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INTRODUCTION

KEY POINTS

  • Human immunodeficiency virus (HIV) infection is associated with a wide range of dermatologic conditions.

  • Mucocutaneous findings, such as thrush, sebopsoriasis, and herpes zoster, may manifest as the initial clinical presentation of HIV infection.

  • Some HIV-associated skin conditions first appear with deteriorating immunity, especially when CD4 counts fall less than 200 cells/μL. The appearance of the skin disease can reflect the patient's immune status.

  • Antiretroviral therapy dramatically reduces morbidity and mortality for HIV-infected patients and has a profound effect on the appearance and course of many skin conditions, ie, Kaposi sarcoma (KS). However, skin problems may continue to affect individuals living with HIV.

Approximately 37 million people worldwide were living with human immunodeficiency virus (HIV) in 2014; alarmingly, more than 19 million were unaware of their infection.1 Although there is no racial predominance, individuals with skin of color bear the brunt of the infection globally, with 70% of HIV cases residing in sub-Saharan Africa with the predominant mode of transmission being heterosexual sexual activity. It is estimated that there are 5 million HIV-infected people in Asia and the Pacific and 1.7 million in Latin America.1 In the United States, the main form of transmission continues to be male-to-male sexual activity.1 According to statistics from the Centers for Disease Control and Prevention (CDC), African Americans—predominantly men who have sex with men (MSM)—account for 47% of new cases of HIV infection in the United States; African American women constitute 30% of cases.2 Hispanics are also disproportionally affected, accounting for 21% of new HIV cases.1 HIV depletes cluster of differentiation (CD) 4 cells, leading to profound immunodeficiency that results in infectious, inflammatory, neoplastic autoimmune, and metabolic disease.

Some infections or atypical presentations of skin diseases are highly suggestive of HIV infection and warrant evaluation for the virus.3 While combination antiretroviral treatment (ARVT) revolutionized the treatment of HIV infection and effectively reduced the frequency and severity of opportunistic skin infections and malignancies, only 30% of those living with HIV control their infection.4 Some skin diseases (such as warts [Figure 60-1], psoriasis, photodermatitis, molluscum, contagiosum, prurigo nodularis, and pruritic disorders) remain common concerns in individuals with low CD4 counts. Patients adequately treated with ARVT may still develop xerosis, eczema, drug reactions, lipodystrophy, immune reconstitution inflammatory syndrome-related diseases, and even Kaposi sarcoma (KS).3

FIGURE 60-1.

Multiple exophytic verruca vulgaris (warts) on a human immunodeficiency virus–infected man. (Used with permission from the Ronald O. Perelman Department of Dermatology, NYU School of Medicine, NYU Langone Medical Center, NY.)

NONVIRAL AND NONBACTERIAL DISEASES

Exanthem of Acute Retroviral Syndrome

Acute retroviral syndrome (ARS) has been reported in 25% to 75% of new HIV infections; it may present within 2 to 4 weeks and up to 3 months after initial ...

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