Skin problems

There are three main causes of skin problems in people with HIV: interactions between the immune system and HIV, infections, and side-effects of drugs. Some HIV-related skin conditions or treatment-related side-effects can be very serious and require urgent medical attention.

The immune system and HIV
When people first get HIV, they may have flu-like symptoms called a seroconversion illness. This illness may include a non-itchy, red rash lasting 2-3 weeks. During ongoing infection, the immune system becomes dysregulated and this may lead to red and itchy (pruritic) skin. This may be treated with steroid creams or anti-histamines. Skin problems may also occur when the immune system starts to recover due to anti-HIV drugs (especially acne and folliculitis) and appear to be a good sign of returning immune capacity.

Skin problems caused by infection
Infections are generally divided into three main groups: bacterial, fungal or viral infections. Eczema (dry or irritated skin) has many causes and may be treated with anti-histamines. To alleviate any dry skin condition, avoid long baths and the use of soap, shower gels and other potential irritants. Instead, use aqueous cream (E45) or moisturiser. Dermatitis (inflammation of the skin) is identified by red patches and a flaky rash. It may be caused by fungal infections or eczema. Seborrhoeic dermatitis (inflammation of the skin's oil glands) often occurs in hairy parts of the body and looks like yellowish dandruff. It's common in symptomatic HIV. Dermatitis may be treated with steroid ointments or anti-fungal creams or tablets. Some scalp problems are treated with anti-dandruff or anti-fungal shampoos.

Tinea is a fungal infection that causes flaky red skin and moist white patches. It is treated with anti-fungal creams. Diluted tea-tree oil may be effective. Keep skin dry and avoid irritants, e.g. deodorants. Folliculitis (small lumps or pustules in the follicles – the hair's root) is a skin infection, most likely caused by yeast, which is treated with anti-fungals. Impetigo is a bacterial skin infection indicated by yellow crusty red sores. Skin follicles may also become infected, leading to boils or abscesses, which are treated with antibiotics.

Small pearly pimples may be caused by viral infections such as the pox virus, Molluscum contagiosum, or by fungal infections such as cryptococcosis. Molluscums and spread very quickly and require treatment at your HIV clinic.

Warts, particularly genital and anal warts caused by the HPV virus are often seen in people with HIV. See the NAM factsheet on genital warts.

Herpes (see NAM factsheet 25) and the AIDS defining cancer Kaposi's sarcoma (see NAM factsheet 16) also affect the skin.

Drug side-effects
People with HIV often develop skin-related side-effects, such as rash. Most are mild and treatment can be continued. To minimize the chance of side-effects you can start some drugs, e.g. nevirapine, at a low dose and increase to the full dose over two weeks. Reducing your dose may also be effective, though you should never do this without advice from your doctor.

If the rash is mild, you may be able to re-start the drug at a later date. If the rash is severe, the drug should not be taken again.

The NNRTIs nevirapine and delavirdine cause rashes in 20-30% of people, and efavirenz in less than 5%. This rash is usually mild and disappears as your body gets used to the drug. A steroid called prednisone may be useful in reducing the frequency of rash in people taking nevirapine.

A very small number of people develop a life-threatening reaction called Stevens Johnson Syndrome (SJS). Toxic epidermal necrosis (TEN) is another severe skin condition. Serious skin reactions such as SJS and TEN may cause severe rash, crusting or ulcers of the mouth or genitals, burning skin and large layers of skin to flake off (exfoliative dermatitis). If these symptoms develop within two weeks of starting a drug, stop the drug and see your doctor immediately.

Rash is also a sign of an allergic reaction to the anti-HIV drug abacavir. If this reaction occurs, you should contact your doctor immediately. If you stop taking abacavir because you developed the allergic rash you must not take the drug again as this can cause potentially fatal side-effects.

Other drugs which are regularly used to treat infections commonly seen in people with HIV can also cause rash and skin reactions. These include Co-trimoxazole, dapsone, pyrimethamine, clindamycin, atovaquone, the aminopenicillins, thiacetazone and sulphadiazine.