Cutaneous Markers of HIV
HIV-infected patients should be carefully examined for specific skin findings that serve as clinical markers of disease stage and immune status, with seborrheic dermatitis, Kaposi sarcoma, oral candidiasis, and molluscum contagiosum being the most important indicators of disease progression.
Early-Stage Cutaneous Markers (Higher CD4 Counts)
The following skin findings appear early in HIV infection and increase in severity as disease progresses:
Seborrheic dermatitis is one of the earliest and most persistent cutaneous markers, occurring in early Walter Reed stage 1 and increasing in occurrence and severity with disease progression 1. In HIV patients, it presents with distinct features including erythematous scaly papules and plaques extending beyond typical seborrheic areas, thick greasy scalp scale, and increased frequency of erythroderma 2.
Xerosis (dry skin) and asteatotic eczema are among the most frequent and persistent findings, appearing early and worsening with disease progression 3.
Folliculitis and acne vulgaris flares show peak occurrence in early to mid-stage disease, then decrease in late-stage disease 3.
Fungal infections including tinea and onychomycosis appear early but become more diffuse and treatment-resistant as disease advances 1, 3.
Psoriasis may present with increased severity in HIV-infected patients 1, 4.
Mid to Late-Stage Cutaneous Markers (Lower CD4 Counts)
As immunosuppression progresses, additional markers emerge:
Kaposi sarcoma requires specific examination of skin and oral mucosa, particularly in patients with advanced disease 1.
Oral candidiasis shows marked increase in occurrence with advanced disease and has statistically significant association with disease progression 1, 3.
Oral hairy leukoplakia increases with advanced disease and is significantly associated with stage progression 1, 3.
Molluscum contagiosum demonstrates marked increase in occurrence with advanced disease and correlates with disease stage changes 1, 3.
Herpes simplex infections become more frequent and severe in advanced disease 1, 3.
Herpes zoster is significantly associated with disease progression, and when occurring in young individuals should raise suspicion for underlying HIV 3, 5.
Staphylococcus aureus infections increase markedly with advanced disease 3.
Additional Important Cutaneous Findings
Condylomata acuminata and verrucae appear early but become more diffuse and treatment-resistant with progression 3.
Hyperpigmentation (nail, oral, and skin) is significantly associated with disease stage changes 3.
Drug eruptions are significantly associated with disease progression and should prompt evaluation 3.
Prurigo nodularis should be specifically assessed during examination 1.
Eosinophilic folliculitis is a specific HIV-associated papular dermatosis 1, 4.
Critical Clinical Pearls
Proximal subungual onychomycosis (PSO) deserves special mention as it is uncommon in the general population but common in AIDS patients and has been considered a useful marker of HIV infection 1. In AIDS patients, it often spreads rapidly from the proximal margin producing gross white discoloration without obvious thickening 1.
Cutaneous anergy (inability to mount delayed-type hypersensitivity responses) increases with declining CD4 counts, with approximately 80% of patients showing anergy when CD4 counts fall below 50 cells/mm³ 1.
Examination Priorities
During physical examination, pay particular attention to:
- Skin texture and evidence of xerosis 1
- Scalp for seborrheic dermatitis with thick, greasy scale 2
- Face and trunk for seborrheic distribution lesions 1
- Oropharynx for candidiasis, oral hairy leukoplakia, Kaposi sarcoma, and aphthous ulceration 1
- Anogenital region for condylomata, herpes simplex, and other STDs 1
- Nails for fungal infections, particularly proximal subungual pattern 1
- Overall body habitus for lipodystrophy in patients on antiretroviral therapy 1
Common pitfall: When cutaneous diseases occur in unusual settings (such as zoster in young individuals), are increased in severity, or fail to respond to routine therapy, underlying HIV immunodeficiency should be suspected 5. Skin findings may be the earliest sign of HIV disease or AIDS 5, 6.