DR11.1 | Dermatologic Manifestations of HIV — Summary & Reflection

KEY TAKEAWAYS

More than 90% of people living with HIV develop cutaneous disease, and the skin is a readable window into immune status because dermatoses track the CD4 count. At preserved counts (>500), inflammatory conditions predominate — seborrhoeic dermatitis, pruritic papular eruption, and psoriasis flares. At moderate immunosuppression (200–500), latent viruses and fungi reactivate atypically — oral hairy leukoplakia (EBV), extensive molluscum, recurrent herpes zoster, candidiasis, and eosinophilic folliculitis. At advanced immunosuppression (<200), control collapses, allowing Kaposi sarcoma (HHV-8), chronic atypical herpes simplex, severe molluscum, and bacillary angiomatosis (Bartonella — a curable mimic of Kaposi sarcoma). Diagnosis combines the clinical pattern with the two anchor tests — CD4 count and HIV serology (4th-generation antigen/antibody assay) — supplemented by skin biopsy, KOH mount, and Tzanck smear. Management rests on antiretroviral therapy as the cornerstone (immune reconstitution clears most dermatoses), plus condition-specific treatment, recognition and steroid-supported management of IRIS, and timely referral. Mastering this CD4-stratified approach is the essence of competency DR11.1. (CD4 thresholds are approximate and should be confirmed against current NACO guidance.)

REFLECT

Think back to a patient you have examined — in the skin OPD, the medical ward, or during a community posting — who had a stubborn or unusual skin or mucosal complaint: an extensive dandruff-like rash, a non-healing genital or oral ulcer, a cluster of molluscum in an adult, or a severe shingles. With the CD4-stratified framework in mind, ask yourself: would you now consider HIV in that differential, and what single investigation would you have ordered first? Reflect also on the counselling dimension — how would you sensitively raise HIV testing with a patient whose skin has prompted your suspicion? Connecting the morphology you see to the immune status it reflects, and then to the human conversation that must follow, is what turns dermatological pattern-recognition into competent, compassionate HIV care.