Being Alive 1995 Apr 5: 11
Dermatology is a visual specialty. Dermatology is also about
touching people-touching their skin to make a diagnosis.
Before asking a lot of questions about a particular rash or
lesion, dermatologists must look closely and describe for
themselves what they see. It is only then that a diagnosis
can be made and a treatment plan developed.
Almost everyone knows that opportunistic infections in people
infected with HIV become more prevalent as CD4 counts fall.
This is also true of skin problems in patients with HIV. In
fact, almost 100% of all patients with CD4 counts less than
200 will have some sort of dermatologic condition. Although
dermatologic conditions like dry skin, seborrheic dermatitis
and scabies are not life-threatening diseases (like
pneumocystis pneumonia or cryptococcal meningitis), these
disorders impact greatly on the quality of life of someone
with HIV. It is not uncommon for a dermatologist to be
referred a patient who is taking ten different kinds of
medications, who has disseminated MAC and is going blind from
CMV, who tells us that they can live with all of that, but
the thing that is driving them "crazy" is this terrible itch.
This tells us something about the patient's quality of life.
And the good news is that dermatologists can have a positive
impact on a person's quality of life by alleviating some of
their symptoms and possibly even curing some of their skin
The following is a quick review of a wide range of
dermatologic manifestations seen in patients with HIV
infections along with the standard treatment. As with all
medical treatments, working with your physician is essential
because not all people or viruses, bacteria or fungi respond
exactly the same every time.
Rash of Seroconversion
Individuals who are in the process of seroconverting to being
HIV+ may develop a fever, malaise, muscle and bone pain, a
sore throat, enlarged lymph nodes and even a rash. This rash,
which can be described as faint background redness that is
distributed primarily over the trunk, is easily missed and
lasts only a short period of time.
The most common skin problems associated with HIV infection
are viral in nature. As people become sicker, herpes
infections tend to become recurrent, persistent and even
widely disseminated. In clinic, dermatologists often see many
individuals with perianal herpes. Acyclovir usually clears up
the problem in seven to ten days. If the lesions persist, it
is often a sign that there is associated infection with
bacteria, fungus or even another type of virus. Foscarnet,
although a toxic and poorly tolerated medication, can be used
for acyclovir resistant strains of herpes.
In 1982, Dr. Rietmeijer began working at one of the sexually
transmitted disease clinics in Amsterdam. At that time, AIDS
was perceived as something that was very far away from
Amsterdam. It was across the ocean. Nobody thought they would
ever have a problem with it there, but by the middle of that
year, they began to see more and more gay men with herpes
zoster or "shingles." In retrospect, 12 years later, it is
obvious that these individuals were infected with HIV and
that "shingles" was the first manifestation of their illness.
"Shingles" is produced by the same virus that causes chicken
pox. Although the chicken pox rash may go away, the
individual remains infected with the virus which hides out in
the nervous system. As people become sicker and their immune
systems become more compromised, the virus is reactivated
producing painful blisters along the distribution of a nerve.
"Shingles" is treated with acyclovir, but in doses four times
that used for the treatment of herpes simplex.
Human Papilloma Virus (HPV)
This virus produces warts which can occur anywhere on the
body including the genitals, anus, mouth, hands, arms and
feet. The lesions are often extensive and very hard to treat.
Liquid nitrogen and podophylline are the main forms of
This is an infection produced by a pox virus. Lesions are
described as firm, flesh colored bumps with a central
depression which tend to occur on the scalp, face and genital
area. They can be very extensive and disfiguring. Treatment
is similar to that used for warts.
"Ringworm" and "athlete's foot" are common in patients
infected with HIV and can be treated with topical or oral
antifungal therapy. Although rare, cryptococcus can involve
the skin. Lesions are often mistaken for molluscum. This
infection can be life threatening and is more difficult to
Impetigo, recurrent "boils" and microbacterial infections are
also seen. Basilary angiomatosis, which is caused by the "cat
scratch" organism, has been described only in HIV+ patients.
We have not seen a case of this in Denver. These infections
are all treated with antibiotics.
Infection is caused by a mite which burrows into the upper
layers of the skin where it lives and lays its eggs. The
body's immune response to the mite produces a very itchy
rash. Treatment involves the use of Kwell or Permethrim
lotion and close followup.
More commonly known as "dandruff," this disorder is
characterized by yellow to white scale on the scalp. In
people infected with HIV, the lesions can also become more
extensive (also involving the central face and chest) and
more severe. It may also be an initial sign of HIV infection.
Treatment includes the use of an anti-dandruff shampoo,
topical steroid ointments and antifungals.
One to three percent of people with AIDS develop psoriasis.
This is a disorder characterized by red bumps and plaques
with thick silvery white scale that are most commonly found
on the scalp, trunk, elbows, knees and buttocks. It is not an
infectious process, but all kinds of infections can make it
much worse. Unfortunately, the disorder can become severe
(even requiring hospitalization) and is often very difficult
Nearly all individuals with CD4 counts below 100 will at some
time in the course of their illness suffer from severe
itching. One disorder that often causes this symptom is
eosinophilic folliculitis (commonly called "itchy bump
syndrome"). Patients develop very itchy red bumps around the
hair follicles on their neck, upper trunk and arms. Since the
cause of the disorder is unknown, treatment is empiric with
the use of itraconazole and indocin along with good basic
This is a problem for people living in Colorado where the
climate is dry, but in particular, for people infected with
HIV. Treatment involves taking fewer showers or baths and the
use of lots of moisturizers and topical steroids.
Reactions to medications are more common in people who are
HIV+ than in the general population and reactions become more
frequent as the disease progresses. Bactrim and penicillin
cause the most reactions, but people with central nervous
system toxoplasmosis who are taking anti-seizure medications
appear to be at high risk for the most serious kinds of drug
(This article was excerpted from the presentation given by
Margaret F. Muldrow, MD and Kees Rietmeijer, MD at the 10th
Annual Rocky Mountain Regional Conference on HIV Disease held
February 2-4, 1995 in Denver, CO and is reprinted from the
April 1995 issue of Resolute!)