Advertisement

The Spectrum of HIV-Associated Infective and Inflammatory Dermatoses in Pigmented Skin

Published:January 24, 2014DOI:https://doi.org/10.1016/j.det.2013.12.006

      Keywords

      Key points

      • The introduction of antiretroviral medication has changed the epidemiology, morbidity, and mortality of HIV disease.
      • Antiretrovirals have also altered the incidence of infective and inflammatory diseases affecting the skin.
      • Cutaneous disorders due to HIV infection remain a major problem in HIV-infected patients.
      • In patients with pigmented skin, HIV-associated dermatoses result in special challenges, particularly with regard to diagnosis and treatment.
      • Due to the common problem of dyspigmentation caused by these conditions in pigmented skin, early diagnosis and effective treatment are of utmost importance.

      Introduction

      Patients living with HIV and AIDS are susceptible to various infective and inflammatory dermatoses. Even after the introduction of antiretroviral medication, the visible impact of skin lesions remains a major area of concern in patients living with HIV,
      • Zancanaro P.C.
      • McGirt L.Y.
      • Mamelak A.J.
      • et al.
      Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience.
      affecting their quality of life and self-esteem. In patients with pigmented skin, postinflammatory hyperpigmentation is a common finding and may lead to stigmatization and misdiagnosis.
      Inflammatory and infective dermatoses can affect patients at any stage of HIV disease, with some considered markers of immunosuppression.
      Skin lesions can predict treatment response or failure of antiretroviral medication; some worsen or appear initially after the initiation of antiretrovirals due to the immune reconstitution inflammatory syndrome (IRIS). Introduction of antiretroviral medication has changed the profile of HIV-associated dermatoses.
      • Cedeno-Laurent F.
      • Gómez-Flores M.
      • Mendez N.
      • et al.
      New insights into HIV-1-primary skin disorders.
      There is a dramatic decrease in opportunistic infections, whereas certain inflammatory conditions are on the increase.
      In the setting of HIV/AIDS, it is important for physicians to be aware that infective and inflammatory dermatoses are often atypical, more severe, and more resistant to treatment.
      • Zancanaro P.C.
      • McGirt L.Y.
      • Mamelak A.J.
      • et al.
      Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience.
      • Amerson E.H.
      • Maurer T.A.
      Dermatologic manifestations of HIV in Africa.
      There is a paucity of literature on HIV-associated skin disorders in pigmented skin, especially in Africans. This article focuses on the clinical presentation in patients with pigmented skin of the most common HIV-associated infective and inflammatory dermatoses.

      Viral infections

      Herpes Simplex Virus Infection

      Herpes simplex virus (HSV) infection causes substantial morbidity in patients with HIV. HSV can serve as a cofactor in the progression of HIV.
      • Lupi O.
      Prevalence and risk factors for herpes simplex infection among patients at high risk for HIV infection in Brazil.
      This is suggested by simultaneous isolation of HSV and HIV from the same lesion, reduction of HIV shedding in coinfected individuals undertaking antiherpetic treatment, and data suggesting that HSV infection may adversely affect the progression of immunodeficiency in HIV-infected persons.
      • Lupi O.
      Prevalence and risk factors for herpes simplex infection among patients at high risk for HIV infection in Brazil.
      Herpes labialis caused by HSV type 1 (HSV-1) is common in HIV. In the setting of HIV, it tends to be more aggressive and lesions tend to last longer (Fig. 1). Herpes genitalis caused by HSV type 2 (HSV-2) is the most frequent genital ulcer disease among HIV seropositive patients.
      • Lupi O.
      Prevalence and risk factors for herpes simplex infection among patients at high risk for HIV infection in Brazil.
      Herpes genitalis presents as vesicles, erosions, and ulcers on the genitalia. In patients with AIDS, the severity and duration of recurrent genital herpes may be more severe than that seen in normal hosts.
      • Lupi O.
      Prevalence and risk factors for herpes simplex infection among patients at high risk for HIV infection in Brazil.
      Figure thumbnail gr1
      Fig. 1Herpes labialis is an HIV-infected patient.

      Molluscum Contagiosum

      Molluscum contagiosum caused by a poxvirus is common in HIV. Lesions are skin-colored, dome-shaped papules or nodules with central umbilication.
      In the setting of HIV, molluscum contagiosum tends to be atypical and extensive (Fig. 2). Atypical lesions may resemble other conditions, such as basal cell carcinoma, keratoacanthomas, and cryptococcosis. Although it is a clinical diagnosis, biopsy may be necessary to confirm the diagnosis. Histopathology shows intracytoplasmic inclusion bodies, called molluscum bodies or Henderson-Paterson bodies.
      Treatment of molluscum contagiosum in HIV patients includes restoration of immune competence by highly active antiretroviral therapy.
      In some patients, lesions may respond to immunomodulators, such as imiquimod 5% cream. Resistant lesions may be treated with cryotherapy, which involves application of liquid nitrogen onto the lesions for cold-induced cell destruction; however, this may not be possible in patients with extensive disease. Complications of cryotherapy are hypopigmentation, hyperpigmentation, and scarring.

      Herpes Zoster

      Herpes zoster is also common in HIV setting and tends to be multidermatomal (Fig. 3). HIV patients often get recurrent episodes. It presents as painful blisters after a dermatome. The pain may be severe in some patients and they are more likely to require medical attention.
      Figure thumbnail gr3
      Fig. 3Herpes zoster on maxillary and mandibular divisions of trigerminal nerve.
      Treatment of herpes zoster is aimed at speedy healing of skin lesions, limiting disease progression, pain reduction, and prevention of complications, such as postherpetic neuralgia.
      Systemic antivirals, such as oral acyclovir (800 mg 5 times a day for 7–10 days) or valacyclovir (1000 mg 3 times a day for 7 days), are helpful. A combination of analgesics and antiinflammatories should be given for pain.
      A common complication of herpes zoster is postherpetic neuralgia, in which the pain of herpes zoster remains long after the skin disease has healed. Management of postherpetic neuralgia includes analgesics, antiinflammatories, and a tricyclic antidepressant, such as amitriptyline. Antiepileptics, such as carbamazepine, can also be used instead of amitriptyline.

      Viral Warts

      Human papillomavirus warts are also common in HIV patients. They tend to be multiple in these patients. They can present in the form of verruca vulgaris or verruca plana. HIV patients with viral warts must be on antiretroviral therapy to boost the immune system.
      Topical therapies, such as trichloroacetic acid and podophyllin resin in a compound tincture of benzoin, applied on to the lesions may help. Podophyllin acts by way of antimitotic activity. Immunomodulators, such as imiquimod 5% cream, may also be helpful.
      Ablative therapies, such as cryotherapy and curettage, can also help in patients with fewer lesions. Long-pulsed Nd:YAG laser has also been used successfully in some patients.

      Baterial infections

      Staphylococcus aureus Infection

      Staphylococcus aureus is the most common bacterial pathogen in HIV. It causes folliculitis, impetigo, ecthyma, and skin abscesses. Treatment of staphylococcal skin disease includes the use of systemic antibiotics, such as cloxacillin, and application of topical antibiotics, such as mupirocin or fucidin. The use of antiseptic solutions in bath water may prevent recurrent episodes.

      Bacillary Angiomatosis

      Bacillary angiomatosis is a vascular proliferative disease common in HIV.
      • Draganova-Tacheva R.A.
      • Domsky S.
      • Paralkar V.
      • et al.
      Bacillary angiomatosis as an initial presentation in an HIV-positive Man.
      It is caused by Bartonella henselae and Bartonella quintana. The proliferative vascular lesions most commonly involve the skin but may be present in many other tissues, including lymph nodes, bone, brain, respiratory and gastrointestinal tracts, cardiac valves, and bone marrow.
      • Draganova-Tacheva R.A.
      • Domsky S.
      • Paralkar V.
      • et al.
      Bacillary angiomatosis as an initial presentation in an HIV-positive Man.
      It has been suggested that cutaneous lesions of bacillary angiomatosis may be a marker of systemic bacillary angiomatosis infection, especially in HIV-positive patients.
      • Grilo N.
      • Modi D.
      • Barrow P.
      Cutaneous bacillary angiomatosis: a marker of systemic disease in HIV.
      Cutaneous lesions of bacillary angiomatosis are angiomatous papules and nodules, which bleed easily on contact (Fig. 4). Treatment of choice is erythromycin (500 mg 4 times a day for 3 months). Doxycycline, ceftriaxone, and the fluoroquinolones can be useful.
      • Grilo N.
      • Modi D.
      • Barrow P.
      Cutaneous bacillary angiomatosis: a marker of systemic disease in HIV.
      Figure thumbnail gr4
      Fig. 4Bacillary angiomatosis. These lesions bleed easily.

      Syphilis

      Syphilis is common in the setting of HIV, especially in HIV-positive men who have sex with men. Syphilis and HIV are particularly suited to being acquired together because both are sexually transmitted and the risk factors for acquisition are the same.
      • Muldoon E.G.
      • Mooka B.
      • Reidy D.
      • et al.
      Long-term neurological follow-up of HIV-positive patients diagnosed with syphilis.
      • Zellen J.
      • Augenbraun M.
      Syphilis in the HIV-infected patient: an update on epidemiology, diagnosis and management.
      Furthermore, ulcers of primary syphilis are known to facilitate the transmission of HIV.
      • Fleming D.T.
      • Wasserheit J.N.
      From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.
      • Zetola N.M.
      • Klausner J.D.
      Syphilis and HIV infection: an update.
      In addition, syphilis has been reported to have immunologic effects on HIV infection, and HIV is known to modulate both the manifestations of syphilis and the serologic response to therapy.
      • Muldoon E.G.
      • Mooka B.
      • Reidy D.
      • et al.
      Long-term neurological follow-up of HIV-positive patients diagnosed with syphilis.
      It has been postulated that the presentation of syphilis differs between HIV-infected patients and patients without HIV infection.
      First, HIV-infected patients with primary syphilis are more likely to have multiple chancres compared with non-HIV patients.
      • Zellen J.
      • Augenbraun M.
      Syphilis in the HIV-infected patient: an update on epidemiology, diagnosis and management.
      In HIV patients, these ulcers tend to be larger and deeper.
      • Zetola N.M.
      • Klausner J.D.
      Syphilis and HIV infection: an update.
      Second, HIV-infected patients with secondary syphilis frequently have simultaneous genital ulcers, thus have overlap of primary and secondary syphilis (Fig. 5).
      • Zellen J.
      • Augenbraun M.
      Syphilis in the HIV-infected patient: an update on epidemiology, diagnosis and management.
      • Zetola N.M.
      • Klausner J.D.
      Syphilis and HIV infection: an update.
      It is unclear whether the overlapping of stages of syphilis in HIV patients represents slower than normal healing of primary syphilis or an accelerated progression to secondary syphilis.
      • Zellen J.
      • Augenbraun M.
      Syphilis in the HIV-infected patient: an update on epidemiology, diagnosis and management.
      Figure thumbnail gr5
      Fig. 5Overlap of primary and secondary syphilis in an HIV patient.
      Third, HIV patients with syphilis have a higher likelihood of developing neurosyphilis.
      • Zellen J.
      • Augenbraun M.
      Syphilis in the HIV-infected patient: an update on epidemiology, diagnosis and management.
      In HIV patients with syphilis, atypical serologic tests and even serologically defined treatment failures have been reported.
      • Knaute D.F.
      • Graf N.
      • Lautenschlager S.
      • et al.
      Serological response to treatment of syphilis according to disease stage and HIV status.

      Cutaneous Tuberculosis

      Cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multidrug-resistant pulmonary tuberculosis.
      • Wozniacka A.
      • Schwartz R.A.
      • Sysa-Jedrzejowska A.
      • et al.
      Lupus Vulgaris: report of two cases.
      • Padvamathy L.
      • Ras L.L.
      • Ethirajan N.
      • et al.
      Ulcerative Lupus Vulgaris of face: an uncommon presentation in India.
      Skin involvement with Mycobacterium tuberculosis is divided into 3 categories: inoculation tuberculosis, a primary infection of the skin that is introduced by an exogenous source; secondary tuberculosis, either contiguous or hematogenous spread from a primary focus that leads to skin involvement; and, lastly, tuberculids, which are hypersensitivity reactions to M tuberculosis components.
      • Libraty D.H.
      • Byrd T.F.
      Cutaneous miliary tuberculosis in the AIDS era: case report and review.
      Lupus vulgaris remains the most common form of cutaneous tuberculosis,
      • Wozniacka A.
      • Schwartz R.A.
      • Sysa-Jedrzejowska A.
      • et al.
      Lupus Vulgaris: report of two cases.
      and it can be due to primary infection of the skin or due to hematogenous spread. Lupus vulgaris presents as an asymptomatic enlarging plaque that later ulcerates and become verrucous, fungating, and destructive (Fig. 6). The nose and center of the face is a common area but any part of the body can be affected.
      Figure thumbnail gr6
      Fig. 6Verrucous, fungating lupus vulgaris on the face.
      Scrofuloderma is another common form of cutaneous tuberculosis. It represents direct extension into the skin from an underlying tuberculosis focus, most commonly a lymph node or bone.
      In HIV, dissemination of M tuberculosis to extrapulmonary sites, such as the skin, is more common, resulting in disseminated miliary tuberculosis of the skin, also known as tuberculosis cutis miliaris disseminata.
      • Libraty D.H.
      • Byrd T.F.
      Cutaneous miliary tuberculosis in the AIDS era: case report and review.
      It is an uncommon form of tuberculosis characterized by a papulopustular eruption and hematogenous dissemination of tubercle bacilli to multiple organs, including the skin, and often has a poor prognosis.
      • Daikos G.L.
      • Uttamchandani R.B.
      • Tuda C.
      • et al.
      Disseminated miliary tuberculosis of the skin in patients with AIDS: report of four cases.
      • Regnier S.
      • Ouagari Z.
      • Perez L.
      • et al.
      Cutaneous Miliary resistant tuberculosis in a patient infected with human immunodeficiency virus: case report and literature review.
      Papulonecrotic tuberculid occurs frequently in HIV patients. It is a symmetric eruption of necrotizing papules, appearing in crops and healing with scar formation (Fig. 7).
      • Fernandes C.
      • Maltez F.
      • Lourenco S.
      • et al.
      Papulonecrotic tuberculid in a human immunodeficiency virus type-1 patient with multidrug- resistant tuberculosis.
      It is thought to be an immunologic response to M tuberculosis components in a previously sensitized patient after hematogenous spread from a focus of infection elsewhere.
      • Akhras V.
      • McCarthy G.
      Papulonecrotic tuberculid in an HIV-positive patient.
      Figure thumbnail gr7
      Fig. 7Papulonecrotic tuberculid with atrophic scars.

      Fungal infections

      Dermatophytes

      Both dermatophytes and deep fungal infections are common in HIV. They are a major source of morbidity and mortality. Dermatophytes infections are caused by fungi that invade the superficial dead layer of the skin as well as keratinized tissues, such as hair and nails. They occur commonly in temperate and tropical climates of Africa,
      • Clayton Y.M.
      Superficial fungal infections.
      • Nweze E.I.
      Dermatophytoses in Western Africa: a review.
      and HIV-positive patients are particularly susceptible. In a study by Petmy and colleagues
      • Petmy J.L.
      • Lando A.J.
      • Kaptue L.
      • et al.
      Superficial mycoses and HIV infection in Yaounde.
      in Yaounde, Cameroon, 53% of HIV-positive patients were found to have at least 1 superficial fungal infection. The causative fungi are either geophilic, zoophilic, or anthropophilic, and they include Epidermophyton floccosum, Microsporum canis, Trichophyton mentagrophytes, Trichophyton rubrum, Trichophyton tonsurans, and Trichophyton violaceum.
      Tinea corporis, tinea cruris, tinea pedis, and onychomycosis all occur commonly in patients with HIV infection.
      • Aly R.
      • Berger T.
      Common superficial fungal infections in patients with AIDS.
      Tinea cruris presents as an expanding scaling plaque of the upper thighs and groin with central clearing and an active border (Fig. 8). Tinea corporis in the setting of HIV disease virtually always is tinea cruris that has extended beyond the groin into the trunk.
      • Aly R.
      • Berger T.
      Common superficial fungal infections in patients with AIDS.
      In severely immunosuppressed patients with AIDS, lesions may have little inflammation and often lack the elevated border and central clearing typical of tinea.
      • Aly R.
      • Berger T.
      Common superficial fungal infections in patients with AIDS.
      Figure thumbnail gr8
      Fig. 8Tinea cruris. Note the active border and central clearing.
      Onychomycosis is also common in HIV-positive patients. In non-HIV patients, the distal subungual pattern is the most common and occurs when the fungus invades the nail bed in the distal hyponychial area.
      In HIV/AIDS patients, the proximal white subungual onychomycosis is the common type and is considered an early clinical marker of HIV infection.
      • Aly R.
      • Berger T.
      Common superficial fungal infections in patients with AIDS.
      In HIV patients, the clinical manifestations of dermatophyte infections may be atypical, making a diagnosis difficult. To ensure a correct diagnosis, skin scrapings should be collected for potassium hydroxide preparations and cultures.
      • Aly R.
      • Berger T.
      Common superficial fungal infections in patients with AIDS.
      Dermatophyte infections in HIV respond well to topical antifungal agents. Systemic antifungals are reserved for extensive, chronic diseases.
      • Aly R.
      • Berger T.
      Common superficial fungal infections in patients with AIDS.
      • Elmets C.A.
      Management of common superficial fungal infections in patients with AIDS.

      Deep Fungal Infections

      Deep fungal infections, such as cryptococcosis and histoplasmosis, are also common in HIV patients.
      • Durden F.M.
      • Elewski B.
      Fungal infections in HIV-Infected patients.
      Cryptococcus neoformans is a yeast with a predilection to the skin and the central nervous system. Cryptococcosis associated with HIV is common in Africa and Southeast Asia and is a frequent cause of death in patients with AIDS in these regions.
      • Ramos-e-Silva M.
      • Lima C.M.
      • Schechtman R.C.
      • et al.
      Systemic mycoses in immunodepressed patients (AIDS).
      Skin lesions occur in up to 10% of all patients with disseminated cryptococcosis and include papules, ulcerated nodules, subcutaneous nodules, Kaposi sarcoma–like lesions, and molluscum contangiosum–like lesions (Fig. 9).
      • Ramos-e-Silva M.
      • Lima C.M.
      • Schechtman R.C.
      • et al.
      Systemic mycoses in immunodepressed patients (AIDS).
      Central nervous system involvement is common and occurs in 75% of HIV-infected patients with cryptococcosis. Unfortunately, symptoms and signs may be subtle, making early diagnosis difficult.
      • Durden F.M.
      • Elewski B.
      Fungal infections in HIV-Infected patients.
      Ideally all patients with cutaneous cryptococcosis should have their cerebrospinal fluid examined because some patients may have cryptococcal meningitis with no symptoms and signs. Other areas that may be affected by cryptococcosis are the eyes, kidneys, prostate, adrenals, heart, liver, spleen, bone, muscles, and lymph nodes.
      • Ramos-e-Silva M.
      • Lima C.M.
      • Schechtman R.C.
      • et al.
      Systemic mycoses in immunodepressed patients (AIDS).
      Figure thumbnail gr9
      Fig. 9Cryptococcosis in an HIV patient with meningitis.
      Histoplasma capsulatum is a dimorphic fungus that grows as an intracellular yeast in the host and as a mold in vitro. It is also a common deep fungal infection. The etiologic agent of histoplasmosis associated with AIDS is Histoplasma capsulatum var. capsulatum.
      • Ramos-e-Silva M.
      • Lima C.M.
      • Schechtman R.C.
      • et al.
      Systemic mycoses in immunodepressed patients (AIDS).
      The clinical presentation includes fever, weight loss, hepatomegaly, splenomegaly, enteritis, chorioretinitis, endocarditis, meningitis, encephalitis, skin lesions, and pulmonary involvement.
      • Durden F.M.
      • Elewski B.
      Fungal infections in HIV-Infected patients.
      • Ramos-e-Silva M.
      • Lima C.M.
      • Schechtman R.C.
      • et al.
      Systemic mycoses in immunodepressed patients (AIDS).
      Cutaneous involvement occurs in 11% of patients owing to hematogenous dissemination from the pulmonary focus. Skin lesions are nonspecific and may be papules, patches, nodules, abscesses, plaques, pustules, and ulcers (Fig. 10).
      Figure thumbnail gr10
      Fig. 10Ulcerative lesions of histoplasmosis in an HIV patient.
      Histology of the skin lesions may be diagnostic but the small size of organisms may elude easy detection. In disseminated disease, blood cultures and bone marrow cultures have the highest yield of organisms.
      In treatment of both cryptococcosis and histoplasmosis, amphotericin B is the drug of choice. The initial induction therapy is generally amphotericin B, 0.5 to 1 mg/kg/d, followed by maintenance therapy with fluconazole or intraconazole.
      • Durden F.M.
      • Elewski B.
      Fungal infections in HIV-Infected patients.
      Treatment must be given for longer periods because recurrences are common in immunocompromised patients. Other deep fungal infections that can occur in HIV patients are coccidiomycosis, blastomycosis, paracoccidiomycosis, and sporotrichosis.
      • Ramos-e-Silva M.
      • Lima C.M.
      • Schechtman R.C.
      • et al.
      Systemic mycoses in immunodepressed patients (AIDS).

      Parasitic infestations

      HIV patients often develop Norwegian scabies (crusted scabies), characterized by massive proliferation of Sarcoptes scabiei and highly contagious.
      • Portu J.J.
      • Santamaria J.M.
      • Zubero Z.
      • et al.
      Atypical scabies in HIV-positive patients.
      The combination of an atypical eruption and a high density of mites makes these patients a potential source of nosocomial scabies in hospitals and closed communities, such as residential homes.
      • Portu J.J.
      • Santamaria J.M.
      • Zubero Z.
      • et al.
      Atypical scabies in HIV-positive patients.
      • Jessurun J.
      • Romo-Garcia J.
      • Lopez-Denis O.
      • et al.
      Crusted scabies in a patient with the acquired immunodeficiency syndrome.
      Clinically the lesions are generalized, hyperkeratotic scaly plaques that fall off easily (Fig. 11). Unlike in ordinary scabies, pruritus in Norwegian scabies is usually slight or absent.
      • Portu J.J.
      • Santamaria J.M.
      • Zubero Z.
      • et al.
      Atypical scabies in HIV-positive patients.
      Figure thumbnail gr11
      Fig. 11Generalized Norwegian scabies in an HIV patient.
      Although Norwegian scabies is a clinical diagnosis, there is often a delay in diagnosis because the cutaneous disease may resemble other scaly dermatoses that affect patients with AIDS, such as seborrheic dermatitis, psoriasis, or drug induced eruptions.
      • Portu J.J.
      • Santamaria J.M.
      • Zubero Z.
      • et al.
      Atypical scabies in HIV-positive patients.
      Early diagnosis is essential to prevent dissemination of this highly contagious form of scabies. Biopsy usually confirms the diagnosis. Unlike in ordinary scabies where mites or ova are difficult to find, in crusted scabies the stratum corneum is filled with these parasites (Fig. 12).
      Figure thumbnail gr12
      Fig. 12Histopathology showing numerous ova of Sarcoptes scabiei (hematoxylin-eosin, original magnification ×40).
      Patients' clothes and linens must be soaked and washed with hot water. Benzyl benzoate cream must be applied daily, but this is a skin irritant that may not be tolerated by children, in which case 10% sulfur in emulsifying ointment can be used. In many African countries where parasites are a major problem, severe cases of Norwegian scabies are treated with intramuscular or oral ivermectin, but in South Africa, ivermectin is only registered for veterinary use.

      Inflammatory dermatoses

      Seborrheic Dermatitis

      Seborrheic dermatitis is a common chronic inflammatory dermatosis usually affecting infants before 3 to 6 months of age and adults at any age from puberty onwards.
      • Sampaio A.L.
      • Mameri A.C.
      • Vargas T.J.
      • et al.
      Seborrhoeic dermatitis.
      This condition usually affects the sebaceous gland–rich areas of the body (ie, scalp, face, upper trunk, and skin folds).
      • Stefanaki I.
      • Katsambas A.
      Therapeutic update on seborrhoeic dermatitis.
      The incidence of seborrheic dermatitis in the general population is 2.35% to 11.3%.
      • Palamaras I.
      • Kyriakis K.P.
      • Stavrianeas N.G.
      Seborrhoeic dermatitis: lifetime detection rates.
      In patients with HIV disease, the incidence increases to 30% to 80%, depending on the population studied.
      • Mathes B.M.
      • Douglass M.C.
      Seborrhoeic dermatitis in patients with acquired immunodeficiency syndrome.
      • Soeprono F.F.
      • Schinella R.A.
      • Cockerell C.J.
      • et al.
      Seborrhoeic-like dermatitis of acquired immunodeficiency syndrome. A clinicopathologic study.
      In a recent study, seborrheic dermatitis was the second most frequent cutaneous finding in HIV-infected patients.
      • Blanes M.
      • Belinchón I.
      • Merino E.
      • et al.
      Current prevalence and characteristics of dermatoses associated with human immunodeficiency virus infection.
      The pathogenesis is the same as in immune-competent hosts and there is currently no consensus as to whether the growth of Malassezia yeasts on the skin of patients with HIV disease is increased or not.
      • Wikler J.R.
      • Nieboer C.
      • Willemze R.
      Quantitative skin cultures of Pityrosporum yeasts in patients seropositive for the humanimmunodeficiency virus with and without seborrhoeic dermatitis.
      • Eisenstat B.A.
      • Wormser G.P.
      Seborrhoeic dematitis and butterfly rash in AIDS.
      The subtype of Malassezia spp is thought to be different in HIV-positive individuals.
      • Rincón S.
      • Celis A.
      • Sopó L.
      • et al.
      Malassezia yeast species isolated from patients with dermatologic lesions.
      Immunologic factors play an important role in the pathogenesis of seborrheic dermatitis and may explain the increased incidence in HIV.
      • Bergbrant I.M.
      • Johansson S.
      • Robbins D.
      • et al.
      An immunological study in patients with seborrhoeic dermatitis.
      The clinical picture of seborrheic dermatitis in HIV patients can be similar to that in immune-competent hosts, but it is usually atypical and more severe (Fig. 13A, B ).
      • Mathes B.M.
      • Douglass M.C.
      Seborrhoeic dermatitis in patients with acquired immunodeficiency syndrome.
      • Marino C.T.
      • McDonald E.
      • Romano J.F.
      Seborrhoeic dermatitis in acquired immunodeficiency syndrome.
      The severity of the disease may correlate with the degree of immune suppression and the stage of HIV disease.
      • Alessi E.
      • Cusini M.
      • Zerboni R.
      Mucocutaneous manifestations in patients infected with human immunodeficiency virus.
      • Matis W.L.
      • Triana A.
      • Shapiro R.
      • et al.
      Dermatologic findings associated with human immunodeficiency virus infection.
      The increased severity of seborrheic dermatitis in HIV and the correlation with severity with advanced disease, however, are not confirmed by all investigators.
      • Senaldi G.
      • Di Perri G.
      • Di Silverio A.
      • et al.
      Seborrhoeic dermatitis:an early manifestation in AIDS.
      • Vidal C.
      • Girard P.M.
      • Dompmartin D.
      • et al.
      Seborrhoeic dermatitis and HIV infection: qualitative analysis of skin surface lipids in men seropositive and seronegative for HIV.
      Figure thumbnail gr13
      Fig. 13Severe seborrheic dermatitis in HIV/AIDS. Note the extension of the dermatitis beyond the seborrheic areas.
      In patients with HIV/AIDS, the dermatitis usually commences in the seborrheic areas but rapidly becomes more widespread and can even affect the extremities.
      • Soeprono F.F.
      • Schinella R.A.
      • Cockerell C.J.
      • et al.
      Seborrhoeic-like dermatitis of acquired immunodeficiency syndrome. A clinicopathologic study.
      In Mali, seborrheic dermatitis was found a common presenting feature of HIV disease and can, therefore, be used as a predictor for HIV infection.
      • Mahe A.
      • Simon F.
      • Coulibaly S.
      Predictive value of seborrhoeic dermatitis and other common dermatoses for HIV infection in Bamako, Mali.
      The morphology can vary from that of acute dermatitis to psoriasiform plaques. In pigmented skin, seborrheic dermatitis can also present with annular hypopigmented patches, called petaloid seborrheic dermatitis. Erythema in pigmented skin is less visible and postlesional hyperpigmentation is common.
      Due to the atypical presentation of seborrheic dermatitis in HIV disease, some investigators have argued that it should be considered to be a separate disease. The term, seborrheic-like dermatitis of AIDS, was proposed.
      • Soeprono F.F.
      • Schinella R.A.
      • Cockerell C.J.
      • et al.
      Seborrhoeic-like dermatitis of acquired immunodeficiency syndrome. A clinicopathologic study.
      The histopathologic features and expression of heat shock proteins in seborrheic dermatitis in the setting of HIV are also different.
      • Eisenstat B.A.
      • Wormser G.P.
      Seborrhoeic dematitis and butterfly rash in AIDS.
      • Puig L.
      • Fernandez-Figueras T.
      • Ferrandiz C.
      • et al.
      Epidermal expression of 65 and 72 kD heat shock proteins in psoriasis and AIDS-associated psoriasiform dermatitis.
      Any atypical presentation (more severe, atypical locations, and age distribution) of seborrheic dermatitis should alert clinicians to the possibility of HIV immunosuppression.
      There are no clear guidelines for managing seborrheic dermatitis in the setting of HIV disease. The dermatitis is usually more resistant to treatment. The treatment consists of antifungal shampoos and creams, topical corticosteroids,
      • Dann F.J.
      • Tabibian P.
      Cutaneous diseases in human immunodeficiency virus-infected patients referred to the UCLA Immunosuppression Skin Clinic: reasons for referral and management of select diseases.
      tacrolimus, or pimecrolimus in steroid-sensitive areas. Oral ketoconazole is often used in resistant cases.
      • Ford G.P.
      • Farr P.M.
      • Ive F.A.
      • et al.
      The response of seborrhoeic dermatitis to ketoconazole.
      • Buchness M.R.
      Treatment of skin diseases in HIV-infected patients.
      • Ortonne J.P.
      • Lacour J.P.
      • Vitetta A.
      • et al.
      Comparative study of ketoconazole 2% foaming gel and betamethasone dipropionate 0.05% lotion in the treatment of seborrhoeic dermatitis in adults.
      Treating the underlying HIV/AIDS with antiretrovirals is important to control the disease, although this is not confirmed by all investigators.
      • Zancanaro P.C.
      • McGirt L.Y.
      • Mamelak A.J.
      • et al.
      Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience.

      Psoriasis

      The incidence of psoriasis in the general population is 2% to 3%. In HIV disease, the prevalence of psoriasis is usually the same or slightly increased.
      • Mallon E.
      • Bunker C.B.
      HIV-associated psoriasis.
      Psoriasis can be the presenting sign of HIV infection in some patients but can occur at any stage of HIV infection.
      • Mallon E.
      • Bunker C.B.
      HIV-associated psoriasis.
      In the setting of HIV, psoriasis is usually more severe and the severity correlates with the degree of immunosuppression (Fig. 14).
      • Montazeri A.
      • Kanitakis J.
      • Bazex J.
      Psoriasis and HIV infection.
      Figure thumbnail gr14
      Fig. 14Psoriasis in an HIV-positive patient. Widespread hyperpigmented plaques on the back.
      (Courtesy of Professor Anisa Mosam, PhD, University of KwaZulu-Natal, South Africa.)
      HIV disease frequently causes flares or worsening of preexisting psoriasis.
      • Menon K.
      • Van Voorhees A.S.
      • Bebo B.F.
      • et al.
      Psoriasis in patients with HIV infection: from the Medical Board of the National Psoriasis Foundation.
      Any clinical subtype of psoriasis can occur in patients with HIV but erythrodermic,
      • Morar N.
      • Dlova N.
      • Gupta A.K.
      • et al.
      Erythroderma: a comparison between HIV positive and negative patients.
      guttate, and inverse psoriasis are more common. This clinical subtype depends on the population studied. In HIV-positive patients, it is common for these subtypes to occur together in the same patient.
      • Montazeri A.
      • Kanitakis J.
      • Bazex J.
      Psoriasis and HIV infection.
      Rupioid psoriasis (coin-shaped, hyperkeratotic crusted plaques) is another clinical form that can present in HIV-positive patients.
      • Morar N.
      • Willis-Owen S.A.
      • Maurer T.
      • et al.
      HIV-associated psoriasis: pathogenesis, clinical features, and management.
      Sebopsoriasis is a term used when there are overlapping clinical features of psoriasis and seborrheic dermatitis. The lesions lack the typical psoriasiform scaling and are more crusted and exudative (Fig. 15). The seborrheic areas are usually involved and the treatment should include topical or systemic antifungals.
      • Morar N.
      • Willis-Owen S.A.
      • Maurer T.
      • et al.
      HIV-associated psoriasis: pathogenesis, clinical features, and management.
      Dyspigmentation and a lack of erythema are common characteristics of psoriasis in pigmented skin.
      • McMichael A.J.
      • Vachiramon V.
      • Guzmán-Sánchez D.A.
      • et al.
      Psoriasis in African-Americans: a caregivers' survey.
      Psoriatic arthritis is also more common and severe in the setting of HIV disease.
      • Mallon E.
      • Bunker C.B.
      HIV-associated psoriasis.
      • Montazeri A.
      • Kanitakis J.
      • Bazex J.
      Psoriasis and HIV infection.
      Figure thumbnail gr15
      Fig. 15Sebopsoriasis in an HIV-positive patient. Thick crusted plaques affecting the seborrheic areas of the face and scalp.
      In the setting of HIV/AIDS, psoriasis tends to be progressive and more resistant to treatment.
      • Duvic M.
      • Johnson I.M.
      • Rapini R.E.
      • et al.
      Acquired immunodeficiency syndrome-associated Psoriasis and Reiter's syndrome.
      Treating psoriasis in HIV-positive patients is especially challenging due to the immunosuppressive effects of most of the systemic medications. Using these medications in already immunosuppressed patients can lead to serious complications.
      • Montazeri A.
      • Kanitakis J.
      • Bazex J.
      Psoriasis and HIV infection.
      The general principle in treating HIV patients with psoriasis is to individualize the treatment according to a specific patient’s needs. The severity of the psoriasis, other comorbidities, and the degree of immunosuppression due to the HIV should be kept in mind. The benefit-risk ratio for all treatment options should be carefully weighed and discussed with patients.
      • Menon K.
      • Van Voorhees A.S.
      • Bebo B.F.
      • et al.
      Psoriasis in patients with HIV infection: from the Medical Board of the National Psoriasis Foundation.
      In 2010, a task force of the Medical Board of the National Psoriasis Foundation published a consensus document on the treatment of psoriasis in HIV disease.
      • Menon K.
      • Van Voorhees A.S.
      • Bebo B.F.
      • et al.
      Psoriasis in patients with HIV infection: from the Medical Board of the National Psoriasis Foundation.
      Their recommendations included the use of topical agents (calcipotriol [calcipotriene], corticosteroids, tazarotene, and a combination formulation of calcipotriol and betamethasone dipropionate) as the first-line treatment of mild to moderate disease. UV therapy (UV-B or psoralen–UV-A) and antiretrovirals should be used in moderate to severe psoriasis. Oral retinoids are second-line therapy for moderate to severe disease. In cases of more severe and refractory psoriasis, the immunosuppressants (cyclosporine, methotrexate, tumor necrosis factor [TNF]-α, inhibitors, and hydroxyurea) can be considered. When these drugs are used, however, it is important to carefully monitor patients for toxicities and side effects. All HIV patients with psoriasis need regular follow-up and careful monitoring for side effects. The management of patients with HIV and psoriasis is challenging and should preferably be in conjunction with an infectious diseases specialist.
      • Menon K.
      • Van Voorhees A.S.
      • Bebo B.F.
      • et al.
      Psoriasis in patients with HIV infection: from the Medical Board of the National Psoriasis Foundation.

      Reiter Syndrome

      Reactive arthritis (Reiter syndrome) is characterized by the classic triad of urethritis, arthritis, and conjunctivitis.
      • Wu I.B.
      • Schwartz R.A.
      Reiter’s syndrome: the classic triad and more.
      As in HIV-negative patients, Reiter syndrome is usually triggered by preexisting gastrointestinal or urogenital infection. There is an association between Reiter syndrome and HIV, although reports in the literature vary. Some investigators report a prevalence of 4.6% in HIV-positive patients, which is 140 times higher than in the general population. This increase seems to be the highest, however, in HLA-B27–positive patients.
      • Winchester R.
      • Brancato L.
      • Itescu S.
      • et al.
      Implications from the occurrence of Reiter’s syndrome and related disorders in association with advanced HIV infection.
      In a review of 3 large cohort studies, however, no association was found between HIV and Reiter syndrome.
      • Clark M.R.
      • Solinger A.M.
      • Hochberg M.C.
      Human immunodeficiency virus infection is not associated with Reiter’s syndrome: data from three large cohort studies.
      The mucocutaneous manifestations include thick hyperkeratotic plaques on the palms and soles (keratoderma blenorrhagicum), annular dermatitis on the glans penis (circinate balanitis), ulcerative vulvitis, oral lesions, and nail changes. The clinical picture in HIV-positive patients is usually more severe
      • Wu I.B.
      • Schwartz R.A.
      Reiter’s syndrome: the classic triad and more.
      and progressive in its course (Fig. 16).
      • Duvic M.
      • Johnson I.M.
      • Rapini R.E.
      • et al.
      Acquired immunodeficiency syndrome-associated Psoriasis and Reiter's syndrome.
      In practice, the combination of mucocutaneous features, arthritis, and systemic symptoms can be difficult to distinguish from secondary syphilis.
      • Kishimoto M.
      • Lee M.J.
      • Mor A.
      • et al.
      Syphilis mimicking Reiter's syndrome in an HIV-positive patient.
      Figure thumbnail gr16
      Fig. 16Reiter syndrome in HIV/AIDS. Thick keratotic plaques on the lower legs.
      The treatment of the cutaneous lesions is the same as of HIV-negative patients and includes topical steroids and salicylic acid.
      • Wu I.B.
      • Schwartz R.A.
      Reiter’s syndrome: the classic triad and more.
      Immunosuppressive agents, as in the treatment of psoriasis, are generally not used. Acitretin could be used as an alternative systemic drug and improves skin and joint symptoms.
      • Blanche P.
      Acitretin and AIDS-related Reiter’s disease.
      There are also reports of successful treatment with antiretroviral medication and TNF-α inhibitors.
      • McGonagle D.
      • Reade S.
      • Marzo-Ortega H.
      • et al.
      Human immunodeficiency virus associated spondyloarthropathy: pathogenic insights based on imaging findings and response to highly active antiretroviral treatment.
      • Gaylis N.
      Infliximab in the treatment of an HIV positive patient with Reiter’s syndrome.

      Pruritic Papular Eruption

      Pruritic papular eruption (PPE) is a common cutaneous manifestation in patients with HIV infection. Although the cause is not clearly established, it is thought to be a hypersensitivity reaction to insect bites.
      • Resnick Jr., J.S.
      • Van Beek M.
      • Furmanski L.
      • et al.
      Etiology of pruritic papular eruption with HIV infection in Uganda.
      The histologic picture of PPE also confirms this theory.
      • Resnick Jr., J.S.
      • Van Beek M.
      • Furmanski L.
      • et al.
      Etiology of pruritic papular eruption with HIV infection in Uganda.
      The incidence of PPE varies between 12% and 46% depending on the geographic location.
      • Farsani T.T.
      • Kore S.
      • Nadol P.
      • et al.
      Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India.
      Clinically, PPE presents as extremely pruritic, symmetric, skin-colored to erythematous papules or pustules on the distal extremities (Fig. 17). With time, the eruption can become more widespread, affecting the trunk and face and making it difficult to distinguish from eosinophilic folliculitis.
      Figure thumbnail gr17
      Fig. 17PPE of HIV. Bilateral symmetric hyperpigmented papules and pustules on the legs. Note the extensive postlesional hyperpigmentation.
      Bilateral, symmetric pruritic papules occurring for more than a month on the extremities are considered highly suggestive of PPE (79.2%).
      • Farsani T.T.
      • Kore S.
      • Nadol P.
      • et al.
      Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India.
      Due to the pruritic nature of the disease, these papules become excoriated, secondarily infected, and prurigo nodularis–like.
      • Hevia O.
      • Jimenez-Acosta F.
      • Ceballos P.
      • et al.
      Pruritic papular eruption of the acquired.
      Hyperpigmentation is common in patients with pigmented skin and can lead to morbidity and stigmatization.
      • Muyinda H.
      • Seeley J.
      • Pickerine H.
      • et al.
      Social aspects of AIDS-related stigma in rural Uganda.
      PPE occurs in patients with a low CD4+ count (<350 cells/μL) and usually in advanced HIV disease. Therefore, it could be considered a marker for immunosuppression and the initiation of antiretroviral medication in areas where resources are scarce.
      • Farsani T.T.
      • Kore S.
      • Nadol P.
      • et al.
      Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India.
      Symptomatic treatment with topical corticosteroids, emollients, and antihistamines are usually of limited value.
      • Farsani T.T.
      • Kore S.
      • Nadol P.
      • et al.
      Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India.
      The cornerstone of treatment is the use of antiretroviral medication, often resulting in a dramatic improvement of symptoms. In contrast, recurrences may be associated with antiretroviral treatment failure.
      It was, therefore, suggested that PPE can be used to monitor response to antiretroviral treatment in resource-poor areas.
      • Castelnuovo B.
      • Byakwaga H.
      • Menten J.
      • et al.
      Can response of a pruritic papular eruption to antiretroviral therapy be used as a clinical parameter to monitor virological outcome?.
      In resistant cases, narrow-band UV-B phototherapy can also be considered a treatment option.
      • Bellavista S.
      • D'Antuono A.
      • Infusino S.D.
      • et al.
      Pruritic papular eruption in HIV: a case successfully treated with NB-UVB.

      Eosinophilic Folliculitis

      Eosinophilic folliculitis (HIV-EF) is another pruritic eruption occurring in HIV-positive patients. HIV-EF is a unique disease entity and differs form classic EF (Ofuji disease), closely resembling PPE.
      • Nervi S.J.
      • Schwartz R.A.
      • Dmochowski M.
      Eosinophilic pustular folliculitis: a 40 year retrospect.
      There are only quantitative differences in the histopathology and immunohistochemistry between PPE and EF. They can probably be considered, therefore, as different ends of a disease spectrum of hypersensitivity reactions in the setting of HIV disease.
      • Afonso J.P.
      • Tomimori J.
      • Michalany N.S.
      • et al.
      Pruritic papular eruption and eosinophilic folliculitis associated with human immunodeficiency virus (HIV) infection: a histopathological and immunohistochemical comparative study.
      The exact incidence of HIV-EF is unknown, partly because the terms, PPE and HIV-EF, are used interchangeably in the literature. Follicular edematous papulovesicles or pustules mainly affecting the face, neck, and upper arms characterize this condition (Fig. 18). These papules are extremely pruritic and become secondary excoriated.
      • Eisman S.
      Pruritic papular eruption in HIV.
      Postinflammatory hyperpigmentation is a major concern in patients with pigmented skin related to facial involvement in HIV-EF.
      Figure thumbnail gr18
      Fig. 18HIV eosinophilic folliculitis. Numerous erythematous papules on the face. Excoriation, depigmentation, hyperpigmentation, and scarring are visible.
      As in PPE, HIV-EF usually occurs in HIV patients with low CD4+ counts (<300 cells/μL). HIV-EF can also occur as part of the IRIS.
      • Eisman S.
      Pruritic papular eruption in HIV.
      The cause is debated, but a hypersensitivity reaction induced by various antigens in a dysregulated immune system is the most likely explanation.
      • Nervi S.J.
      • Schwartz R.A.
      • Dmochowski M.
      Eosinophilic pustular folliculitis: a 40 year retrospect.
      There is no specific treatment protocol for HIV-EF. Ketoconazole and griseofulvin have been used with positive results.
      • Nervi S.J.
      • Schwartz R.A.
      • Dmochowski M.
      Eosinophilic pustular folliculitis: a 40 year retrospect.
      Oral antihistamines, metronidazole, itraconazole, prednisone, dapsone, ivermectin, and isotretinoin have also been used. Topical application of permethrin and 0.1% topical tacrolimus ointment may be beneficial. As for the treatment of PPE, the use of UV-B phototherapy can also be considered.
      • Eisman S.
      Pruritic papular eruption in HIV.
      There is a definite improvement of HIV-EF with the use of antiretroviral therapy.
      • Rajendran P.M.
      • Dolev J.C.
      • Heaphy Jr., M.R.
      • et al.
      Eosinophilic folliculitis: before and after the introduction of antiretroviral therapy.

      Xerosis

      Dry skin (xerosis) is a common finding in HIV-positive patients. In some studies, it is the most common skin manifestation (37.6%), even in patients on antiretroviral therapy.
      • Blanes M.
      • Belinchón I.
      • Merino E.
      • et al.
      Current prevalence and characteristics of dermatoses associated with human immunodeficiency virus infection.
      It is also one of the major causes of pruritus in these patients.
      • Blanes M.
      • Belinchón I.
      • Portilla J.
      • et al.
      Pruritus in HIV-infected patients in the era of combination antiretroviral therapy: a study of its prevalence and causes.
      It usually starts on the extremities
      • Cedeno-Laurent F.
      • Gómez-Flores M.
      • Mendez N.
      • et al.
      New insights into HIV-1-primary skin disorders.
      and becomes more widespread with time (Fig. 19).
      Figure thumbnail gr19
      Fig. 19Widespread xerosis in a HIV-positive patient, involving the back (left) and lower legs (right).
      Xerosis worsens with a decrease in the CD4+ count; therefore, it can be considered a marker for disease progression.
      • Cedeno-Laurent F.
      • Gómez-Flores M.
      • Mendez N.
      • et al.
      New insights into HIV-1-primary skin disorders.
      The cause is unknown, but changes in the blood flow and nutrient supply to the skin as well as diminished oil and sweat production in the skin could play a role.
      • Cedeno-Laurent F.
      • Gómez-Flores M.
      • Mendez N.
      • et al.
      New insights into HIV-1-primary skin disorders.
      The liberal use of emollients remains the cornerstone of treatment.

      Photosensitivity Disorders

      Photosensitivity is reported in approximately 5.4% of HIV-positive patients. It is also known that African Americans are 6.68 times more likely to develop photosensitivity.
      • Bilu D.
      • Mamelak A.J.
      • Nguyen R.H.
      • et al.
      Clinical and epidemiologic characterization of photosensitivity in HIV-positive individuals.
      The reason why patients with pigmented skin are disproportionately affected is unclear. Patients on antiretroviral medication are also more likely to develop photosensitivity.
      • Bilu D.
      • Mamelak A.J.
      • Nguyen R.H.
      • et al.
      Clinical and epidemiologic characterization of photosensitivity in HIV-positive individuals.
      Although photosensitizing medications (trimethoprim-sulfamethoxazole, nonsteroidal inflammatory drugs, and antiretrovirals) can play a role in the pathogenesis, it is thought that HIV infection per se can cause photosensitivity.
      • Philips R.C.
      • Motaparthi K.
      • Krishnan B.
      • et al.
      HIV photodermatitis presenting with widespread vitiligo-like depigmentation.
      Photosensitivity reactions usually manifest in patients with low CD4+ counts.
      • Berger T.G.
      • Dhar A.
      Lichenoid photoeruptions in human immunodeficiency virus infection.
      Photosensitivity reactions observed in HIV patients include polymorphic light eruption, actinic prurigo, chronic actinic dermatitis, porphyria cutanea tarda, photosensitive granuloma annulare, and lichenoid photoeruptions.
      • Philips R.C.
      • Motaparthi K.
      • Krishnan B.
      • et al.
      HIV photodermatitis presenting with widespread vitiligo-like depigmentation.
      Photosensitivity in HIV-positive patients has long been a well-recognized clinical entity.
      • Bilu D.
      • Mamelak A.J.
      • Nguyen R.H.
      • et al.
      Clinical and epidemiologic characterization of photosensitivity in HIV-positive individuals.
      The lesions are distributed in sun-exposed areas with a sharp demarcation at covered areas (Fig. 20). In severe cases, it can overflow to involve sun-protected skin and even become generalized. The clinical morphology varies and may resemble lichen planus or eczema.
      • Bilu D.
      • Mamelak A.J.
      • Nguyen R.H.
      • et al.
      Clinical and epidemiologic characterization of photosensitivity in HIV-positive individuals.
      Figure thumbnail gr20
      Fig. 20Photodermatitis in HIV/AIDS. Note the sharp demarcation at covered areas. Dyspigmentation (hyperpigmentation and depigmentation) is clearly visible.
      Hyperpigmentation is especially common in patients with pigmented skin. On the contrary, vitiligo-like depigmentation has also been described.
      • Philips R.C.
      • Motaparthi K.
      • Krishnan B.
      • et al.
      HIV photodermatitis presenting with widespread vitiligo-like depigmentation.
      Treatment is difficult and sun protection and topical steroids are often used.
      • Philips R.C.
      • Motaparthi K.
      • Krishnan B.
      • et al.
      HIV photodermatitis presenting with widespread vitiligo-like depigmentation.

      Summary

      The introduction of antiretroviral medication has changed the epidemiology, morbidity, and mortality of HIV disease. Antiretrovirals have also altered the incidence of infective and inflammatory diseases affecting the skin. Nevertheless, cutaneous disorders due to HIV infection remain a major problem in HIV-infected patients. In patients with pigmented skin, HIV-associated dermatoses result in special challenges, particularly with regard to diagnosis and treatment. Due to the common problem of dyspigmentation caused by these conditions in pigmented skin, early diagnosis and effective treatment are of utmost importance. Clinicians should be aware of the differences in clinical presentation and the treatment options available. The influence of the HIV-associated dermatoses on a patient’s quality of life should never be underestimated.

      References

        • Zancanaro P.C.
        • McGirt L.Y.
        • Mamelak A.J.
        • et al.
        Cutaneous manifestations of HIV in the era of highly active antiretroviral therapy: an institutional urban clinic experience.
        J Am Acad Dermatol. 2006; 54: 581-588
        • Cedeno-Laurent F.
        • Gómez-Flores M.
        • Mendez N.
        • et al.
        New insights into HIV-1-primary skin disorders.
        J Idaho Acad Sci. 2011; 14: 1-11
        • Amerson E.H.
        • Maurer T.A.
        Dermatologic manifestations of HIV in Africa.
        Top HIV Med. 2010; 18: 16-22
        • Lupi O.
        Prevalence and risk factors for herpes simplex infection among patients at high risk for HIV infection in Brazil.
        Int J Dermatol. 2011; 50: 709-713
        • Draganova-Tacheva R.A.
        • Domsky S.
        • Paralkar V.
        • et al.
        Bacillary angiomatosis as an initial presentation in an HIV-positive Man.
        Clinl Microbiol Newsl. 2009; 31: 150-152
        • Grilo N.
        • Modi D.
        • Barrow P.
        Cutaneous bacillary angiomatosis: a marker of systemic disease in HIV.
        S Afr Med J. 2009; 99: 220-221
        • Muldoon E.G.
        • Mooka B.
        • Reidy D.
        • et al.
        Long-term neurological follow-up of HIV-positive patients diagnosed with syphilis.
        Int J STD AIDS. 2012; 23: 676-678
        • Zellen J.
        • Augenbraun M.
        Syphilis in the HIV-infected patient: an update on epidemiology, diagnosis and management.
        Curr HIV/AIDS Rep. 2004; 1: 142-147
        • Fleming D.T.
        • Wasserheit J.N.
        From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection.
        Sex Transm Infect. 1999; 75: 3-17
        • Zetola N.M.
        • Klausner J.D.
        Syphilis and HIV infection: an update.
        Clin Infect Dis. 2007; 44: 1222-1228
        • Knaute D.F.
        • Graf N.
        • Lautenschlager S.
        • et al.
        Serological response to treatment of syphilis according to disease stage and HIV status.
        Clin Infect Dis. 2012; 55: 1615-1622
        • Wozniacka A.
        • Schwartz R.A.
        • Sysa-Jedrzejowska A.
        • et al.
        Lupus Vulgaris: report of two cases.
        Int J Dermatol. 2005; 44: 299-301
        • Padvamathy L.
        • Ras L.L.
        • Ethirajan N.
        • et al.
        Ulcerative Lupus Vulgaris of face: an uncommon presentation in India.
        Indian J Tuberc. 2007; 54: 52-54
        • Libraty D.H.
        • Byrd T.F.
        Cutaneous miliary tuberculosis in the AIDS era: case report and review.
        Clin Infect Dis. 1996; 23: 706-710
        • Daikos G.L.
        • Uttamchandani R.B.
        • Tuda C.
        • et al.
        Disseminated miliary tuberculosis of the skin in patients with AIDS: report of four cases.
        Clin Infect Dis. 1998; 27: 205-208
        • Regnier S.
        • Ouagari Z.
        • Perez L.
        • et al.
        Cutaneous Miliary resistant tuberculosis in a patient infected with human immunodeficiency virus: case report and literature review.
        Clin Exp Dermatol. 2009; 34: e690-e692
        • Fernandes C.
        • Maltez F.
        • Lourenco S.
        • et al.
        Papulonecrotic tuberculid in a human immunodeficiency virus type-1 patient with multidrug- resistant tuberculosis.
        J Eur Acad Dermatol Venereol. 2004; 18: 369-394
        • Akhras V.
        • McCarthy G.
        Papulonecrotic tuberculid in an HIV-positive patient.
        Int J STD AIDS. 2007; 18: 643-644
        • Clayton Y.M.
        Superficial fungal infections.
        in: Harper J. Orange A. Prose N. Textbook of pediatric dermatology. Blackwell Science, London2002: 447-472
        • Nweze E.I.
        Dermatophytoses in Western Africa: a review.
        Pak J Biol Sci. 2010; 13: 649-656
        • Petmy J.L.
        • Lando A.J.
        • Kaptue L.
        • et al.
        Superficial mycoses and HIV infection in Yaounde.
        J Eur Acad Dermatol Venereol. 2004; 18: 301-304
        • Aly R.
        • Berger T.
        Common superficial fungal infections in patients with AIDS.
        Clin Infect Dis. 1996; 22: S128-S132
        • Elmets C.A.
        Management of common superficial fungal infections in patients with AIDS.
        J Am Acad Dermatol. 1994; 31: S60-S63
        • Durden F.M.
        • Elewski B.
        Fungal infections in HIV-Infected patients.
        Semin Cutan Med Surg. 1997; 16: 200-212
        • Ramos-e-Silva M.
        • Lima C.M.
        • Schechtman R.C.
        • et al.
        Systemic mycoses in immunodepressed patients (AIDS).
        Clin Dermatol. 2012; 30: 616-627
        • Portu J.J.
        • Santamaria J.M.
        • Zubero Z.
        • et al.
        Atypical scabies in HIV-positive patients.
        J Am Acad Dermatol. 1996; 34: 915-917
        • Jessurun J.
        • Romo-Garcia J.
        • Lopez-Denis O.
        • et al.
        Crusted scabies in a patient with the acquired immunodeficiency syndrome.
        Virchows Arch A Pathol Anat Histopathol. 1990; 415: 461-463
        • Sampaio A.L.
        • Mameri A.C.
        • Vargas T.J.
        • et al.
        Seborrhoeic dermatitis.
        An Bras Dermatol. 2011; 86: 1061-1074
        • Stefanaki I.
        • Katsambas A.
        Therapeutic update on seborrhoeic dermatitis.
        Skin Therapy Lett. 2010; 15: 1-4
        • Palamaras I.
        • Kyriakis K.P.
        • Stavrianeas N.G.
        Seborrhoeic dermatitis: lifetime detection rates.
        J Eur Acad Dermatol Venereol. 2012; 26: 524-526
        • Mathes B.M.
        • Douglass M.C.
        Seborrhoeic dermatitis in patients with acquired immunodeficiency syndrome.
        J Am Acad Dermatol. 1985; 13: 947-951
        • Soeprono F.F.
        • Schinella R.A.
        • Cockerell C.J.
        • et al.
        Seborrhoeic-like dermatitis of acquired immunodeficiency syndrome. A clinicopathologic study.
        J Am Acad Dermatol. 1986; 14: 242-248
        • Blanes M.
        • Belinchón I.
        • Merino E.
        • et al.
        Current prevalence and characteristics of dermatoses associated with human immunodeficiency virus infection.
        Actas Dermosifiliogr. 2010; 101: 702-709
        • Wikler J.R.
        • Nieboer C.
        • Willemze R.
        Quantitative skin cultures of Pityrosporum yeasts in patients seropositive for the humanimmunodeficiency virus with and without seborrhoeic dermatitis.
        J Am Acad Dermatol. 1992; 27: 37-39
        • Eisenstat B.A.
        • Wormser G.P.
        Seborrhoeic dematitis and butterfly rash in AIDS.
        N Engl J Med. 1984; 189 ([letter]): 311
        • Rincón S.
        • Celis A.
        • Sopó L.
        • et al.
        Malassezia yeast species isolated from patients with dermatologic lesions.
        Biomedica. 2005; 25: 189-195
        • Bergbrant I.M.
        • Johansson S.
        • Robbins D.
        • et al.
        An immunological study in patients with seborrhoeic dermatitis.
        Clin Exp Dermatol. 1991; 16: 331-338
        • Marino C.T.
        • McDonald E.
        • Romano J.F.
        Seborrhoeic dermatitis in acquired immunodeficiency syndrome.
        Cutis. 1991; 50: 217-218
        • Alessi E.
        • Cusini M.
        • Zerboni R.
        Mucocutaneous manifestations in patients infected with human immunodeficiency virus.
        J Am Acad Dermatol. 1988; 19: 290-297
        • Matis W.L.
        • Triana A.
        • Shapiro R.
        • et al.
        Dermatologic findings associated with human immunodeficiency virus infection.
        J Am Acad Dermatol. 1987; 17: 46-51
        • Senaldi G.
        • Di Perri G.
        • Di Silverio A.
        • et al.
        Seborrhoeic dermatitis:an early manifestation in AIDS.
        Clin Exp Dermatol. 1987; 12 ([letter]): 72-73
        • Vidal C.
        • Girard P.M.
        • Dompmartin D.
        • et al.
        Seborrhoeic dermatitis and HIV infection: qualitative analysis of skin surface lipids in men seropositive and seronegative for HIV.
        J Am Acad Dermatol. 1990; 23: 1106-1110
        • Mahe A.
        • Simon F.
        • Coulibaly S.
        Predictive value of seborrhoeic dermatitis and other common dermatoses for HIV infection in Bamako, Mali.
        J Am Acad Dermatol. 1988; 38: 1084-1086
        • Puig L.
        • Fernandez-Figueras T.
        • Ferrandiz C.
        • et al.
        Epidermal expression of 65 and 72 kD heat shock proteins in psoriasis and AIDS-associated psoriasiform dermatitis.
        J Am Acad Dermatol. 1995; 33: 985-989
        • Dann F.J.
        • Tabibian P.
        Cutaneous diseases in human immunodeficiency virus-infected patients referred to the UCLA Immunosuppression Skin Clinic: reasons for referral and management of select diseases.
        Cutis. 1995; 55: 85-88
        • Ford G.P.
        • Farr P.M.
        • Ive F.A.
        • et al.
        The response of seborrhoeic dermatitis to ketoconazole.
        Br J Dermatol. 1984; 111: 603-609
        • Buchness M.R.
        Treatment of skin diseases in HIV-infected patients.
        Dermatol Clin. 1995; 13: 231-238
        • Ortonne J.P.
        • Lacour J.P.
        • Vitetta A.
        • et al.
        Comparative study of ketoconazole 2% foaming gel and betamethasone dipropionate 0.05% lotion in the treatment of seborrhoeic dermatitis in adults.
        Dermatology. 1992; 184: 275-280
        • Mallon E.
        • Bunker C.B.
        HIV-associated psoriasis.
        AIDS Patient Care STDS. 2000; 14: 239-246
        • Montazeri A.
        • Kanitakis J.
        • Bazex J.
        Psoriasis and HIV infection.
        Int J Dermatol. 1996; 35: 475-479
        • Menon K.
        • Van Voorhees A.S.
        • Bebo B.F.
        • et al.
        Psoriasis in patients with HIV infection: from the Medical Board of the National Psoriasis Foundation.
        J Am Acad Dermatol. 2010; 62: 291-299
        • Morar N.
        • Dlova N.
        • Gupta A.K.
        • et al.
        Erythroderma: a comparison between HIV positive and negative patients.
        Int J Dermatol. 1999; 38: 895-900
        • Morar N.
        • Willis-Owen S.A.
        • Maurer T.
        • et al.
        HIV-associated psoriasis: pathogenesis, clinical features, and management.
        Lancet Infect Dis. 2010; 10: 470-478
        • McMichael A.J.
        • Vachiramon V.
        • Guzmán-Sánchez D.A.
        • et al.
        Psoriasis in African-Americans: a caregivers' survey.
        J Drugs Dermatol. 2012; 1: 478-482
        • Duvic M.
        • Johnson I.M.
        • Rapini R.E.
        • et al.
        Acquired immunodeficiency syndrome-associated Psoriasis and Reiter's syndrome.
        Arch Dermatol. 1987; 123: 1622-1632
        • Wu I.B.
        • Schwartz R.A.
        Reiter’s syndrome: the classic triad and more.
        J Am Acad Dermatol. 2008; 59: 113-121
        • Winchester R.
        • Brancato L.
        • Itescu S.
        • et al.
        Implications from the occurrence of Reiter’s syndrome and related disorders in association with advanced HIV infection.
        Scand J Rheumatol Suppl. 1988; 74: 89-93
        • Clark M.R.
        • Solinger A.M.
        • Hochberg M.C.
        Human immunodeficiency virus infection is not associated with Reiter’s syndrome: data from three large cohort studies.
        Rheum Dis Clin North Am. 1992; 18: 267-276
        • Kishimoto M.
        • Lee M.J.
        • Mor A.
        • et al.
        Syphilis mimicking Reiter's syndrome in an HIV-positive patient.
        Am J Med Sci. 2006; 332: 90-92
        • Blanche P.
        Acitretin and AIDS-related Reiter’s disease.
        Clin Exp Rheumatol. 1999; 17: 105-106
        • McGonagle D.
        • Reade S.
        • Marzo-Ortega H.
        • et al.
        Human immunodeficiency virus associated spondyloarthropathy: pathogenic insights based on imaging findings and response to highly active antiretroviral treatment.
        Ann Rheum Dis. 2001; 60: 696-698
        • Gaylis N.
        Infliximab in the treatment of an HIV positive patient with Reiter’s syndrome.
        J Rheumatol. 2003; 30: 407-411
        • Resnick Jr., J.S.
        • Van Beek M.
        • Furmanski L.
        • et al.
        Etiology of pruritic papular eruption with HIV infection in Uganda.
        JAMA. 2004; 292: 2614-2621
        • Farsani T.T.
        • Kore S.
        • Nadol P.
        • et al.
        Etiology and risk factors associated with a pruritic papular eruption in people living with HIV in India.
        J International AIDS Society. 2013; 16: 1-6
        • Hevia O.
        • Jimenez-Acosta F.
        • Ceballos P.
        • et al.
        Pruritic papular eruption of the acquired.
        J Am Acad Dermatol. 1991; 24: 231-235
        • Muyinda H.
        • Seeley J.
        • Pickerine H.
        • et al.
        Social aspects of AIDS-related stigma in rural Uganda.
        Health Place. 1997; 3: 143-147
        • Castelnuovo B.
        • Byakwaga H.
        • Menten J.
        • et al.
        Can response of a pruritic papular eruption to antiretroviral therapy be used as a clinical parameter to monitor virological outcome?.
        AIDS. 2008; 22: 269-273
        • Bellavista S.
        • D'Antuono A.
        • Infusino S.D.
        • et al.
        Pruritic papular eruption in HIV: a case successfully treated with NB-UVB.
        Dermatol Ther. 2013; 26: 173-175
        • Nervi S.J.
        • Schwartz R.A.
        • Dmochowski M.
        Eosinophilic pustular folliculitis: a 40 year retrospect.
        J Am Acad Dermatol. 2006; 55: 285-289
        • Afonso J.P.
        • Tomimori J.
        • Michalany N.S.
        • et al.
        Pruritic papular eruption and eosinophilic folliculitis associated with human immunodeficiency virus (HIV) infection: a histopathological and immunohistochemical comparative study.
        J Am Acad Dermatol. 2012; 67: 269-275
        • Eisman S.
        Pruritic papular eruption in HIV.
        Dermatol Clin. 2006; 24: 449-457
        • Rajendran P.M.
        • Dolev J.C.
        • Heaphy Jr., M.R.
        • et al.
        Eosinophilic folliculitis: before and after the introduction of antiretroviral therapy.
        Arch Dermatol. 2005; 141: 1227-1231
        • Blanes M.
        • Belinchón I.
        • Portilla J.
        • et al.
        Pruritus in HIV-infected patients in the era of combination antiretroviral therapy: a study of its prevalence and causes.
        Int J STD AIDS. 2012; 23: 255-257
        • Bilu D.
        • Mamelak A.J.
        • Nguyen R.H.
        • et al.
        Clinical and epidemiologic characterization of photosensitivity in HIV-positive individuals.
        Photodermatol Photoimmunol Photomed. 2004; 20: 175-183
        • Philips R.C.
        • Motaparthi K.
        • Krishnan B.
        • et al.
        HIV photodermatitis presenting with widespread vitiligo-like depigmentation.
        Dermatol Online J. 2012; 18 (Available at:) (Accessed September 20, 2013): 6
        • Berger T.G.
        • Dhar A.
        Lichenoid photoeruptions in human immunodeficiency virus infection.
        Arch Dermatol. 1994; 130: 609-613