HIV Dermatology
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Direct answer
Nearly every CD4 stratum stamps its own signature on the skin, and reading those signatures is cheaper than a flow cytometer: severe or recalcitrant seborrhoeic dermatitis appears early, eosinophilic folliculitis and oral hairy leukoplakia cluster below roughly 250–200 cells/microlitre, and giant molluscum, disseminated fungal infection and bacillary angiomatosis declare profound immunosuppression under 100. For NEET-PG Medicine, pairing the eruption with the CD4 band — and recognising immune reconstitution inflammatory syndrome after antiretroviral therapy — is the skill tested.
What you must remember
- Acute retroviral syndrome: a morbilliform, infectious-mononucleosis-like rash with fever and mucosal ulcers during seroconversion.
- Seborrhoeic dermatitis that is severe, treatment-resistant or extensive is a classical early marker and worsens as CD4 falls.
- Oral hairy leukoplakia: white, corrugated, non-scrapable plaques on the lateral tongue borders from Epstein-Barr virus — distinct from thrush, which scraps off.
- Eosinophilic folliculitis: intensely pruritic urticarial follicular papules on face, trunk and upper arms at CD4 counts typically below 250; treated with phototherapy, topical steroids, itraconazole or isotretinoin.
- Kaposi sarcoma (HHV-8): violaceous-brown macules, plaques or nodules; hard palate and lower-limb involvement are characteristic.
- Molluscum contagiosum: giant, numerous, facial lesions reflect advanced immunosuppression.
- Bacillary angiomatosis (Bartonella): friable red papules mimicking Kaposi; responds to erythromycin — biopsy with Warthin-Starry staining distinguishes it.
- In northeastern India and Southeast Asia, disseminated Talaromyces (Penicillium) marneffei presents with umbilicated acneiform papules plus fever and anaemia.
- Immune reconstitution inflammatory syndrome: paradoxical worsening of tuberculosis, leprosy or cryptococcosis weeks after ART initiation — treat the infection, usually continue ART.
How to work through a typical case
A 38-year-old man, newly diagnosed HIV-positive with CD4 90 cells/microlitre, is evaluated before starting antiretroviral therapy. He reports months of intractable itching with urticarial papules over the face and chest, and examination reveals white ridged plaques along the lateral tongue margins plus several flesh-coloured umbilicated papules on the forehead.
Step one: read the eruption as an immunological gauge — the pruritic follicular eruption is eosinophilic folliculitis (CD4 typically <250), the lateral-tongue plaques are oral hairy leukoplakia, and the umbilicated papules are molluscum; together they confirm profound depletion without waiting for the count. Step two: verify the spot diagnoses cheaply — the leukoplakia does not rub off with a gauge (unlike candida), and a skin biopsy of the folliculitis shows eosinophilic infiltration of follicles with negative cultures for the mimics. Step three: search for other organ threats at this CD4 level — dilated fundoscopy for cytomegalovirus retinitis, chest imaging for tuberculosis and Pneumocystis, and a careful oral and perianal examination. Step four: initiate opportunistic-infection prophylaxis per national guidelines — cotrimoxazole prophylaxis at this count — and start ART at the appropriate time. Step five: anticipate immune reconstitution inflammatory syndrome in the first weeks to months of ART, particularly in India where latent tuberculosis and leprosy commonly unmask; worsening lesions with a rising CD4 count after therapy is paradoxical inflammation, not drug failure, and management centres on treating the unmasked infection with short adjunctive steroids in severe cases.
Where students slip
The commonest error is confusing oral hairy leukoplakia with candidiasis: the exam expects "white, lateral border, cannot be scraped" for leukoplakia versus "creamy plaques that wipe off, pseudohyphae on smear" for thrush. The second slip is mislabelling every violaceous nodule as Kaposi — bacillary angiomatosis is the named differential that responds to erythromycin, and biopsy separates them. Third, candidates forget the geographic star: umbilicated papules with fever in a patient from the Northeast suggest talaromycosis, not molluscum alone. Finally, IRIS misread as "ART failure" or "drug allergy" leads to the wrong action; the correct response is infection-directed therapy with continuation of ART in most situations.
Frequently asked questions
Which skin condition suggests a CD4 count below 250 cells/microlitre?
Eosinophilic folliculitis — intensely itchy urticarial follicular papules on the face and trunk — and oral hairy leukoplakia typically appear below this band.
How is oral hairy leukoplakia distinguished from oral candidiasis?
Hairy leukoplakia forms white corrugated plaques on the lateral tongue that cannot be scraped off and is EBV-driven; candidiasis forms creamy pseudomembranes that scrape away, revealing hyphae on KOH.
Which condition mimics Kaposi sarcoma and responds to erythromycin?
Bacillary angiomatosis due to Bartonella species — friable red papules distinguished on biopsy by Warthin-Starry staining and treated with erythromycin or doxycycline.
What is immune reconstitution inflammatory syndrome?
Paradoxical worsening or unmasking of infections such as tuberculosis, leprosy or cryptococcosis within weeks of starting ART as immunity recovers, managed by treating the infection with adjunctive steroids in severe cases while usually continuing ART.
Which dimorphic fungus produces umbilicated skin lesions in Indian patients with advanced HIV?
Talaromyces (Penicillium) marneffei, endemic in parts of northeast India and Southeast Asia, presenting with fever, anaemia and acneiform umbilicated papules.