear on the:

• face
• upper body
• arms
• legs

The condition can be present at any stage of HIV, but the rapid growth and spread of molluscum contagiosum is a marker of disease progression. It’s often seen when the CD4 count dips below 200 cells per mm3 (which is also the point when a person will be diagnosed with AIDS).

Molluscum contagiosum doesn’t cause any significant medical complications, so treatment is primarily cosmetic. Current treatment options include freezing the bumps with liquid nitrogen, topical ointments, and laser removal.

Oral hairy leukoplakia

Oral hairy leukoplakia is an infection that’s associated with the Epstein-Barr virus (EBV). If a person contracts EBV, it’ll remain in their body for the rest of their lives. The virus is usually dormant, but it can be reactivated when the immune system is weakened (as it is in HIV).

It’s characterized by thick, white lesions on the tongue and is likely caused by tobacco use or smoking.

Oral hairy leukoplakia is typically painless and resolves without treatment.

Although direct treatment of the lesions isn’t required, people with HIV may consider ongoing antiretroviral therapy regardless. It’ll improve the body’s immune system, which may also help the EBV go dormant.

Warts

Warts are growths on the top layer of the skin or mucous membrane. They’re caused by the human papillomavirus (HPV).

They usually resemble bumps with black dots on them (known as seeds). These seeds are commonly found on the back of the hands, the nose, or the bottom of the feet.

Genital warts, however, are usually dark or flesh-colored, with tops that look like cauliflower. They can appear on the thighs, mouth, and throat as well as the genital area.

HIV-positive people are at an increased risk of anal and cervical HPV, so it’s important that they undergo more frequent anal and cervical Pap smears.

Warts can be treated with a few procedures, including freezing or removal via minor surgery. However, HIV makes it much harder for the immune system to get rid of warts and prevent them in the future.

HIV-positive and HIV-negative people alike can reduce their risk for genital warts by receiving the HPV vaccine. The vaccine is only administered to people age 26 and younger.

HIV increases a person’s risk of certain types of cancer, including a few that affect the skin.

Carcinoma

People with HIV may be more likely than the general population to develop basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). BCC and SCC are the most common types of skin cancer in the United States. However, they’re rarely life-threatening.

Both conditions are associated with past sun exposure and tend to affect the head, neck, and arms.

A Danish study of people living with HIV found increased rates of BCC in HIV-positive men who have sex with men (MSM). Increased rates of SCC were also observed in people with low CD4 counts.

Treatment consists of surgery to remove the skin growths. Cryosurgery may also be performed.

Melanoma

Melanoma is a rare but potentially fatal form of skin cancer. It usually causes moles that are asymmetrical, colorful, or relatively large. The appearance of these moles may change over time. Melanoma can cause bands of pigmentation under the nails as well.

Melanoma may be more aggressive in people living with HIV, especially those with fair complexions.

Like carcinomas, melanoma is also treated with surgery to remove the growths or cryosurgery.

Kaposi sarcoma (KS)

Kaposi sarcoma (KS) is a form of cancer that affects the lining of the blood vessels. It appears as dark brown, purple, or reddish skin lesions. This form of cancer can affect the lungs, digestive tract, and liver.

It may cause shortness of breath, difficulty breathing, and swelling of the skin.

These lesions often appear when the white blood cell (WBC) count drops dramatically. Their appearance is often a sign that HIV has turned into AIDS, and that the immune system is severely compromised.

KS responds to chemotherapy, radiation, and surgery. Antiretroviral medications have significantly reduced the number of new KS cases in people with HIV as well as the severity of existing KS cases.

If a person has HIV, they’ll probably experience one or more of these skin conditions and rashes.

However, getting diagnosed in the early stages of HIV, starting treatment soon after, and adhering to a treatment regimen will help people avoid the more severe symptoms. Keep in mind that many skin conditions associated with HIV will improve with antiretroviral therapy.

Side effects of HIV drugs

Some common HIV medications can also cause rashes, including:

• non-nucleoside reverse transcriptase inhibitors (NNRTIs), such as efavirenz (Sustiva) or rilpivirine (Edurant)
• nucleoside reverse transcriptase inhibitors (NRTIs), such as abacavir (Ziagen)
• protease inhibitors, such as ritonavir (Norvir) and atazanavir (Reyataz)

Based on their environment and the strength of their immune system, an individual can have more than one of these conditions at the same time. Treatment might need to address them individually or all at once.

If a rash is present on the skin, consider discussing symptoms with a healthcare provider. They’ll assess the type of rash, consider current medications, and prescribe a treatment plan to relieve the symptoms.

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