Rashes and other dermatological conditions have long been linked to HIV — according to the Mayo Clinic, before the advent of highly effective HIV therapies, as many as 92 percent of people with the virus experienced skin symptoms at some point.

A rash can still be one of the first signs of HIV. Other skin conditions related to HIV/AIDS include:

Dry skin
Rosacea (discoloration and small bumps in the center of the face)
Dandruff
Warts from HPV (human papillomavirus)
Sores or blisters from a herpes virus
Skin cancer
Anal cancer

All of this explains why a dermatologist is an important part of an HIV care team.

“Every Tuesday, we have dermatology [our dermatology specialists] see people with HIV because there are so many skin manifestations of the disease,” says Monica Gandhi MD, the medical director of the Ward 86 HIV Clinic at San Francisco General Hospital. “We consider it part and parcel of giving care. Skin is a big part of HIV.”

Dry Skin, Facial Blemishes, and Dandruff Can Be Part of Life With HIV

According to Dr. Gandhi, the most commonly prescribed medications for HIV worldwide are integrase strand transferase inhibitors, such as dolutegravir or bictegravir, usually combined with medications called nucleoside reverse transcriptase inhibitors (NRTIs).

The medications prevent the virus from converting RNA into DNA, which keeps it from replicating. “By blocking viral replication, the virus stays at very low levels in the body and does not decrease important immune cells called CD4 cells, which fight infection,” Gandhi says.

But even people with well-managed HIV can experience skin problems. “Because of advances in medications, the skin issues are now mostly dry skin, rosacea [discoloration and small bumps in the center of the face], and dandruff, rather than the really bad issues associated with immunosuppression,” says Gandhi.

Gandhi recommends talking to a dermatologist about moisturizers and other reputable products you can use to alleviate skin symptoms of HIV.

If that’s not enough, “Please ask your doctor about a change in medication if needed,” Gandhi says.

Sores and Warts Can Also Be Concerns With HIV

Having HIV can increase outbreaks from other viruses that affect the skin, such as HPV.

“I have a lot of patients who are doing great with their HIV, but they are struggling with HPV because at some point they had HPV when they also had a low CD4 count, and that virus can really cause some damage,” says Carrie Kovarik, MD, a professor of dermatology and infectious diseases at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

Dr. Kovarik says that warts around the nail folds, mouth, or genitals are common in people with HPV and HIV who had low CD4 counts at some point. “HPV can do a lot of damage when your CD4 count is low. Even if the patient is healthy now, they can have a lot of issues if they have HPV,” she says.

Kovarik adds that skin issues can become a particular problem if people with HIV — even well-managed HIV — start taking immunosuppressant medication for another condition, such as rheumatoid arthritis. This could trigger outbreaks of HPV or herpes viruses such as herpes zoster (which causes shingles blisters) and herpes simplex 1 and 2 (which result in sores on the lips, mouth, or genitals).

“I tell my patients that you need to talk to your HIV doctor before you go on other medications,” Kovarik says.

HIV Increases Risk for Skin and Anal Cancer

Some strains of HPV can also cause cancers that can be screened for during a skin check. According to Kovarik, the most common among people who have both HIV and HPV is anal cancer.

“That’s external, so that’s our area as dermatologists,” she says, adding that men who have sex with men (MSM) face a ninefold increase in anal cancer risk when their sex partners have HIV, compared with MSM whose sex partners do not have HIV.

Having HIV also increases the risk for nonmelanoma skin cancers, specifically basal cell carcinoma and squamous cell carcinoma.

According to a research paper published in 2019 in the journal Cancer Treatment and Research, 25 percent of human cancers are caused by viruses and bacteria, which impact the immune system. People whose immune systems are suppressed, including those with HIV or AIDS, are at significantly higher risk for cancers caused by viruses or bacteria.

Aside from HPV, certain types of herpes viruses can also cause cancers of the skin, liver, lung, spleen, and gastrointestinal tract.

According to Johns Hopkins Medicine, kaposi sarcoma, a disease that causes cancer cells to form in the skin or in the mucous membranes that line the gastrointestinal tract, is always caused by human herpesvirus 8, also known as kaposi sarcoma–associated herpesvirus (KSHV). People with AIDS are 20,000 times more likely than those in the general population to have KSHV.

“It can occur even in people with higher C4 counts, and it’s a cancer that’s treated with chemotherapy,” says Gandhi. “If you have purplish splotches on your skin, you want to be evaluated.”