Cutaneous Signs of AIDS

Cutaneous signs and symptoms associated with acquired immunodeficiency syndrome (AIDS) increase in frequency and severity as the disease advances. However, infection by human immunodeficiency virus (HIV) may produce a transient macular roseola-like eruption. As HIV infection progresses, infectious processes and neoplastic disease are most often seen. Patients also may have symptoms such as pruritus without visible skin lesions.

Cutaneous infections are a common feature of AIDS. Superficial infections such as dermatophytosis, candidiasis, and scabies may be extensive and have altered appearances. Superficial fungal infections may coexist with other pathogens such as herpesvirus or cytomegalovirus to produce unusual complex cutaneous infections.

Cutaneous viral infections also may have unpredictable presentations. Molluscum contagiosum occurs commonly and is persistent; lesions may become quite large. Human papillomavirus-induced lesions may occur, ranging from persistent verrucae to severe anogenital condyloma.

Molluscum contagiosum and human papillomavirus lesions frequently occur in cosmetically sensitive areas. Locally destructive treatments such as curettage and cryotherapy are effective, but lesions almost always recur or new lesions develop, particularly as CD4 counts decrease.

Herpes zoster may be a reliable sign of the presence or progression of HIV infection in an otherwise asymptomatic person. With the diminishing immune response, the usually self-limited herpetic infections become chronic and fail to heal. Chronic herpetic lesions may not have the characteristic morphologic characteristics of acute lesions in immunocompetent individuals. Both herpes simplex and herpes zoster viruses may produce disseminated skin lesions in HIV-infected individuals. The diagnosis of herpetic infections can be made by morphologic features of the clinical lesion, examination of a Tzanck preparation (Wright's stain of a scraping taken from the base of a lesion), skin biopsy, or viral culture and/or molecular diagnostic methods. For chronic or recurrent herpetic infection and for long-term suppression, oral antiviral therapy is helpful.

Unusual primary and disseminated infections occur in the skin in the context of HIV infection. Mucosal and cutaneous lesions of histoplasmosis, cryptococcosis, and other systemic fungal disorders can be signs of disseminated infection in AIDS patients. Mycobacterial infections produced by M. tuberculosis, M. avium-intracellulare, M. haemophilum, and others affect the skin in patients with AIDS. A long list of unusual or unique infections has been observed, including disseminated amebiasis, Trichosporon beigelei, sporotrichosis, Strongyloides infection, alternariosis, and superficial pheohyphomycosis. A new entity, bacillary angiomatosis caused by Bartonella henselae/quintana, produces vascular proliferations in the skin as well as in other sites. Reiter's syndrome, with typical cutaneous findings, is found with increased frequency in patients with AIDS. It is safe to predict that unusual presentations of disseminated infectious diseases will continue to be described in the skin of AIDS patients.