Types of HIV Rash

Rashes are a common symptom associated with an infection with the human immunodeficiency virus (HIV). In fact, around 90% of people with HIV will experience a rash at some point during the course of their infection. Some rashes are the result of HIV itself, and others are caused by opportunistic infections (OIs) or by the medications taken to treat HIV.

This article will help you learn more about rashes linked to HIV, as well as how they present in regards to symptoms and appearance.

HIV Rash

An HIV rash can occur due to a recent HIV infection, usually appearing within two to six weeks after exposure. Other symptoms that can accompany this rash include flulike symptoms, such as fever, chills, and body aches.

This rash is maculopapular, meaning it's characterized by both macules and papules. A macule is a flat and discolored area of the skin, while a papule is a small raised bump.

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Seborrheic Dermatitis

Seborrheic dermatitis is common in people with HIV, most often occurring in the early stages of HIV, when blood counts of CD4 (white blood cells that are important to fighting infections) are at around 400.

Seborrheic dermatitis is marked by:

• Redness
• Dandruff
• Yellow, greasy scales

Seborrheic dermatitis occurs on areas of the skin where there are lots of sebaceous (oil) glands, such as on the scalp. In people with HIV, seborrheic dermatitis often presents much more severely. It is also likely to be diffuse (spread over a large area).

Treatment will vary depending on severity. Adults and children with a mild case of seborrheic dermatitis are treated with topical ketoconazole 2%, which is an antifungal cream, as well as topical corticosteroids.

Eosinophilic Folliculitis

Eosinophilic folliculitis (EF) is an inflammatory skin condition. In people with HIV, it is one of the most common skin conditions, and usually occurs when a person's CD4 count is under 250.

Symptoms of eosinophilic folliculitis can include:

• Itchiness
• Redness
• Pustules (bumps containing pus)

Eosinophilic folliculitis typically affects the face, scalp, neck, and trunk.

It can be treated with:

• Phototherapy: The use of ultraviolet (UV) light to treat skin conditions
• Moderate-to-high-potency topical steroids: Steroid medications applied directly to the skin
• Emollients: Moisturizing creams and ointments
• Antihistamines: A type of allergy medication used to treat allergic reactions

However, antiretroviral therapy (ART) remains the cornerstone treatment of HIV and gives the best, most-lasting results.

While the cause of eosinophilic folliculitis is unclear, it is linked to fungal infections, bacterial infections, and Demodex folliculorum, a type of mite. It's thought that EF may be a follicular hypersensitivity reaction or an autoimmune reaction to sebum, or oil.

Papular Pruritic Rash

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Papular pruritic rash is quite common in people with HIV, with a reported prevalence of 11%–46%. It is more common in advanced stages of HIV, typically occurring when a person's CD4 count is under 200.

A papular pruritic rash is marked by itching papules on the arms, legs face, and trunk.

The cause of a papular pruritic rash is not fully understood. However, a hypersensitivity to insect bites and a form of chronic recall reaction to insect antigens due to HIV-associated immune dysregulation may be to blame.

Treatment includes antihistamines and topical corticosteroids.

Other conditions in which papular pruritic rash is common include:

• Hives: This is a skin rash in response to an irritant.
• Transient acantholytic dermatosis: Also known as Grover disease, this is an itchy rash on the trunk of the body.
• Prurigo simplex: This is a chronic, itchy skin condition that causes skin nodules and lesions.

Xerotic Ezcema

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Xerotic eczema is a common type of HIV rash marked by severe dryness and itchiness. It typically occurs when the CD4 count falls under 200. It is most common and severe during the winter months.

When xerotic eczema develops in an advanced HIV infection, it may be accompanied by acquired ichthyosis and wasting syndrome.

Cytomegalovirus (CMV) Rash

An opportunistic infection (OI) affects people with weakened immune systems, while an AIDS-defining condition indicates that someone has AIDS. CMV is one of 23 AIDS-defining conditions that typically occur when the CD4 count is under 100.

CMV appears as small, elevated, purpuric, reddish papules and macules. CMV may almost manifest as other lesions, such as nonhealing perianal or vulvar ulcers. Diagnostic testing will differentiate a CMV rash from a herpes simplex or varicella zoster (causing chicken pox and herpes zoster) infection.

Chronic CMV infection is treated with Zigran (ganciclovir), an antiviral drug.

Prurigo Nodularis

Prurigo nodularis is a skin condition that causes extremely pruritic and symmetrical papulonodular lesions, usually on the extensor surfaces of the arms and legs. Its cause is still unknown, but it's believed to be due to a variety of factors.

Treatment options include:

• Antihistamines
• Topical corticosteroids
• Phototherapy
• Oraflex (benoxaprofen), a nonsteroidal anti-inflammatory drug (NSAID)
• Steroid injections into the nodules

If someone with HIV develops prurigo nodularis, they should be monitored for the development of neuropathy, which is nerve pain.

Drug Hypersensitivity

Drug hypersensitivity is an adverse immune system reaction to a mediation. In people with HIV, given the many drugs used to manage the infection, these patients are at higher risk of developing drug hypersensitivity.

Mild cases of drug hypersensitivity typically involve a maculopapular rash with a delayed allergic reaction, usually appearing between one to six weeks.

Treating drug hypersensitivity requires a multifaceted approach, given that it is difficult to know which drugs are causing the reaction. Mild cases often don’t require drug discontinuation. However, if the drugs need to be stopped, a patient should be closely monitored.

Stevens-Johnson Syndrome/Toxic Epidermal Necrosis

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Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe forms of drug hypersensitivity. SJS is defined as skin involvement of less than 10%, while TEN is defined as skin involvement of greater than 30%.

SJS and TEN in people with HIV is extremely rare, and is marked by:

• Fever
• Malaise (general feeling of being unwell)
• Upper respiratory tract infection symptoms (cough, rhinitis, sore eyes, and myalgia, muscle pain)
• Blistering rash and erosions on the face, trunk, limbs, and mucosal surfaces

Complications include sepsis and organ failure. Drugs most commonly associated with SJS and TEN in people with HIV include:

• Anticonvulsants
• Beta-lactam antibiotics
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Sulfonamides

Treatment also includes:

• Stopping the drug that causes the SJS or TEN
• Fluid replacement
• Nutritional assessment (may require nasogastric tube feeding)
• Temperature control (warm environment, emergency blanket)
• Pain relief and management
• Supplemental oxygen and, in some cases, intubation with mechanical ventilation

Summary

A rash can be a cause and an effect of an HIV infection. If someone suspects they have HIV and develop a rash, they should begin ART as soon as possible to mitigate the effects.

A Word From Verywell

Starting ART as soon as you learn of your HIV diagnosis is imperative in reducing the risk of disease progression, severe complications, and premature death. HIV is an incredibly treatable condition. Talk to your doctor about any concerns you may have.