European Journal of Cardiovascular Medicine

HIV belongs to the Lentivirus genus of the Retro-viridae family. Retroviruses insert viral RNA into the host DNA. HIV-1 likely originated from chimpanzees (SIV), and HIV-2 from sooty mangabey monkeys. HIV-1: Global prevalence, subtype C common in India. HIV-2: Found in West Africa; less transmissible, slower progression, longer incubation.

HIV primarily targets CD4+ T-helper cells, macrophages, B cells, Langerhans cells, and NK cells. Virus enters cells via gp120 binding to CD4 and CCR5/CXCR4 receptors; gp41 allows viral RNA entry. Reverse transcriptase converts viral RNA to DNA; integrase inserts it into host DNA forming provirus. Virus replication destroys CD4 cells → progressive immunosuppression. Low CD4 counts increase susceptibility to opportunistic infections and cancers → AIDS.

HIV spreads through: Blood, semen, vaginal/rectal fluids, breast milk, CSF. Unprotected sex, mother-to-child, shared needles, transfusions. Not transmitted via casual contact, saliva, sweat, or tears. The virus is fragile; common disinfectants destroy it. Female sex workers, MSM, transgenders, IV drug users, inmates, long-distance truckers are the high-risk groups.

Early infection: often asymptomatic or flu-like illness. Progressive infection: opportunistic infections, weight loss, chronic diarrhoea, fever. Dermatological changes often indicate disease stage.

WHO Clinical Stages of HIV

Stage 1: Asymptomatic or generalized lymphadenopathy

Stage 2: Moderate weight loss, recurrent infections, herpes zoster, angular cheilitis, fungal nail infections, seborrheic dermatitis

Stage 3: Severe weight loss, chronic diarrhoea, persistent fever, oral candidiasis, pulmonary TB, severe bacterial infections

Stage 4 (AIDS): Wasting, Pneumocystis pneumonia, chronic HSV, Kaposi sarcoma, CNS infections, malignancies.

WHO Immunological Classification

CD4 >500: No significant immunodeficiency

CD4 350–499: Mild

CD4 200–349: Advanced

CD4 <200: Severe immunodeficiency

Mucocutaneous Manifestations of HIV

Infectious Disorders

Bacterial: Staphylococcus aureus, MRSA, Streptococcus, Pseudomonas, bacillary angiomatosis, cutaneous TB.

HSV, VZV, HPV (warts/cervical cancer), Molluscum contagiosum, CMV, EBV (oral hairy leukoplakia).

Fungal: Candida (oral, vaginal, cutaneous), dermatophytosis, onychomycosis, cryptococcosis, histoplasmosis, penicilliosis, aspergillosis.

Parasitic: Scabies (classical and crusted), demodicosis.

Non-Infectious Dermatoses

Psoriasis (severe, atypical), seborrheic dermatitis, eosinophilic folliculitis, pitryosporum folliculitis, pruritic papular eruption, hyperpigmentation, xerosis.

Neoplasms: Kaposi sarcoma, non-Hodgkin’s lymphoma, skin cancers.

Drug Reactions; HAART and other drugs may cause rashes, Stevens-Johnson syndrome, TEN, hypersensitivity reactions.

Hair: Thinning, coarse hair, alopecia, premature greying, hypertrichosis.

Nails: Beau’s lines, discoloration (blue, yellow, grey), onycholysis, pigmentation changes, periungual Kaposi sarcoma.

Oral Mucosal Manifestations; Aphthous ulcers, linear gingival erythema, necrotizing periodontal disease, abnormal pigmentation.

Inclusion criteria 1. Patients whose HIV status has been proved by NACO guidelines. 2.HIV/AIDS patients with symptoms and signs suggestive of dermatological study. Exclusion criteria Pregnant and Lactating women with HIV/AIDS and Children below 18 years. SAMPLE SIZE A sample size of 140 was collected. The patient's demographic data, duration and symptoms of the present illness, duration of HIV disease, HAART treatment history, CD4 count, relevant investigations pertaining to the disease was done in atypical cases. Noted in a pre-designed proforma after taking informed and written consent.

figure 1.

This Pie chart categorizes the study subjects by sex. There are slightly more female subjects (56%) than male subjects (44%).

figure 2.

The table and the graph represent age group of 31-40 (38%) years are more in the study population followed by 41-50 years (33%), >50 years (19%), 21-30 years (9%) and <20 years (1%). The mean age is 41.22 years.

FIGURE 3.

The graph represents the disease duration of the subjects, patients had disease duration of 6-10 years (30%), followed by 1 to 2 years (28%), 3-5 years (26%), >10 years (10) and <1 years (6%).

figure 4.

This graph represents 136 patients are on HAART remaining 4 patients are not using HAART

FIGURE 5.

The pie diagram represents 94% of the patients acquired the infection through heterosexual followed by homosexual 4%. 2% of the cases acquired through unknown sources.

FIGURE 6.

The graph represents 46% of the cases are in HIV clinical stage-2 followed by stage-1 (24%), stage-3 (22%) and stage-4 (7%).

FIGURE 7.

The graph represents 8% of the HIV patients with mucocutaneous manifestation are having severe immunosuppression followed by 14% are at advanced immunosuppression, 26% are in mild immunosuppression and 52% of the cases are observed with no significant immunosuppression.

Table 1. FREQUENCY OF VARIOUS CUTANEOUS MANIFESTATIONS

Among the total mucocutaneous manifestations observed, non-infectious conditions accounted for the majority (54.3%, n=76), while infectious manifestations were present in 45.7% (n=64). This highlights a slightly higher prevalence of non-infectious dermatological conditions in the study population.

TABLE 2. CD4 CELL COUNTS AND INFECTIOUS DERMATOSES

Mucocutaneous manifestations demonstrated varied associations with CD4 cell counts. Among the infectious conditions, Tinea corporis was the most frequently observed (n=17), with a mean CD4 count of 671 cells/mm³, followed by Scabies (n=11, CD4: 626 cells/mm³). Other infectious presentations such as warts, leprosy, and pityriasis versicolor also had mean CD4 values above 490, suggesting that a majority of infectious dermatoses occurred even in patients with moderate to preserved immune function.

However, a subset of patients with advanced immunosuppression (CD4 <200 cells/mm³) presented with conditions known to be associated with severe immune compromise. These included cases of oral candidiasis, herpes genitalis, and extensive pyoderma which were predominantly seen in patients with lower CD4 values, reinforcing their role as clinical markers of significant immunodeficiency

TABLE 3. CD4 CELLS COUNT AND NON-INFECTIOUS DERMATOSES

Among non-infectious manifestations, Pruritic Papular Eruption (PPE) was the most common (n=19), with a mean CD4 count of 379, typically associated with moderate immunosuppression. Other manifestations like Xerosis (CD4: 575), Xanthelasma palpebrarum (CD4: 697), Vitiligo (CD4: 675), and Fixed Drug Eruption (CD4: 672) occurred at higher CD4 levels, suggesting their emergence in early HIV infection.

The mean age is 41.22 years. With the highest percentage [38%] of subjects between 31-40years. Similar findings were reported by Dr. A. Kiran Raju et al. [1] and Vijay Kumari et al. [2], who observed that 46% and 47% of cases, respectively, were within the 31–40 age group. These results emphasize a significant link between mucocutaneous symptoms and the immune status of individuals with HIV. Zancanaro et al. [3] reported that 52.45% of patients, and Sen et al. [4]. found that 73.7% of patients, fell within the 21–40 age group, almost similar to the present study. Jing et al. [5], who observed a similar distribution of 66.3% in the same age group. This is also comparable with Sai Sreenivasulu Nookal et al [6]. Same age group was commonly affected C Chandrakala et al [7] also. This demonstrates that the majority of the HIV positive patients are in the sexually active age group.

The gender distribution showed a slight female predominance with 44% male and 56% female subjects. the results of this study are in agreement with several other research findings. The male-to-female ratio observed was 0.79:1, which is similar to the ratio of 1:1.05 reported by Shashi Chopra et al. [8], and also aligns closely with the 0.9:1 ratio found in the study by Jindal et al. [9]. Findings from Krishna Santosh et al. [10]. also closely resemble those of the present study. The rising number of HIV cases among women may be linked to shifts in lifestyle. This research indicates a gradual increase in HIV prevalence among women, especially among young, less-educated housewives living in rural areas.

The highest proportion of patients had a disease duration of 6–10 years (30%), followed by durations of 1–2 years (28%), 3–5 years (26%), more than 10 years (10%), and less than 1 year (6%). It means a substantial proportion of patients with longer disease duration (e.g., 6–10 years and beyond) likely reflects sustained access to HAART and improved survival, highlighting the long-term effectiveness of treatment. Conversely, the presence of patients with shorter disease durations (<1 year to 2 years) may indicate recent diagnoses and the ongoing need for timely initiation of HAART to prevent disease progression. Monitoring disease duration can therefore provide insight into treatment coverage, retention in care, and the evolving epidemiology of HIV within the study population.

Most cases (94%) were transmitted through heterosexual contact, indicating it as the predominant mode of transmission. Homosexual contact accounted for 4% of the transmissions. In 2% of cases, the mode of transmission was unknown, highlighting a small but uncertain portion. Unprotected heterosexual route was the most common route of transmission with a rate of 85.6% in our study which is on par with findings of Singh et al [11] and Srikanth et al, [12] who reported 94% and 77%. Similar findings were observed in Krishna Santosh et all study [13].

Stage 2 accounted for the highest proportion of cases at 46%, This was followed by Stage 1, which made up 24% of cases. Stage 3 contributed to 22% of the total cases. Stage 4 had the lowest percentage, with 7% of cases. Similar findings were observed in the study by Kore et al.,[14].

Various cutaneous manifestations are PPE (13%) followed oral candidiasis (12%), xerosis (8%), scabies (7) warts (5%), FDE (3%), furuncle (3%), leprosy (3%), tinea corporis (3%) pityriasis versicolor (3%) psoriasis (2%), vitiligo (2%) folliculitis (2%) Herpes zoster (2%) etc. followed by lichen planus, angular cheilitis and lichenoid dermatitis etc were seen in 1% of cases (one each).

Immunological staging based on CD4 counts revealed that while a majority of patients (52%) exhibited no significant immunosuppression (CD4 > 500 cells/mm³), a substantial proportion continued to experience varying degrees of immune deficiency: 26% had mild immunosuppression (CD4 350–499 cells/mm³), 14% had advanced immunosuppression (CD4 200–349 cells/mm³), and 8% remained severely immunosuppressed (CD4 < 200 cells/mm³). These findings underscore the heterogeneity in immune recovery among individuals on antiretroviral therapy (HAART) and highlight the need for ongoing monitoring and individualized patient management. This study shows similarity with Parmar BV et al.,[15].

Non-infectious conditions accounted for the majority (54.3%), while infectious manifestations were present in (45.7%). This highlights a slightly higher prevalence of non-infectious dermatological conditions in the study population. Infectious diseases were common in Kore SD et al.,[16], C. Chandrakala et al.,[17], Parmar BV et al.,[18]. Studies. This may be due to earlier detection and antiretroviral therapy (ART), which suppresses opportunistic infections but doesn’t prevent immune-mediated skin conditions. Non-infectious dermatoses are often associated with immune dysregulation in HIV, especially in the chronic phase.

Among infectious mucocutaneous conditions, fungal infections are the most prevalent, constituting 45% of cases. Viral infections accounted for 20%, while bacterial and parasitic infections were equally observed, each contributing 17% to the infectious disease burden. In a study by Kore SD et al.,[19] fungal infection (30.1%) was also most common infectious condition followed by viral infection (29.7%). This study is also comparable with Kiran Raju et al.,[20].

Fungal infections are an early manifestation of immunosuppression. Among fungal infections, oral candidiasis was the most common manifestation, seen in 58.6% of cases. This was followed by tinea corporis and pityriasis versicolor (each 10.3%), while less frequent conditions included vulval candidiasis and onychomycosis (6.9% each), and rare presentations like Sporotrichosis (3.4% each). The most common type of fungal infection in the present study was oral candidiasis (27.2%) and seen across all four CD4 count group. This study was close to the study conducted by Ampajwalam.,[21} and Shobhana et al.,[22].

Bacterial infections, Leprosy and Furuncle were the most frequently reported, each contributing 25% of cases. Other bacterial conditions such as Folliculitis, Syphilis, Paronychia, and Erythrasma were less common, each accounting for 8.3% to 16.7% of the total bacterial manifestations.  Similar findings were reported by Spira et al.,[23] and Garbe et al.,[24] in their study with bacterial infections as most common. Most common infections were bacterial with staphylococcal infections, more common, followed by folliculitis in Santhosh k et al.,[25] study.

Warts were the most common manifestation, seen in 38.5% of cases. Other presentations included Herpes zoster (15.4%) and a range of less frequent conditions such as Herpes genitalis, Herpes simplex, Varicella, and Molluscum contagiosum (each 7.7%). HSV infection was the most common viral infection in the other studies by Mandal BK et al.,[26], Cohen et al.,[27] and Lahoti et al.,[28]. In HIV-infected individuals, HPV holds greater clinical significance than HSV due to its strong association with malignancies, higher persistence, and limited response to HAART, underscoring the need for vigilant screening and preventive strategies.

Scabies was the sole parasitic manifestation observed, accounting for 100% of the parasitic infections in the study population. Scabies in HIV patients is significant due to its frequent atypical and severe presentations, especially in the form of highly contagious crusted scabies, necessitating early recognition and aggressive treatment to prevent complications and transmission.

The most common non-infectious mucocutaneous manifestation was pruritic popular eruption, observed in 19 patients. PPE was the most common non-infectious condition seen in Mohammed et al.,.[29]. Xerosis was next common similar to Kumaraswamy et al.,[30], who reported as 37% in his study.

The most infectious skin conditions, like tinea corporis and scabies, occurred in HIV patients with moderate to preserved immunity (CD4 >490 cells/mm³), while severe infections such as oral candidiasis and genital herpes were seen in those with advanced immunosuppression (CD4 <200 cells/mm³), highlighting their value as clinical markers of immune status. Similar findings were observed in Raju p et al., and Singh et al., study.

Among non-infectious manifestations, pruritic papular eruption (PPE) was the most common (n=19), occurring at a mean CD4 count of 379, indicative of moderate immunosuppression. In contrast, conditions such as xerosis (CD4: 575), xanthelasma palpebrarum (CD4: 697), vitiligo (CD4: 675), and fixed drug eruption (CD4: 672) were observed at relatively higher CD4 counts, suggesting their occurrence in the earlier stages of HIV infection.

This aligns with findings from Raju PV et al., and Patel et al., who reported PPE as a frequent dermatosis in HIV patients with CD4 counts typically ranging between 200–500 cells/mm³. Similarly, Ramesh et al., identified PPE as a hallmark of moderate immune decline in Indian cohorts.

xerosis (CD4: 575), xanthelasma palpebrarum (CD4: 697), vitiligo (CD4: 675), and fixed drug eruption (CD4: 672)—were observed at higher CD4 counts, suggesting an occurrence in patients with relatively preserved immunity. This pattern is supported by Mohan Kumar et al., and Singh et al., who noted that conditions like xerosis and vitiligo often emerge in early-stage HIV infection or as incidental findings not directly correlated with severe immunosuppression.  

Our study shows that mucocutaneous manifestations are important clinical clues in HIV infection. These skin and mucosal changes can appear at any stage of the disease, making them useful markers of a patient’s immune status. Some conditions were strongly linked with severe immunosuppression and can help identify advanced disease. We also found that common skin problems may appear in unusual or more severe forms in HIV-positive individuals. These atypical presentations can make diagnosis difficult, especially when HIV status is not known. Therefore, clinicians need to stay alert and familiar with the wide range of skin changes seen in HIV. Early recognition of these manifestations helps ensure timely antiretroviral treatment and better management of opportunistic infections. Including regular dermatological evaluation in HIV care can improve overall outcomes and help identify patients who need further immune assessment.

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