HIV-Related Skin Disease in the Era of Antiretroviral Therapy: Recognition and Management

Abstract

Antiretroviral therapy (ART) has revolutionized the treatment and prognosis of people living with HIV (PLHIV). With increased survival and improved overall health, PLHIV are experiencing dermatologic issues both specific to HIV and common to the general population. In this new era of ART, it is crucial for dermatologists to have a strong understanding of the broad range of cutaneous disease and treatment options in this unique population. In this review, we outline the most common skin diseases in PLHIV, including HIV-associated malignancies, inflammatory conditions, and infections, and focus on the role of ART in altering epidemiology, clinical features, diagnosis, and treatment of cutaneous conditions.

Fig. 1

A) HIV associated KS. A 25-year old male with HIV (CD4+ count 350, VL 25) presented with nodules and tumors, which started nine months prior. His lesions progressed despite antiretroviral therapy (ART). He presented with severe respiratory distress secondary to pulmonary KS. Given his progressive disease despite ART and symptomatic visceral involvement, systemic chemotherapy was added to his ART. B) Bacillary angiomatosis is a clinical mimicker of KS that can be distinguished on histopathology.

Fig. 2

A) HPV-associated SCC. A 48-year old woman with HIV (CD4+ count 560, VL 0) presented with a long-standing history of small lesions on buttocks and legs and two-week history of painful wound on the vulva. Hypopigmented thin papules were scattered on the legs and buttocks. B) Vulva, perineum, and perianal region had multiple exophytic, hyperpigmented and eroded plaques, .Biopsy at the border of an exophytic plaque demonstrated squamous cell carcinoma

Fig. 3

Eosinophilic folliculitis. A 30-year old woman with HIV (CD4+ count 12, VL 140,000) presented for new onset pruritic papules and pustules on the face and ears of three weeks duration. She has been on ART intermittently since her HIV diagnosis two years ago and initiated second-line ART three weeks prior.

Fig. 4

Community acquired MRSA. A 17-year old woman with HIV (CD4+ count 10, VL 680,000) on second-line ART presented with a 2 year history of intermittent pustules, crusted plaques, and scars on the feet and legs. Some healed spontaneously and others healed with oral medications (unknown what kind). She was started on doxycycline with improvement.

Fig. 5

VZV. An 18-year old man with HIV (CD4+ count 24, VL 550,000), not on ART, presented with one week of scattered vesicles, some umbilicated and crusted, in the setting of new shortness of breath and increased liver function enzymes. Tzanck smear demonstrated multinucleated giant cells. He was started on empiric IV acyclovir for possible disseminated VZV.

Fig. 6

Molluscum. Henderson-Patterson bodies.

Fig. 7

Candida. Pseudohyphae are present.