HIV Rash: Appearance and Types

An HIV rash is a common symptom among people living with human immunodeficiency virus (HIV). In addition to a rash that appears as an early sign of HIV, you may be at risk for other types of rashes if you have HIV.

If you have a rash and are concerned that you might have HIV, the only way to know if HIV is the cause of your rash is to get tested by a healthcare provider.

Around 90% of people with HIV will experience skin conditions related to the virus at some point. These conditions can cause itching, red bumps, pain, and more. Pictures of the types of possible rashes with HIV can help you better understand the rashes associated with the virus.

For example, some rashes are caused by opportunistic infections (OIs), and some are caused by medications taken to treat HIV. While rashes are common among individuals with HIV, many of the rashes listed tend to be more common in countries with reduced access to HIV medications or in individuals who are not taking medications to reduce their viral load.

HIV Rash

A painful or itchy rash may be one of the first symptoms of HIV. This rash typically appears as a flat, red rash. The rash may appear anywhere from two to six weeks after exposure to the virus. Features of this rash include the following:

• It's maculopapular, which means it is characterized by both macules and papules. Macules are flat, discolored areas of the skin, and papules are small, raised bumps.
• It affects the upper part of the body.
• It may include ulcers in the mouth or on the genitals.
• The areas affected by the rash may be itchy or painful.

On light skin, the rash may look reddish, flushed, or discolored. On dark skin, it may be deep purple. Skin and rash appearance in individuals with HIV can vary widely.

Along with other early signs of the virus, an HIV rash may last for only a few days or up to several weeks.

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HIV Rashes Caused by Other Conditions

HIV affects the immune system, so healthcare providers use several tests to monitor the immune system in individuals living with HIV. One blood count providers watch is the CD4 cell count.

CD4 cells are white blood cells essential in fighting infection. As HIV progresses, the CD4 count may drop. Individuals with lower CD4 counts are more prone to opportunistic infections, including various skin conditions.

Many of these skin conditions may present with a more severe presentation due to the individual's compromised immune system. They may also present atypically or differently than in individuals who are otherwise healthy.

Additionally, it can be more challenging to treat rashes and skin conditions in those with HIV, and rashes may require multiple courses of treatment to be effective.

Rashes and skin conditions in individuals with HIV may include but are not limited to, inflammatory skin conditions, such as:

• Sebhorrheic dermatitis
• Eosinophilic folliculitis
• Papular pruritic rash
• Xerosis
• Prurigo nodularis

Infectious causes of rashes may include, but are not limited to:

• Cytomegalovirus (CMV)
• Kaposi sarcoma
• Mucocutaneous candidiasis
• Molluscum contagiosum
• Herpes zoster
• Persistent herpes simplex infection
• Tinea infections

Additionally, individuals with HIV are much more likely to experience skin-related side effects of medications. As immune function decreases, the likelihood of experiencing a skin-related side effect from medication increases.

Seborrheic Dermatitis

Seborrheic dermatitis is common in people with HIV, most often occurring in the early stages 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 many sebaceous (oil) glands, such as 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 mild cases 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

Theories on the cause of HIV-related eosinophilic folliculitis include fungal infections, bacterial infections, and Demodex folliculorum, a type of mite. It's also thought that EF may be an autoimmune reaction to sebum, or oil in the skin. Yet research findings for these causes have been inconsistent.

Papular Pruritic Rash

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A papular pruritic rash is quite common in people with HIV. One study of 100 HIV-positive people with itchy rash symptoms reported the diagnosis in 11.3% of cases. 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, hypersensitivity to insect bites due to HIV-associated immune dysregulation may be to blame.

Treatment includes antihistamines and topical corticosteroids, as well as:

• Oral antibiotics
• Emollients and anti-itch lotions
• Antifungal creams
• Scabies treatments (otherwise used for certain mite infections). Some people with HIV can develop a severe type of scabies infection.
• Phototherapy

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 body's trunk.
• Prurigo simplex: This chronic, itchy skin condition causes skin nodules and lesions.

Xerosis

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Xerosis (sometimes called asteatotic eczema) occurs in people without HIV but is a common type of HIV rash marked by severe dryness and itchiness.

It is most common and severe during the winter months, resulting in deep cracks and fissures in the skin, which resemble a dry riverbed. When xerotic eczema develops in an advanced HIV infection, it may be accompanied by acquired ichthyosis and wasting syndrome.

Topical lotions and creams can be used to treat the skin, some of which require a prescription from a healthcare provider.

Prurigo Nodularis

Prurigo nodularis is a skin condition that causes extremely itchy 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, including immune responses and neural dysfunction. Prurigo nodularis can also occur with other skin conditions, most often atopic dermatitis (eczema).

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 (nerve pain).

Cytomegalovirus (CMV) Rash

An opportunistic infection (OI) affects people with weakened immune systems, while an AIDS-defining condition indicates that someone has AIDS. Cytomegalovirus (CMV) is one of 24 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 appear to 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.

Kaposi sarcoma

Kaposi sarcoma (KS) is a type of cancer that affects the lining of blood vessels. It typically appears as skin tumors or tumors on mucosal surfaces (e.g., inside the mouth). However, it can also appear in other places, such as lymph nodes or the digestive tract.

While there are a few different types of KS, one variant is primarily seen in individuals with HIV. There are several different treatments for KS, including chemotherapy, radiation, and immunotherapy. Additionally, adherence to medications for HIV can also help to control the spread.

HIV Rashes Caused by Medication

Drug hypersensitivity is an adverse immune system reaction to medication. Given the many drugs used to manage the infection, people with HIV 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.

Several of the medications used to treat HIV may cause a mild or moderate rash. Examples of drugs that can cause a rash include non-nucleoside reverse transcriptase inhibitors (NNRTIs) and Darunavir (DRV).

In most cases, mild rashes will resolve without needing to switch medications. However, if the medication that caused the rash is Nevirapine (NVP), it is more likely to require a medication switch. If you do develop a rash after beginning a new medication for HIV or at any point in your treatment, consult your healthcare provider for advice.

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 are extremely rare, and are marked by:

• Fever
• Malaise (general feeling of being unwell)
• Upper respiratory tract infection symptoms (cough, rhinitis, sore eyes, and myalgia or 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

HIV Rash Treatment

Treatment for an HIV rash depends on the type of rash. You may also need to consider other underlying health issues. Discuss proper treatments with your healthcare provider. For early-stage HIV rashes, they may recommend hydrocortisone cream to help relieve the itching and swelling.

Avoiding hot showers and direct sunlight can also help prevent further irritation to skin rashes.

For some rashes, antiretroviral treatment can relieve symptoms or help prevent the development of other types of skin problems.

When to See a Healthcare Provider

If you have already been diagnosed with HIV, see a healthcare provider anytime you develop a rash so they can determine whether the rash is related to HIV or another cause.

For those who have not been diagnosed, see a healthcare provider right away if you think you have been exposed to HIV, even if you do not have a rash or other early symptoms. You may be able to receive HIV postexposure prophylaxis (PEP) treatments within 72 hours of exposure, which can protect you from developing HIV.

When you see your healthcare provider, they will run an HIV test. This usually consists of taking a blood or saliva sample. This will be done whether you show symptoms or are concerned that you may have been infected.

If the preliminary test is positive, your healthcare provider will perform another more sensitive test to confirm the result.

Summary

A rash can be a cause and an effect of an HIV infection. If someone has HIV and develops a rash, they should begin antiretroviral therapy as soon as possible to mitigate the effects.

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 a treatable condition. Talk to your healthcare provider about any concerns you may have.