The skin and HIV

HIV positive people are more likely to have an allergic reaction to medication

Our skin is the barrier with the outside world. A barrier that we like to show as beautiful as possible. Poor skin often results in anxiety and embarrassment. Somebody with an HIV infection has a greater chance of a skin condition than other people. About 90% of HIV positive people will get skin problems either caused by HIV itself, by other infections, or by the medication being used. The most important skin conditions are discussed in this article.

One of the functions of the skin is to make sure that unwanted intruders do not penetrate into the body. In the upper layers of the skin (in the epidermis) cells form a closed barrier because they are tightly connected to each other. This epidermis also keeps the body from drying out. In the layers under the epidermis there are many cells that can activate the immune system when bacteria, viruses or other pathogens pass through the skin barrier. During the course of the HIV infection when the immune system becomes weakened, the skin will more often and more severely show signs of infection. 

Seborrhoeic eczema
The most common skin condition among HIV positive people is seborrhoeic eczema. This condition makes the skin turn red, scaly and very itchy. Seborrhoeic eczema mainly occurs on the face (between the eyebrows, next to the nose and in the area where the beard grows), on a head that has hair and on the chest. Seborrhoeic eczema also occurs among many HIV negative people, but to HIV positive people it is more extensive and more difficult to treat. How this eczema develops is unknown. It is probably a superficial infection caused by a certain kind of yeast. This yeast can be suppressed by ointments containing Ketokonazole, but sometimes tablets work more effectively.

Pruritus
Itching is a frequently occurring problem that HIV positive people experience. There are many causes for pruritus: dry skin, seborrhoeic eczema, allergic disorders or decreased functioning of the kidneys or liver.
It is very important to ensure that the skin does not dry out. This won't solve the cause of itching, but it will decrease the inconvenience. Dry skin 'feels' the itching more than a well-oiled skin. You can prevent your skin from drying out by showering less, showering in cooler water, using less soap, and applying lotion. For the latter, you can use a body lotion, but even better is an ointment containing 10 to 20% Vaseline. These ointments are readily available at the chemist. When these measures do not work sufficiently, it might be a good idea to visit a doctor to inquire if the itching can be treated. In many cases this is not possible and the itching will have to be suppressed with medicines that are also used for allergies, such as Cetrizine.

Psoriasis
Psoriasis (another scaly skin disease) does not occur more among HIV positive people, but it progresses more seriously. Also, HIV positive people who suffer from psoriasis often have arthritis.

Infections
Many infectious diseases coexist with skin conditions. Sometimes these conditions are typical for a specific infection, such as with chicken pox or measles. Often the symptoms are less specific and the condition is described as a rash or an exanthema. For some HIV positive people, the infectious disease does not show its characteristic skin symptoms (as happens with HIV negative people). This makes it more difficult to recognise an infectious disease and can delay diagnosis.
HIV itself can cause short-lived skin conditions just after the moment of infection. Just after being infected with HIV, apart from flu-like symptoms, some people suffer with red spots and bumps (sometimes with scaly edges). Usually this rash occurs on the torso, but it can also occur on the arms and legs. Because various viral infections can cause rashes, this indication towards a possible HIV infection often goes unrecognised. These skin conditions often disappear within a few weeks.
When the immune system is compromised, skin infections caused by viruses, bacteria or other pathogens can occur more often and the outbreak is more severe. Fortunately since the introduction of combination therapy, a compromised immune system occurs less frequently. As a result, serious skin infections have become a lot more rare in the last few years.

Herpes
Many people contract the herpes simplex virus (HSV) in the course of their lives. After the first signs of infection, this virus remains in the body and can manifest itself any time immunity is low in the form of painful vesicles (blisters) and ulcers on the lips (cold sore) or around the vagina or anus (genital herpes). As long as these vesicles are present, that person is contagious and can transmit the HSV on to others. As long as the immune system is up-and-running, HIV positive people usually do not suffer herpes any more often or more severely than others. When the immune system is seriously weakened (the CD4 count drops under 100), a flaring-up of the herpes infection can be more severe and more persistent. With the help of Aciclovir, Valaciclovir or Famciclovir, the skin symptoms of a herpes infection can be controlled or shortened. But the virus cannot be eliminated from the body indefinitely. However, it is important to begin treatment as quickly as possible after the first symptoms.

Shingles
Shingles is also caused by a herpes virus. Most people contract this virus in childhood; first contact with the virus results in chicken pox. Thereafter it remains in the body. When the immune system is (temporarily) compromised, the virus will again cause vesicles on the skin (often limited to the area of one cutaneous nerve). An area like this is usually as large as a belt a few centimetres in width. About the torso these belts run from back to belly, hence the name 'shingles'. The more the immune system continues to weaken, the more shingles can return and over larger areas.

Molluscum contagiosum (water warts)
Molluscum contagiosum or water warts are thick round warts with a little hole in the middle. They often occur in children and are difficult to treat because they are very contagious. The infection usually abates by itself. When the immune system is depressed, molluscum contagiosum occurs more often. Under these circumstances they often are larger and return quicker after local treatment (for example by using liquid nitrogen).

Kaposi's sarcoma
Kaposi's sarcoma (KS) is a kind of cancer of the blood vessels that appears in the form of red, brown or purple spots on the skin. It is caused by a herpes virus (HHV-8) and usually occurs when the immune system is compromised. That's why it occurs less now than it did 15 years ago. Kaposi's sarcoma occurs mainly in HIV positive men who engage in unsafe homosexual contact. People think it is sexually transmitted, but how exactly remains a mystery. The course of Kaposi's sarcoma is variable: some spots spontaneously disappear; others continue to grow slowly. Because it is a malignant condition, it is wise to contact a dermatologist when Kaposi's sarcoma is suspected. Different kinds of (topical) treatment are available. Which one is best depends on the extent and the localisation of the Kaposi-spots. The dermatologist and the HIV specialist have the best knowledge about this.

Skin anomalies caused by medication
Practically all medication can cause skin anomalies. Sometimes it is due to an allergic reaction. HIV positive people are more likely to have an allergic reaction to medication, probably because HIV continuously stimulates the immune system. These allergic reactions manifest themselves in many different ways.

‘Rash’
Pinkish-red to purplish-red spots and bumps on the torso, the upper arms and upper legs are common allergic reactions to medication, especially with antibiotics and HIV inhibitors. This rash usually starts two to ten weeks after starting new medication and can itch intensely. When the medication is stopped, it usually takes one to two weeks before the skin recovers completely. During the healing process, sometimes the skin peels. Doctors refer to a skin reaction like this as a 'maculopapulous rash'. It occurs mainly with the use of Amoxicillin, Co-trimoxazole, Nevirapine and Tipranavir. But it could be caused by any medication. The symptoms can disappear after stopping the medication, but they can return quicker and/or more vigorously when the medication is started again.

Hives
Hives (urticaria) are small or big very itchy pinkish-red bumps usually with a pale centre. They resemble the bumps you get after contact with a stinging-nettle. They can occur over the entire body and can disappear after a few hours, reappearing later on a difference part of the body.
Many people get hives without any known cause. Hives can, however, also be a symptom of an allergic reaction. An allergic reaction can spread to the bronchial tubes (resulting in tightness of the chest in combination with squeaky breathing) or to the circulatory system (resulting in heart palpitations and ultimately unconsciousness and shock). When hives occur shortly after starting new medication, it is possible that the hives are a result of an allergic reaction. In these cases, the medication needs to be replaced after consultation with the doctor who prescribed it. Afterwards the hives should disappear within a few hours to a few days. An anti-itch medicine (such as an antihistamine) can expedite this. Hives are not as common with the use of HIV inhibitors as with other medicines. The exception is FTC (Emtricitabine), which seems to result in hives occurring more often.

Blisters
Blisters that occur within a few weeks after new medication has been started can be the first sign of a rare allergic reaction. Antibiotics, remedies for epilepsy or Nevirapine can be the cause of this serious reaction. It often starts as red spots in which the skin can easily be peeled from the bottom layer. Spots like this (sometime blisters) can also occur on the mucous membrane of the mouth, throat, eyes, anus and vagina. Before skin abnormalities occur, people often suffer from fever, feeling poorly, headache, nausea, and muscle and/or joint pain. This reaction, also known as Steven-Johnson Syndrome (SJS) can ultimately result in skin peeling off large areas. The resultant open wounds can easily become infected. In the more serious condition, TEN (toxic epidermal necrolysis), the skin sometimes peels of in its entirety. Patients with one of these extreme allergic reactions usually have to be treated in a burn unit because of the large areas of damaged skin.
When such a reaction is suspected, all newly started medication and all unnecessary medication must be stopped immediately. Luckily these kinds of reactions are rare; less than seven in one million people fall victim to them.

Conclusion
Luckily skin conditions caused by a strongly compromised immune system do not occur as much as they used to. But at the same time, skin problems are not a thing of the past. Skin conditions such as seborrhoeic eczema occur more among HIV positive people regardless of how well their immune system is functioning. Moreover, someone with HIV has a greater chance of getting an allergic reaction to an antibiotic or an HIV inhibitor than people without HIV. In case of doubt it is always wise to ask a doctor or a dermatologist for his or her opinion.

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