Original Articles

By Dr. B M Shashikumar , Dr. M R Harish , Dr. K Hanumanthayya , Dr. Pradeep V Bhagwat , Dr. Raghavendra Tophakhane
Corresponding Author Dr. B M Shashikumar
Dept. of Dermatology, MIMS,Mandya, - India 571401
Submitting Author Dr. B M Shashikumar
Other Authors Dr. M R Harish
Dept. of Dermatology, Mandya Institute of Medical Sciences,Mandya, Karnataka, - India

Dr. K Hanumanthayya
Dept. of Dermatology, PESIMSR, Kuppam, - India

Dr. Pradeep V Bhagwat
Dept. of Dermatology, KIMS, Hubli, - India

Dr. Raghavendra Tophakhane
Dept. of Dermatology, KIMS, Hubli, - India


HIV, CD4 count, Mucocutaneous manifestations, Candidiasis, Dermatophytosis, Seborrheic dermatitis

Shashikumar BM, Harish MR, Hanumanthayya K, Bhagwat PV, Tophakhane R. CD4 Count: A Monitoring Tool in HIV. WebmedCentral DERMATOLOGY 2012;3(4):WMC003274
doi: 10.9754/journal.wmc.2012.003274

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 22 Apr 2012 02:44:27 PM GMT
Published on: 23 Apr 2012 03:33:42 PM GMT


Background and objectives: Mucocutaneous manifestations are extremely common and varied in HIV infected patients. Their frequencies, pattern and associated factors have been shown to vary from region to region. The present study was done to know the overall prevalence of mucocutaneous manifestations and their relationships with CD4 count among HIV patients.
Methods: This cross sectional study was conducted for a period of one year at Dermatology department and ART centre, KIMS, Hubli. A total of 150 HIV seropositive patients with skin manifestations were included in the study after obtaining their informed consent. Detailed history, thorough physical examination, CD4 count and relevant investigations were done to confirm the mucocutaneous manifestations.
Results: Of the 150 HIV positives, mean age was 34.1years and male to female ratio was 1.73:1. A total of 376 dermatoses were diagnosed with an average of 2.5 conditions per patient and a mean CD4 count was 228cells/mm³. The commonest cutaneous manifestation was infections, especially fungal (34.7%). Oral candidiasis was the most common infectious condition (14%) with mean CD4 count of 159cells/mm³. Increased prevalence of cutaneous manifestations was seen with lowering CD4 counts. Other common infectious conditions seen were staphylococcal skin infections (17.3%), dermatophytosis (12%), HSV (9.3%), HZ (7.3%), and scabies (10%). Seborrheic dermatitis was the most common non-infectious dermatoses (16.7%). Other non infectious dermatoses included PPE (14.7%), generalized xerosis(14%) and ichthyosis (6%). A correlation between the dermatologic manifestations and CD4 cell count was found.
Conclusion: Mucocutaneous lesions are useful clinical predictors of level of immunosuppresion. Correlating CD4 counts to skin lesions could serve as a guide to start and monitor antiretroviral therapy.


The HIV (Human Immunodeficiency Virus) pandemic has wreaked enormous financial, political, and health- related havoc.[1] HIV infection does not affect one organ or one system, but practically affects all the tissues and organs of the human body.  Skin is the most commonly affected organ. Mucocutaneous disorders are often the commonest indicator for initial HIV testing.[2] The incidence and severity of several common cutaneous diseases are increased in patients with HIV and this correlates in many instances with the absolute number of CD4 T-helper cells.[3] The dermatological complications of HIV and AIDS sheds light on both the immunopathological natural history of HIV infection and the etiology of common and rarer dermatoses that happens to be found with a higher incidence in HIV infected patients. Their occurrence emphasizes the importance of the skin as a dynamic immunological organ.[4] Some Indian authors have concluded that the pattern of mucocutaneous involvement in HIV might be different in Indian patients. This study has been taken up since the cutaneous manifestations and their incidence and prevalence in the Indian population has not been studied thoroughly.

Aims and objectives

To describe the various dermatological manifestations in HIV infected patients attending the department of Dermatology and ART centre, KIMS hospital, Hubli and to correlate the dermatological manifestations with CD4 count.


The present study dealt with 150 HIV seropositive patients with skin manifestations selected from the patients attending Dermatology department and ART centre, KIMS, Hubli. Patients were examined with detailed history, physical examination with a special emphasis on cutaneous, mucosal and nail involvement. CD4 count was done in all patients. Also, Patients whose CD4 counts done with in 3 weeks of examination were also recorded. Specific investigations like skin biopsy, culture and sensitivity for bacterial infections, Gram's stain, potassium hydroxide mount and fungal culture were done for the confirmation of diagnosis in doubtful situation. The statistical analysis was done using Chi-square test for non parametrical data and a Student T-test while comparing two groups of unequal variance.


The total number of patients examined during the course of this study was 150. A total of 376 dermatoses were diagnosed with an average of 2.5 conditions per patient and a mean CD4 count of 228cells/mm³. This includes infectious, non-infectious, hair and nail changes, but more often the conditions coexisted. Among the 150 patients studied, 94 (62.7%) were male and 56 (37.3%) were female, age ranging between 4 to 65 years. Majority of the patients were in the age group of 31-40 years (49.3%) with the mean age being 34.1 years. Majority of male patients and only 6 out of 56 female were having multiple sex partners. Heterosexual route was the most common route of transmission seen in 136 (90.7%) followed by vertical in 12 (8%) cases. 2 (1.3%) were bisexuals. No patients of IVDU were observed in this study. Fever and weight loss were the common systemic symptoms with 42(28%) each, followed by cough in 21 (14%), generalized weakness in 10 (6.7%), diarrhea in 9 (6%), headache in 2(1.3%), and loss of bowel and bladder control, CSOM and weakness of limbs in to 1(0.7%) each. Generalized itching was the most common dermatological presenting symptom, seen in 60(40%) patients.
Various mucocutaneous manifestations observed in our study are shown in Illustration 1.The commonest cutaneous manifestation was infections, especially fungal (34.7%). Oral candidiasis was the most common infectious condition (14%) with mean CD4 count of 159cells/mm³. Among non infectious dermatoses, seborrheic dermatitis was seen in 25(16.7%) of patients. Generalized xerosis in 21(14%) patients, generalized ichthyosis in 9 (6%) patients and Pityriasis rosea and Psoriasis in a patient each. Majority of the Seborrheic dermatitis patients presented with diffuse involvement. 32(21.3%) patients had Pruritic papular dermatosis, of which 22(14.7%) had Pruritic papular eruptions and 5(3.3) patients had Insect bite reactions and Eosinophilic folliculitis each. Majority of the patients with PPE were on HAART. Most common ADR was Maculopapular rash, following the administration of Nevirapine, followed by Urticaria (4%) and SJS (2.7%).
Hair changes included diffuse alopecia (Scalp) seen in 11 (7.3%) patients, partial alopecia in 10(6.7%) and spontaneous straightening of hairs in 5 (3.3%) patients. All were predominant in patients with CD4 cell count < 200 cells/mm³. A total of 54 (36.1%) patients had nail changes of which bluish discoloration was the commonest, seen in 19(12.7) patients. Koilonychia was observed in 13 (8.7), followed by longitudinal melanonychia in 9(6%), onychomycosis in 7 (4.7%) and nail dystrophy and subungual hypertrophy in 2 patients each. Of this 54 patients 37 had CD4 count <200 cells/mm³.


Skin disorders are common manifestations of Human Immunodeficiency Virus (HIV) disease; and may be seen in 80% to 95% of HIV infected individuals.[5-8] In this study 96/150 (64%) of patients were having multiple cutaneous manifestations and average manifestation is 2.5 condition per patient. Tzung et al [9] reported an average of 2.2 conditions per patients in his study. Singh[10] et al reported an average of 2.35 conditions per patients with an average of 3.15 conditions in group IV (CDC classification) patients and 1.5 conditions in group II category. In present study average manifestations per patient was more in advanced immunosuppression.
Generalized itching was the most common dermatological symptom observed in 60(40%) patients. A study done by Uthayakumar et al [5] in 151 patient showed a similar prevalence of 43.3% and 56.7% between 2 groups.
Itching in HIV infected persons can be due to infectious causes (Dermatophytes, parasites, bacterial folliculitis) or noninfectious causes (Xerosis, Icthyosis, exaggerated insect bites, eosinophilic folliculitis etc). Pruritus represents a hypersensitivity response to a variety of antigens in patients with HIV infection.[11]
Comparisons of present study with other studies is shown in Illustration 2


Skin is the most commonly affected organ in patients with HIV infection /AIDS. While some cutaneous findings are nearly exclusive to HIV seropositive individuals, many are found in the general population. However, HIV-infected individuals often have an increased prevalence or severity, atypical presentation, or difficulty with treatment of the disease.
The frequency of infections like oral candidiasis, candidal balanoposthitis, histoplasmosis and others were higher at lower CD4 count. Frequency of skin manifestations increased with fall of CD4 count. Pruritic papular dermatitis, hair changes like diffuse alopecia, straight hair, and hyperpigmentation (generalized as well as melanonychia) which are of late described in HIV infected persons were also noted and found to be quite common. In resource crunched country like India, where only a limited number of patients have the means to do viral load estimation, the study of skin disease as a window to the level of immunocompromise gains importance. Correlating CD4 counts to skin lesions could serve as a guide to start and monitor antiretroviral therapy.

List of abbreviations

ADR- Adverse drug reaction
AIDS- Acquired Immunodeficiency syndrome
ART- Anti-retroviral therapy
CSOM- Chronic suppurative otitis media
HAART- Highly active anti retroviral therapy
HIV- Human Immunodeficiency Virus
HSV- Herpes simplex virus
HZ- Herpes zoster
IVDU- Intravenous drug use
KOH- Potassium hydroxide
PPE- Pruritic papular eruption


1. Robert J, MacNeal, James GH. Acute retroviral syndrome. Roy C, editors. Dermatologic clinics of North America .New Delhi:Elsevier 2006:431-38.
2. Johnson RA. Cutaneous manifestations of human immunodeficiency virus disease. In: Freedberg IM,Eisen AZ,Wolff K,Austen KF,Goldsmith LA, Katz SI et al, editors. Fitzpatrick’s Dermatology in general medicine.6th ed. Newyork:McGraw-Hill 2003;2138-49.
3. Waner L C, Fischer B K. Cutaneous manifestation of acquired immunodeficiency syndrome. Int j Dermatol. 1986; 25:337-50.
4. Bunker CB,Gotch F. AIDS and the skin. Burns T,Breathnach S,Cox N,Griffiths C,editors.Rook’s Textbook of dermatology. 7th ed.Oxford: Blackwell science 2005; 26.1-26.41.
5. Uthayakumar S, Nandwani R, Drink Water T, et al. The prevalence of skin disease in HIV infection and its relationship to degree of immunosuppression. Br J Dermatol 1997; 137:595-598.
6. Coldiron BM, Bergstresser PR. Prevalence and Clinical spectrum of skin disease in patients infected with HIV. Arch Dermatol 1989; 125:357-361.
7. Tschachler E, Bergstresser PR, Stingl G. HIV-related skin diseases. Lancet 1996; 348:659-63.
8. Coopman SA, Johnson RA, Platt R, Stern RS. Cutaneous diseases and drug reactions in HIV infection. N Engl J Med 1993;328:1670-4.
9. Tzung T Y,Yang C Y,Chao S C,Lee J Y.  Cutaneous manifestations of human immunodeficiency virus infection in Taiwan.  Kaohsiung J Med Sci. 2004 May; 20(5): 216-24.
10. Singh A, Thappa DM, Hamide A. The spectrum of mucocutaneous manifestations during the evolutionary phase of HIV disease: an emerging Indian scenario. J Dermatol. 1999;26(5):294-304.
11. Shah H, Lakhani J, Trivedi S.  Cutaneous manifestations in HIV seropositive cases in a rural hospital of Gujarat. Indian J Sex Transm Dis 1998; 19 (2): 95-7.
12. Kumaraswamy N, Solomon S, Madhivanan P, Ravikumar B, Thyagarajan SP, Yesudian P.  Dermatologic manifestations among human immunodeficiency virus patients in South India. Int J Dermatol 2000; 39: 192-5.
13. Shobana A, Gucha SK, Neogi K.  Mucocutaneous manifestations of HIV infection.  Indian J Dermatol Venereol Leprol 2004; 70: 82-6.
14. Jing W, Ismail R. Mucocutaneous manifestations of HIV infection: a retrospective analysis of 145 cases in a Chinese population in Malaysia.  Int J Dermatol 1999; 38: 457-463.
15. Brig Sharma Y K, Col Sawhney MPS, Lt Col Bhakuni DS, Gera VM. Orocutaneous manifestations as markers of disease progression in HIV infection in Indian setting. MJAFI2004; 60:239-43.

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4 reviews posted so far

CD4 Count: A Monitoring Tool in HIV
Posted by Dr. Nooshin Bagherani on 18 Jun 2012 11:26:12 AM GMT

will consider changing table 2 thank you... View more
Responded by Dr. B M Shashikumar on 16 Jul 2012 05:21:40 AM GMT

Posted by Dr. Raghunatha R Reddy on 07 May 2012 03:33:42 AM GMT

thank you... View more
Responded by Dr. B M Shashikumar on 16 Jul 2012 05:20:48 AM GMT

CD4 Count: A Monitoring Tool in HIV
Posted by Dr. T S Rajshekar on 25 Apr 2012 04:46:56 AM GMT

thank you... View more
Responded by Dr. B M Shashikumar on 16 Jul 2012 05:20:35 AM GMT

CD4 count: A monitoring tool in HIV
Posted by Prof. Valcinir Bedin on 24 Apr 2012 09:46:57 PM GMT

epidemiology and control will be added in review article thank you... View more
Responded by Dr. B M Shashikumar on 16 Jul 2012 05:20:21 AM GMT

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WebmedCentral Article: CD4 Count: A Monitoring Tool In HIV

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