What is HIV?
HIV or Human immunodeficiency Virus is the virus causing the much dreaded disease called AIDS (Acquired Immunodeficiency Syndrome) which is a syndrome that compromises the ability of the human body to fight against diseases.
On entering the human body, the virus starts attacking the policemen of our body, the lymphocytes, particularly T helper cells (CD4 cells).
When these fighter cells are killed by the virus and their number decreases below a critical number (<200), it manifests as full blown AIDS – Acquired immune deficiency syndrome – a disease state with highly compromised immune system.
Early HIV rash
Rash is the most common and important symptom of acute HIV infection.  After getting exposed to the virus, around 85% of the people get flu like illness in the first 2 – 6weeks.
As the symptoms resemble the common cold, it is important to know about the rash and other symptoms of early HIV infection to find it in the budding stage and differentiate it from the numerous other diseases which present with a rash. This acute HIV infection goes into hibernation after 4 – 5 weeks and the person remains symptomless for nearly 9 – 10 years.
If the HIV infection is not diagnosed in the initial few weeks, the chances are more that it will be diagnosed only when it becomes full-blown AIDS. One has to keep in mind that, rash is a symptom nearly as common as fever and should not jump into conclusion based on rash, that they have got HIV until they get tested positive.
Picture 1: HIV rash on face
Causes of Rash in HIV
Rash in a HIV patient may be caused by many reasons. They are
Usually, rashes are more commonly seen in viral infections. Being one among them, almost all HIV infected people experience skin changes at some stage of the disease and rash is the most common skin manifestation of HIV.
As said above, a person infected with HIV has poor ability to fight against many diseases which are easily overcome by people with normal immune system. These diseases are mostly seen among HIV patients and in some other conditions that cause poor immune status like diabetes and are called opportunistic infections. Most of the opportunistic infections cause a rash. The common opportunistic infections in AIDS associated with rash are
It is a viral infection which can be present in both adults and children.
Herpes simplex is a viral disease. In most conditions, patients with HIV have previous history of exposure to Herpes simples which gets reactivated. There is less reports on HIV patient acquiring Herpes simplex for the first time.
Herpes Zoster/ Shingles
It is a viral infection in adults caused by the virus which causes chicken pox in children.
This is a type of cancer seen in AIDS patients which begins as brown, purplish or red skin lesions which darken and become numerous in later stage. [2, 3]
Picture 2: Kaposis sarcoma
Image Source: dermweb.com
The most common side effect of HIV medications is rash and rashes are 100 times more frequent with usage of these medications. [2,3] Almost all anti HIV medications have the potential to cause rash. But it is mostly caused by NNRTI – Non nucleotide reverse transcriptase inhibitor – especially Nevirapine. Women have a higher risk of getting a rash than men by Anti HIV drugs 
As HIV is a disease of the immune system, there are changes in the system that makes a person allergic or hypersensitive to substances which didn’t bother him before, like sunlight and chemicals.
For example Papular Pruritic Eruption or the Itchy red bump disease is an allergic reaction to insect bite in which there is an intensely itchy rash that occurs over the trunk and extremities. It is the common skin manifestation of HIV patients in Sub Saharan Africa. 
HIV Rash Symptoms
How does HIV rash look like?
Acute HIV rash
Usually the HIV rashes are maculopapular which gives a red hue to the skin with small elevations on it. The rash is widely distributed in the body 
Picture 3: Early HIV rash
Photo Source: rashresource.com
Molluscum contagiosum rash
- It presents with firm, pink vesicles with umblications.
- These are 3 times bigger in HIV patients than normal individual.
- It remains for a longer time and cause disfigurement in HIV patients 
Picture 4: Molluscum contagiosum in HIV showing umblicated vesicles
Image Source: cdc.gov
Herpes simplex rash
The Herpes simplex rash which occurs concomitantly in a HIV patient during early stages is similar to that of Herpes simplex in normal people.
The rash appears like a red target with well defined border and has slight elevations. The rash contains fluid filled vesicles, which breaks down to form ulcer. It is very painful. [6, 8]
Picture 5: Herpes simplex rash around the mouth
Photo Source: depts.washington.edu
The rash presents with fluid filled bumps which are very painful. The bumps may break down and form crusts on the skin.
Picture 6: Herpes zoster rash showing cluster of fluid filled vesicle on an erythematous base.
Photo Source: aafp.org
The rash caused by anti HIV drugs are similar to that caused by measles. It is red in color of size 2 -10 mm and appears within a week of starting the medication.
Picture 7: Skin rash due to anti HIV drug Lamivudine
Image Source: ijp-online.com
The associated symptoms in Acute HIV infection are 
- Lymph gland enlargement
- Sore throat
- Loose stools
- Runny nose
- Body aches
The associated symptoms in an allergic reaction are
- Difficulty in breathing
- Kidney damage
HIV Rash Location
Acute HIV rash
Commonly the rashes appear on upper body, shoulder, face and chest, sometimes on feet and hand. But a rash can appear almost anywhere in the body.
Molluscum contagiosum rash
The rash appears in the limbs and upper body in children while it is present in inner aspect of thigh, abdomen and genitals suggesting that it is transmitted sexually.
Herpes simplex rash
Rash caused by herpes simplex 1 is found around the mouth and lips and herpes simplex2 causes rash in the genitals.
Herpes Zoster rash
The rash is confined to the part of skin supplied by the same nerve. It appears simultaneously in limbs of both sides and then move towards the trunk. In individuals with HIV, the distribution of the rash is more extensive 
Rashes caused by Anti retroviral drugs are present in the upper body and in the limbs near the body. Usually they are not present in face.
Does HIV rash itch?
The rash caused by acute HIV infection resembles eczema. But it doesn’t cause itching. The rashes which are caused by opportunistic infections and drugs in the later stage of HIV infection are associated with itching.
Sometimes, a rash which is not itchy initially may begin to itch after taking a faulty medication. So it is necessary to consult a clinician immediately after the appearance of a rash to find the cause and treat it accordingly.
How long does HIV rash last?
Acute HIV rash
The HIV rash which is appears within 6 weeks of exposure to the virus lasts for few weeks and resolve spontaneously.
Usually a single lesion of Molluscum contagiosum lasts for 2 months. It may last longer in case of immunocompromised condition like HIV.
The rash occurs repeatedly. Antibiotic treatment for a period of 14 days maximum is needed to reduce the recurrence rate 
In most conditions, the rashes resolve in 2-3 weeks. But in people with HIV, the rashes take awfully longer duration to get cured and have more chance of recurrence.
The rashes caused by Anti – HIV medications range from mild to severely life threatening. The mild rash appears within 2 weeks of using the medications and they disappear within weeks without any treatment.
But very rarely some medication like Nevirapine causes serious skin lesions like Steven Johnson Syndrome and toxic epidermal necrolysis and affects at least 30% of the total surface area of the skin and may cause death [1, 2].
Treatment of HIV Rash
- Wear light and loose clothes
- Avoid hot showers and exposure to warm sun
- Avoid using new chemical based products which you have never used before
- Get immediate medical help when the rash persists or if associated with other symptoms.
- Liquid nitrogen and Laser treatment for rash associated with Molluscum contagiosum
- Antiviral medication for rash associated with Herpes Simplex and Herpes Zoster.
- Chemotherapy, Radiotherapy and Surgery is the choice for Kaposis Sarcoma
- In case of rashes caused by medication, it can be discontinued and another group of drug can be tried.
- Nevirapine is the most commonly used drug in pregnancy. Physicians have to consider all conditions that could cause rash in pregnancy and make a justifiable decision of continuing the medication for its advantages over a mild discomfort like rash.
Other skin lesions in HIV: [3, 7]
- Seborrheic dermatitis
- Atypical presentation of measles
HIV is a serious and complicated disease with uncommon presentations of common diseases. So, it is important for people with high risk of acquiring HIV and for individuals who have been diagnosed with HIV, not to ignore the subtle and confusing symptoms like rash and fever. Every medical decision and medication should be taken only after consultation with a clinician.
- Davidson 22/e pg 318