HIV infection can impact the immune system’s ability to fight against infection. It can make people more susceptible to disease. HIV-related skin lesions are caused by a variety of infections. Some of these sores and rashes may also occur in people without HIV. However, they may be more serious and/or more common in individuals with uncontrolled HIV or AIDS.This article describes the different types of skin lesions that can appear in people living with HIV and how to manage these symptoms.
Herpes is an extremely common viral illness. It refers to infections caused by two different types of herpes simplex virus (HSV)—HSV-1 or HSV-2. Although HSV-1 used to be referred to as oral herpes and HSV-2 as genital herpes, in theory, either type of virus can affect either site.
Symptoms of herpes infection include one or more sores that break open to become ulcers. These may be preceded by tingling or pain in the affected skin. Genital herpes may also cause pain with urination or sex.
These symptoms usually resolve within a few weeks but may recur repeatedly. Herpes infections can be more serious in people with HIV and recur more often.
Other differences for people with both herpes and HIV include:
Outbreaks that last longer
Larger lesions, or lesions that are otherwise atypical
Herpes that is resistant to acyclovir
Herpes is often diagnosed based on the appearance of sores. However, there are also two types of diagnostic tests available for herpes. Tests for the virus in sores include viral culture and molecular testing for HSV viral DNA. These tests have a risk of false negatives if the sore is sampled at the wrong time.
Type-specific blood tests look for the existence of antibodies to HSV in the blood. With this test, there may be a risk of false positives for people with asymptomatic infection.
Antiviral treatments for herpes infections are available. Acyclovir and valacyclovir are both widely used in individuals who have HSV and HIV coinfection. However, there is a risk of the herpes virus developing resistance to acyclovir treatment in immunocompromised individuals on long-term therapy.
There is limited evidence that being infected with HSV-2 may speed up the progression of HIV disease.Individuals with both HIV and HSV may also have prolonged outbreaks and outbreaks in unusual locations.
Herpes and HIV Transmission
Herpes infections can also increase the risk of HIV transmission through sex.Studies estimate that people with genital herpes have five to seven times the risk of becoming infected with HIV.5Individuals with active genital herpes infections have a higher HIV viral load.
The sores and immune cell changes in the skin may also provide an easier route for new HIV infection.7 Because immune changes in the skin may happen even when sores are not present, the risk of HIV acquisition is not only higher when someone has active herpes lesions, but it may also be higher when someone with herpes has no symptoms.
Shingles is also caused by a type of herpes virus—the varicella zoster virus (VZV). VZV is more often known as the virus that causes chickenpox. Anyone who has ever had chickenpox is at risk of developing shingles. Shingles is a very painful rash that occurs if the VZV reactivates in the skin.
Shingles can be more serious in people who are immunocompromised. Shingles is also much more common in individuals with HIV than in the general population.8 Vaccination against shingles is available for adults over 50, including individuals living with HIV.
Kaposi’s sarcoma is a type of skin cancer that is primarily associated with HIV. Indeed, a sudden increase in Kaposi’s sarcoma was one of the things that led to the discovery of HIV and AIDS in the 1980s. Kaposi’s sarcoma is recognized by the presence of purple skin lesions that can occur on any part of the body.
Kaposi’s sarcoma is caused by Kaposi’s sarcoma-associated herpes virus, also known as human herpes virus-8 (HHV-8).This virus also causes primary effusion lymphoma and other conditions.
Kaposi’s sarcoma is the second most common tumor in individuals with a CD4 count of less than 200.It is an AIDS-defining illness. In other words, if HIV-positive people develop Kaposi’s sarcoma, they will also be diagnosed with AIDS.
Diagnosing and Managing Kaposi’s Sarcoma
Kaposi’s sarcoma is diagnosed by biopsy. A piece (or all) of a lesion is removed and examined by a pathologist. Samples may also be tested for signs of HHV-8. Treatment with highly active antiretroviral therapy can effectively treat Kaposi’s sarcoma in some HIV-positive individuals.
Another form of treatment for Kaposi’s sarcoma includes the removal of lesions. Chemotherapy is also used for treatment, particularly when lesions are spread throughout the body. Drugs used for chemotherapy may include:
Vincristine with bleomycin and doxorubicin (ABV)
Bleomycin with vincristine (BV)
Liposomal anthracyclines (doxorubicin or daunorubicin)
Oral Hairy Leukoplakia
Oral hairy leukoplakia causes white, hairy lesions on the tongue and in the mouth. This condition is benign and does not require treatment. However, it can be a sign that HIV is progressing, as oral hairy leukoplakia is more common in individuals who are more immunocompromised.
Oral hairy leukoplakia is caused by infection with the Epstein Barr virus, a virus that most of the population will experience during their lives. It is generally diagnosed by the appearance of sores. Unlike thrush, which may look similar, leukoplakia sores cannot be scraped off the tongue.
When required or desired, treatment for oral hairy leukoplakia is with acyclovir or similar antiviral medications. Unfortunately, therapy is generally only effective short term, and lesions are likely to recur. Antiretroviral therapy for HIV reduces but does not eliminate the risk of oral hairy leukoplakia.
Molluscum contagiosum is a highly infectious skin condition that is most common in children and adults who are immunocompromised. Although not generally thought of as a sexually transmitted disease, it can be transmitted during sex.
Molluscum contagiosum appears as raised, fluid-filled bumps on the skin. These bumps can range in size, and individuals with HIV may experience more and/or larger bumps.
The bumps associated with molluscum are generally painless, although they can become itchy or irritated. If scratched or broken open, the sores can spread or become infected.
In rare cases, molluscum contagiosum can become disseminated through the body rather than remaining in one area of the skin.
Managing Molluscum Contagiosum
Although there are several available treatments for molluscum contagiosum, none of them are known to be particularly effective.16 In addition, there is limited evidence about the use of these treatments in people with HIV.17
Treating HIV to improve the health of the immune system may be the best option for dealing with atypical molluscum infections.
Seborrheic dermatitis causes red patches on the skin that are covered in moist scales. These scales are generally yellowish in color. Although seborrheic dermatitis occurs in many people without HIV, people with HIV may have larger patches or dermatitis and more swelling.18
Seborrheic dermatitis is thought to be caused by skin infections with particular types of yeast, although there may be other causes as well.19 It is more common and more widespread in individuals who are immunocompromised. As many as 40% to 80% of HIV-positive individuals may experience seborrheic dermatitis.
Managing Seborrheic Dermatitis
For people with HIV, managing seborrheic dermatitis may involve extended use of oral and topical antifungal medications and corticosteroids.Antibiotics may also be needed for any patches of dermatitis that become infected with other bacteria.Recommended treatment of mild dermatitis is with topical ketoconazole alone.
Psoriasis is the most common skin disease in HIV-infected individuals.Although it also occurs in people without HIV, people with HIV may experience more severe psoriasis. Individuals with HIV may also be more likely to experience psoriatic arthritis.
The most common type of psoriasis is plaque psoriasis, which causes silvery scales on the skin. Other forms of psoriasis can cause different types of bumps or lesions. Psoriatic arthritis causes joint pain and swelling. Diagnosis is through examination of lesions or the use of a biopsy.
The most commonly used psoriasis treatments in HIV-negative individuals can suppress the immune system, which is potentially problematic for individuals with HIV.
Some research suggests that acitretin or apremilast may be good options for treating psoriasis in individuals with HIV. For people with an undetectable viral load, Tumor necrosis factor (TNF) agonists may also be a treatment option.24
If psoriasis symptoms are severe in HIV-positive individuals, immunosuppressive drugs may sometimes be needed.Antiretroviral treatment for HIV may also reduce the symptoms of psoriasis as the immune system becomes stronger.
Scabies is a skin infestation caused by a mite. It causes a red or purple rash that is extremely itchy. This rash may contain lines, or burrows, connecting infected areas. It may also have pimples, bumps, or pus.
Scabies is very easy to transmit by skin-to-skin contact. As the rash is similar to many other rashes, it must be diagnosed by a doctor. Diagnosis is usually through examining a scraping of skin under a microscope.
People with HIV may develop more severe manifestations of scabies, sometimes called crusted scabies or Norwegian scabies.These types of scabies may be more difficult to treat. They appear as crusted, grey, raised plaques on the skin. These sores may cause skin breakdown and become infected with bacteria.
In addition to infections caused by skin breakdown, if a scabies infection is scratched there is a risk of secondary infection with bacteria. This can potentially cause severe side effects including skin abscesses, kidney disease, and even rheumatic heart disease.
Both oral and topical treatments are available for scabies. Topical treatment is with permethrin, and oral treatment is with ivermectin.Ivermectin appears to be somewhat preferable in HIV-positive individuals, although the World Health Organization recommends permethrin first for mild cases.11 Additional antibiotics may be needed if a secondary skin infection develops.
Thrush is caused by infection with a type of yeast known as Candida. Thrush is also known as candidiasis. Although most people have Candida on their skin and in the mouth, thrush occurs when this yeast overgrows. The most common symptom of thrush is thick, whitish patches in the mouth and throat. Unlike oral hairy leukoplakia, these patches may be scraped off.
Thrush can also occur in other areas of the body such as in the vagina and the rectum. Symptoms in these locations may include changes in discharge.
Severe thrush, and thrush outside the mouth, are more common in individuals with HIV. In addition, because thrush that occurs outside the mouth is more common in individuals with a CD4 count under 200, it is an AIDS-defining condition.
Systemic thrush and disseminated thrush occur when the yeast infection spreads throughout one or more organs. These conditions can occasionally become very serious or even fatal in individuals with advanced HIV disease. Thrush is diagnosed by the examination of scrapings for Candida species.
Treatment for thrush uses oral or topical antifungal medications. Relapses are common, and treatment may need to be prolonged.Unfortunately, thrush may develop resistance to common forms of treatment in individuals who are immunocompromised and on long-term therapy, such as individuals with HIV.
In both adults and children, oral fluconazole is the preferred treatment for oral thrush. Topical treatment with nystatin or clotrimazole is also an option.
Sores, rashes, and other skin conditions are relatively common in individuals who are immunocompromised from HIV infection. Conditions that produce lesions include herpes, Kaposi’s sarcoma, oral hairy leukoplakia, molluscum contagiosum, seborrheic dermatitis, psoriasis, scabies, and thrush.