Evaluation of dermatologic disorders in HIV

often family history involving first-degree relative, plaques may be pruritic, history of improvement when skin is exposed to sunlight, most HIV-associated cases present shortly after HIV infection

sharply marginated dry, red plaques with thick, lamellar, silvery scale on extensor surfaces, or on flexural areas; with lower CD4 counts, can be more extensive and severe;[72]Obuch ML, Maurer TA, Becker B, et al. Psoriasis and human immunodeficiency virus infection. J Am Acad Dermatol. 1992 Nov;27(5 Pt 1):667-73. http://www.ncbi.nlm.nih.gov/pubmed/1430384?tool=bestpractice.com possible nail pitting and dystrophy, and arthritis

occurs predominantly on scalp (scaly scalp), often chronic, may be mildly or moderately itchy

poorly defined orange, pink, or red scaly patches on scalp, eyebrows, moustache, beard, nose, nasolabial folds, cheeks, groin, gluteal crease; less frequently, on central chest and genitalia; greasy appearance and feel

itchy skin; red lesions commonly on arms and legs; may have chronic course; HIV infection may trigger flare or manifestation; with advancing HIV disease, adults with previous history of atopy may have recurrence[73]Parkin JM, Eales LJ, Galazka AR, et al. Atopic manifestations in the acquired immune deficiency syndrome: response to recombinant interferon gamma. Br Med J (Clin Res Ed). 1987 May 9;294(6581):1185-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1246352/pdf/bmjcred00019-0009.pdf http://www.ncbi.nlm.nih.gov/pubmed/3109572?tool=bestpractice.com

isolated, excoriated 2- to 4-mm papules; chronic cases may also involve intermingled indurated plaques of thickened skin (lichenification) affecting flexural areas, face, neck, and hands; generalized xerosis; possible postinflammatory pigment alteration

possible excessive bathing or use of deodorant or antibacterial soaps; may be more severe in winter and associated with dermatitis; often generalized pruritus;[74]Gelfand JM, Rudikoff D. Evaluation and treatment of itching in HIV-infected patients. Mt Sinai J Med. 2001 Sep-Oct;68(4-5):298-308. http://www.ncbi.nlm.nih.gov/pubmed/11514917?tool=bestpractice.com people with allergic rhinitis, asthma, or previous atopic dermatitis are more susceptible; associated with HIV wasting syndrome; severe xerosis often occurs with chronic diarrhea or malabsorption

roughened surface, fine scaling, occasionally small cracks; commonly on posterior arms and lower legs; often on shins, with typical cracked appearance; possible thickening of palms and soles especially in chronic cases

red rash around mouth, more common in women, usually not itchy but may be associated with mild burning sensation, often recent history of topical corticosteroid use on face

erythematous papules and pustules on sometimes scaly base; usually forms a clear halo around lips, 3 to 5 mm in diameter; a similar eruption (periorbital dermatitis) has been described around eyes

flares more commonly seen once antiretroviral therapy is commenced and patients become immune constituted;[22]Scott C, Staughton RC, Bunker CJ, et al. Acne vulgaris and acne rosacea as part of immune reconstitution disease in HIV-1 infected patients starting antiretroviral therapy. Int J STD AIDS. 2008 Jul;19(7):493-5. http://www.ncbi.nlm.nih.gov/pubmed/18574128?tool=bestpractice.com important to distinguish from eosinophilic folliculitis (EF); EF is more commonly associated with extreme pruritus

red eruption of papulopustular lesions predominantly on face and back; presence of comedones (blackheads) may aid in distinguishing between acne vulgaris and EF

common in HIV-infected patients, and may be more difficult to treat as HIV advances

verrucous papules particularly on hands, genital region, face, or feet; bowenoid papulosis involves flat, sessile, hyperpigmented papules ranging from millimeters to several centimeters in diameter usually on genital region; epidermodysplasia verruciformis presents with extensive involvement of lesions that look like flat warts, typically on neck, dorsal hands, face, and extremities; involvement may become extensive enough to be confluent

recurrent painful cold sores mainly on orogenital and nasal areas; lesions may rupture, crust, and heal in 7 to 10 days; untreated lesions may slowly enlarge; with advancing AIDS, sores may become chronic and persistent[76]Centers for Disease Control and Prevention (CDC). Revised surveillance case definition for HIV infection--United States, 2014. MMWR Recomm Rep. 2014 Apr 11;63(RR-03):1-10. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm http://www.ncbi.nlm.nih.gov/pubmed/24717910?tool=bestpractice.com

grouped blisters or impetiginized eroded lesions; in advancing HIV, lesions may be several centimeters in diameter; HSV should always be considered in HIV-positive patients with ulceration in the anogenital regions

most HIV-infected patients have had varicella previously, manifesting as zoster at relatively normal CD4 counts; prodrome of sensation including paresthesia or pain in a dermatome that may last from 2 to 7 days, followed by grouped vesicular eruption; eye involvement is serious, as it may cause temporary or permanent decrease in visual acuity or even blindness, warranting ophthalmic evaluation and treatment; vesicles last about 2 to 3 weeks; pain associated with lesions will also last 2 to 3 weeks; if lesions involve necrotic areas, time course may extend to ≥6 weeks and involve scarring with severe pain that may last for months; in primary varicella infection, unlike typical chickenpox, varicella involvement may be severe with visceral involvement, especially in children

dermatomal rash with vesiculopustules on an erythematous base, or in more severe cases bullous, hemorrhagic, necrotic, and tender; dissemination is infrequent but more common than disseminated HSV;[78]Cohen PR, Grossman ME. Clinical features of human immunodeficiency virus-associated disseminated herpes zoster virus infection - a review of the literature. Clin Exp Dermatol. 1989 Jul;14(4):273-6. http://www.ncbi.nlm.nih.gov/pubmed/2686873?tool=bestpractice.com if involvement has been chronic, lesions may appear hyperkeratotic, verrucous, or ecthymatous;[79]Pahwa S, Biron K, Lim W, et al. Continuous varicella-zoster infection associated with acyclovir resistance in a child with AIDS. JAMA. 1988 Nov 18;260(19):2879-82. http://www.ncbi.nlm.nih.gov/pubmed/3184352?tool=bestpractice.com [80]Jacobson MA, Berger TG, Fikrig S, et al. Acyclovir-resistant varicella zoster virus infection after chronic oral acyclovir therapy in patients with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med. 1990 Feb 1;112(3):187-91. http://www.ncbi.nlm.nih.gov/pubmed/2297195?tool=bestpractice.com [81]Linnemann CC, Jr., Biron KK, Hoppenjans WG, et al. Emergence of acyclovir-resistant varicella zoster virus in an AIDS patient on prolonged acyclovir therapy. AIDS. 1990 Jun;4(6):577-9. http://www.ncbi.nlm.nih.gov/pubmed/2167103?tool=bestpractice.com in primary infection vesicles can be located throughout the body including sun-exposed areas, trunk, face, and oral mucosa

follicular rash in hairy areas; may be pruritic

follicular pustules in trunk, axilla, face, groin; occasionally involvement of follicles may extend into abscesses; when large areas are involved, sometimes a violaceous plaque may manifest

methamphetamine use, sex work, limited or no condom use, and substance use; in men, having sex with other men

nontender slightly indurated ulcer (primary chancre) on genital or mucocutaneous skin; patchy alopecia; sternal osteochondritis; papulosquamous lesions on trunk, palms, soles, mucosal surfaces (secondary); uveitis; verrucous or hyperkeratotic nodules and noduloulcerative lues maligna; lymphadenopathy

severe pruritus between fingers, at beltline, and in genital region; often pruritus interferes with sleep; infection risk to bed partners, family members, or other people with whom patient is in contact; tends to be more florid in HIV-infected patients; patients with low CD4 counts may have crusted scabies that tends to be minimally itchy and highly infectious

widespread excoriated papules in genital region, webbing of fingers and toes, axillae, and nipples; close inspection may reveal burrows in affected areas; may also manifest as crusted scabies with hyperkeratotic plaques that are less pruritic and often teeming with mites; unlike in those without HIV infection, involvement above the neck is possible in HIV-infected patients

itchy papules; history of environmental, animal, or flea exposure; in southern US, mosquito exposure may be most prevalent etiology

urticarial excoriated papules

a red eruption tending to affect intertriginous areas, groin, axillary, anogenital, or inframammary areas; oral candidiasis also common in HIV; can also involve nails; history of frequent exposure to water, or in moist parts of the body; usually not pruritic, which may help to differentiate candidal infections from tinea

erythematous shallowly eroded eruption with satellite pustules, sometimes with white coating and fissuring; in oropharynx, presents as erythematous or white cheesy papules and plaques that may also have erosions and involve the esophagus (i.e., thrush); candidiasis can be differentiated from oral hairy leukoplakia, as thrush plaques are much more easily scraped off with tongue blade; can also involve fissuring and crusting at corners of mouth (angular cheilitis); with nail involvement often presents with surrounding tissue inflammation and involvement (paronychia), with redness and tenderness of proximal nail fold; onycholysis may also occur, although nail plate usually remains uninvolved; not uncommon to see a greenish hue to nails, which implies concomitant pseudomonal infection

nonhealing tumor on sun-exposed area; risk factors include fair skin, significant prior sun exposure, age, and longer duration of HIV infection

commonly present on back or chest as scaling patches that may not heal, and may bleed or erode; nodular: most commonly one or a few waxy nodules around a central depression, possibly with bleeding, crusting, or ulceration with telangiectasias; morpheic: white sclerotic plaque with telangiectasia; superficial: unlike other forms of BCC, may show up on the trunk or extremities as well as head or neck as a psoriasiform lesion with scale and telangiectasia, often misdiagnosed as eczema or psoriasis; pigmented: brown- or black-pigmented nodular BCC; many subtypes of BCC have rolled edges, which may aid in differentiating BCCs from other lesions

associated with nucleoside reverse transcriptase inhibitor and protease inhibitor use; gradual loss of subcutaneous fat and gain of visceral fat; development of metabolic defects including insulin resistance and dyslipidemia; cardiovascular risk factors should be documented[96]Potthoff A, Brockmeyer NH, Gelbrich G, et al; Competence Center Cardiac Insufficiency and the Competence Network HIV/AIDS. Lipodystrophy: a sign for metabolic syndrome in patients of the HIV-HEART study. J Dtsch Dermatol Ges. 2010 Feb;8(2):92-8. http://www.ncbi.nlm.nih.gov/pubmed/20002869?tool=bestpractice.com

loss of fat over maxilla, over buttocks, and from periphery; gain in fat in central trunk, on neck, and on upper back; pronounced appearance of veins on extremities

onychomycosis is often seen in athletes; indinavir can cause paronychia, but is not commonly used any more; dark nail pigmentation is common with the use of azidothymidine

yellowing and thickening of the nail; painful redness and swelling at the side of the nail; dark pigmentation

unprotected sexual intercourse within the last 2 weeks, burning with urination, penile or vaginal discharge, pelvic pain

penile or vaginal discharge, proctitis, consider asymptomatic pharyngeal or anal infections; complications: arthritis, blepharitis, sepsis

unprotected sexual intercourse, painful urination, proctitis, inguinal lymph node swelling, cervicitis, pelvic pain, infertility; often asymptomatic

penile discharge, genital ulcers, proctoscopy may reveal proctitis

low CD4 cell count and high viral load are risk factors for oral ulcers

minor ulcers are the most common and measure <10 mm and last on average from 10 to 14 days; major ulcers (10-30 mm) last for weeks and months; herpetiform types (1-3 mm) can be multiple in number (up to 100 ulcers per episode)

skin exposure to sun; more likely in patients with background pigment; may result from HIV infection or drugs such as trimethoprim/sulfamethoxazole, nonsteroidal anti-inflammatory drugs (NSAIDs), doxycycline; discontinuing photosensitizer may not lead to resolution

erythematous or darkened patches and plaques on sun-exposed backs of hands, extensor forearms, side of neck, and face; may be seen with swelling; may present as pruritic nodules or blisters

moderate to severely pruritic, pruritus often difficult to control, sometimes associated with hepatitis B or C coinfection, patient may be using methamphetamine (crystal) or cocaine (crack)

dome-shaped excoriated nodules mainly on photo-exposed areas of extremities, may eventually involve trunk to a lesser extent, sparse on mid-back, nodules normally bilateral and symmetric, hyperpigmentation and/or hypopigmentation (scarring)

numerous pruritic lesions; history of insect bite; patient may originate from Africa, Haiti, Brazil, or Thailand, where condition more common; may be presenting sign of HIV

papules may be erythematous and excoriated, and are smaller than those in prurigo nodularis; usually initially on extensor surfaces of extremities; may sometimes involve trunk and face

eruption may coincide with initiation of antiretroviral therapy[66]Rajendran PM, Dolev JC, Heaphy MR, Jr., et al. Eosinophilic folliculitis: before and after the introduction of antiretroviral therapy. Arch Dermatol. 2005 Oct;141(10):1227-31. http://archderm.jamanetwork.com/article.aspx?articleid=399828 http://www.ncbi.nlm.nih.gov/pubmed/16230559?tool=bestpractice.com

edematous urticarial follicular papules and nodules on face, scalp, neck, and upper trunk; minimal or no surrounding erythema; severely pruritic; primary lesions may be excoriated; pustules occasionally present; important to distinguish from acne vulgaris, which is not pruritic

triad of arthritis, conjunctivitis, and urethritis, with any one of these occurring first; patient may be HLA-B27-positive; possible positive family history; arthritis often asymmetric, affecting peripheral weight-bearing joints; often follows gastrointestinal or genitourinary infection; can co-occur with HIV infection; symptoms of reactive arthritis may appear simultaneously with HIV-infective symptoms or occur shortly after HIV infection becomes symptomatic[15]Duvic M, Johnson TM, Rapini RP, et al. Acquired immunodeficiency syndrome-associated psoriasis and Reiter's syndrome. Arch Dermatol. 1987 Dec;123(12):1622-32. http://www.ncbi.nlm.nih.gov/pubmed/3688903?tool=bestpractice.com [23]Winchester R, Bernstein DH, Fischer HD, et al. The co-occurrence of Reiter's syndrome and acquired immunodeficiency. Ann Intern Med. 1987 Jan;106(1):19-26. http://www.ncbi.nlm.nih.gov/pubmed/3789575?tool=bestpractice.com

superficial pustules on palms and soles that dry to form keratotic papules (keratoderma blennorrhagicum); horizontal ridging on nails, and appearance of subungual debris; during severe flares, nail dystrophy may worsen, so that nail plate may seem to be absent; erythematous plaques with similar appearance and histology may manifest in axillae and groin; glans penis may be covered by a dry, well-circumscribed eruption with a sharp lesional border, known as circinate balanitis, that in uncircumcised males mimics candidiasis; oral erosions that are otherwise asymptomatic and ephemeral along with geographic tongue with white patches are sometimes present

lesions may be few or numerous; extensive (>100 lesions) or mucocutaneous involvement often indicates severe immunosuppression; on beard area, shaving can spread lesions; immunosuppression lesions may be persistent and disfiguring; talaromycosis (formerly penicilliosis) more prevalent in Southeast Asia

smooth, shiny, pearly, dome-shaped papules with central umbilication; irritated lesions may develop overlying crust, typically on face, genitalia, and trunk; papules are usually 3 to 5 mm in diameter but other lesions may grow as large as 1 to 1.5 cm in diameter

normally asymptomatic white lesions on tongue

poorly demarcated, corrugated, nontender white plaques, feathered edge, often on lateral border of tongue; unlike oral candidiasis, OHL cannot be removed by scraping

may be asymptomatic or present with flu-like symptoms, lymphadenopathy, pharyngitis, and exanthem on chest, back, oral, and genital areas; frequency of rash may be as high as 50%;[83]Cooper DA, Gold J, Maclean P, et al. Acute AIDS retrovirus infection. Definition of a clinical illness associated with seroconversion. Lancet. 1985 Mar 9;1(8428):537-40. http://www.ncbi.nlm.nih.gov/pubmed/2857899?tool=bestpractice.com [84]Wantzin GR, Lindhardt BO, Weismann K, et al. Acute HTLV III infection associated with exanthema, diagnosed by seroconversion. Br J Dermatol. 1986 Nov;115(5):601-6. http://www.ncbi.nlm.nih.gov/pubmed/3466637?tool=bestpractice.com [85]Rustin MH, Ridley CM, Smith MD, et al. The acute exanthem associated with seroconversion to human T-cell lymphotropic virus III in a homosexual man. J Infect. 1986 Mar;12(2):161-3. http://www.ncbi.nlm.nih.gov/pubmed/3009630?tool=bestpractice.com [86]Tindall B, Barker S, Donovan B, et al. Characterization of the acute clinical illness associated with human immunodeficiency virus infection. Arch Intern Med. 1988 Apr;148(4):945-9. http://www.ncbi.nlm.nih.gov/pubmed/3258508?tool=bestpractice.com [87]Sinicco A, Palestro G, Caramello P, et al. Acute HIV-1 infection: clinical and biological study of 12 patients. J Acquir Immune Defic Syndr. 1990;3(3):260-5. http://www.ncbi.nlm.nih.gov/pubmed/1968096?tool=bestpractice.com [88]Hulsebosch HJ, Claessen FA, van Ginkel CJ, et al. Human immunodeficiency virus exanthem. J Am Acad Dermatol. 1990 Sep;23(3 Pt 1):483-6. http://www.ncbi.nlm.nih.gov/pubmed/2120292?tool=bestpractice.com usually nonpruritic

discrete macules and papules on the upper trunk, as well as oral and genital ulcers; may involve palms and soles

may be more prevalent in hot, humid weather; blisters with yellow crusting in axillae or groin

superficial, flaccid blisters or erosions that may have yellowish crusting; involves axilla or groin

associated with history of intravenous drug use, poor hygiene

shallowly ulcerated or eroded skin with crust on lower extremities, often on shins or dorsal feet; early phase may involve a vesicle or vesiculopustule

chronic and indolent; associated with HIV and diabetes mellitus

purulent, crusted nodules with sinuses that may involve sulfur granules; crusted nodules may be overlain with atrophic scar

history of cat and flea exposure (Bartonella henselae), or poor hygienic conditions; patient may originate from South America, Europe, India, or Africa; associated with fever, night sweats, weight loss

fleshy, friable purple or red papules, ulcers, or nodules that tend to bleed easily, lesions may be surrounded by a collarette of scale; lesions can be extensive; occasionally also manifest as skin-colored subcutaneous swelling

history of travel to, or living in, endemic areas with sand fly exposure: for example, Spain, around Mediterranean, Turkish Republic, Iran, Saudi Arabia

varies from a few spontaneously improving lesions to a diffuse nonhealing eruption that may involve mucocutaneous tissue; lesions begin with slow-growing, indolent papulonodules that may become verrucous, furuncular, or ulcerated; mucocutaneous lesions may begin as ulcers that then progress to dry crusting with further ulceration, often involving nasal cavity and septum but usually sparing nasal bones; tendency for involvement in exposed areas; possible localized or diffuse hyperpigmentation

increased variability of presentation and disease severity in HIV-infected patients

annular lesions with peripheral scale and central clearing on intertriginous areas, especially between toes and in axillae or groin, but may occur on any part of body; atypical manifestations include nummular scaly lesions, or pustules on plaques; groin involvement may be mildly pruritic, but usually spares scrotum; nail involvement involves darkening or yellowing of nail with hyperkeratosis

more prevalent in HIV-infected men who have sex with men; one of the most common HIV-associated malignancies in both adults and children; hemoptysis, dysphagia, or gastrointestinal bleed may imply need for prompt evaluation of visceral involvement and likely chemotherapeutic intervention

dusky vascular purple papules, nodules, or plaques; may be solitary, widespread, grouped, or zosteriform; sizes range from millimeters to several centimeters; often present on extremities, trunk, or oropharynx but may affect any part of cutaneous surface; lymphedema or lymphadenopathy signifies systemic involvement

positive family history; light skin, light eyes, blond or red hair; history of sun exposure, heavy freckling, and easily sunburning; in acral-lentiginous melanoma, Asian or dark-skinned ethnic group

lesions fit ABCD criteria: asymmetry, border irregularity, color variegation, diameter (>6 mm); may present as pedunculated, polypoid, hyperkeratotic, or amelanotic; as brown macule with inset nodule and possible bleeding and ulceration, on sun-exposed site (lentigo maligna melanoma); multicolored lesion often on upper back or legs (superficial spreading melanoma); ulcerated, potentially nodular lesions on feet and hands (acral-lentiginous melanoma); or fungating, friable ulcerated, dome-shaped lesion on sun-exposed area (nodular melanoma)

risk factors include fair skin and significant prior sun exposure, age, and longer duration of HIV infection

discrete, hard, nonhealing lesion on sun-exposed area; indurate elevated base that may evolute to become nodular and ulcerated; more common on head and neck; also, more common on dorsum of hands than basal cell carcinoma

strongly associated with use of trimethoprim/sulfamethoxazole and other antibiotics in HIV-infected patients

diffuse morbilliform, maculopapular eruption

can be seen with abacavir, efavirenz, or nevirapine use; skin rash with at least 1 of the following within 2 months of drug initiation, or 3 of the following without rash: headache, gastrointestinal symptoms, respiratory symptoms, myalgia, fever; rash may be painful and/or pruritic

febrile; facial edema and erythema with morbilliform rash extending on to trunk; lymphadenopathy

associated with sulfa drugs, nevirapine, anticonvulsants, nonsteroidal anti-inflammatory drugs (NSAIDs), allopurinol; influenza-like symptoms precede eruption by a few days

early phases include diffuse redness or macular lesions with purpuric centers that may coalesce, blister, then slough; lesions usually begin on trunk or face then spread outward, and commonly involve mucous surfaces

worsening of general condition, or new opportunistic infection after starting combination antiretroviral therapy; patients with a CD4 count <50 cells/microliter have a higher risk

may demonstrate features of cytomegalovirus (CMV) retinitis or tuberculosis, both of which should be excluded with the relevant investigations before initiating antiretroviral therapy; may present with features of cryptococcal meningitis, multifocal leukoencephalopathy, Kaposi sarcoma, or herpes zoster during the first weeks of treatment

unprotected sexual intercourse within the last 2 weeks, painful genital ulcers; found primarily in developing countries

sharply defined, undermined borders, “kissing ulcers” may develop on opposing surfaces; inguinal lymph node swelling is found in one third of patients

aggressive tumor that metastasizes in lymph nodes, fat, fascia muscles, and lung, liver, brain and bone

painless nodule or tumor, often in light exposed areas

Epstein-Barr virus-associated tumor in children

6 different types: cutaneous type (good prognosis); local subcutaneous type (bad prognosis with early manifestaton in lymph nodes or lung); vascular or genital types (rare: each 5%); intraabdominal leiomyosarcoma (common: 40%); deep leiomyosarcoma of extremity (20%)

a characteristic rash that typically progresses in sequential stages (from macules, to papules, vesicles, and pustules); anorectal symptoms have been reported (e.g., severe/intense anorectal pain, tenesmus, rectal bleeding, or purulent or bloody stools, pruritus, dyschezia, burning and swelling) in recent outbreaks, and may occur in the absence of a rash; fever may be a symptom of the prodromal period (usually preceding the appearance of the rash), but may present after the rash or not at all; other common symptoms may include myalgia, fatigue, asthenia, malaise, headache, sore throat, backache, cough, nausea/vomiting, oral/oropharyngeal ulcers; there may be a history of recent travel to/living in endemic country or country with outbreak, or contact with suspected, probable, or confirmed case within the previous 21 days before symptom onset; symptoms may be atypical and/or more severe in immunocompromised individuals

rash or skin lesion(s) are usually the first sign of infection; physical exam may reveal a rash or lesion(s), and possibly lymphadenopathy; rash generally starts on the face and body and spreads centrifugally to the palms and soles (it may be preceded by a rash affecting the oropharynx and tongue in the 24 hours prior that often passes unnoticed); lesions simultaneously progress through four stages - macular, papular, vesicular, and pustular - with each stage lasting 1-2 days, before scabbing over and resolving; lesions are typically 5-10 mm in diameter, may be discrete or confluent, and may be few in number or several thousand; vesicles are well-circumscribed and located deep in the dermis; the rash may appear as a single lesion in the genital or perioral areas without a prodromal phase; perianal/rectal lesions and proctitis may be present​; lymphadenopathy, typically occurs with onset of fever preceding the rash or, rarely, with rash onset, may be submandibular and cervical, axillary, or inguinal, and occur on both sides of the body or just one side; inguinal lymphadenopathy has been commonly reported