Cutaneous manifestations of immune reconstitution inflammatory syndrome

The introduction of highly active antiretroviral therapy (HAART) has altered the pattern of dermatologic disease among HIV-infected patients. While the majority benefit substantially from highly active antiretroviral therapy-induced immune recovery, a subset of patients experience unmasking of new skin disease or paradoxical worsening of existing dermatologic conditions, attributable to immune reconstitution inflammatory syndrome. We review the current literature regarding the dermatologic manifestations of immune reconstitution inflammatory syndrome.

Cutaneous immune reconstitution inflammatory syndrome is described in association with a range of infectious, inflammatory, neoplastic, and autoimmune disorders. The list of skin manifestations of immune reconstitution inflammatory syndrome continues to grow, with current literature highlighting the emergence of tropical skin diseases, such as leishmaniasis and leprosy, presenting in the context of immune recovery. Increasingly, we are recognizing common skin eruptions such as acne may be associated with immune reconstitution inflammatory syndrome. There are also recent descriptions of previously unreported presentations of well established immune reconstitution inflammatory syndrome-related conditions. These include Mycobacterium avium presenting as cutaneous ulceration and an epidermodysplasia verruciformis-like eruption of warts. Additionally, authors are attempting to define the unique immunopathology associated with immune reconstitution inflammatory syndrome in the context of specific cutaneous diseases.

Optimal management depends on recognition of immune reconstitution inflammatory syndrome as a unique syndrome by healthcare providers, rather than a failure of highly active antiretroviral therapy or an adverse drug reaction. Our understanding of dermatologic immune reconstitution inflammatory syndrome continues to evolve as the diversity of reported cutaneous immune reconstitution inflammatory syndrome-associated disorders expands.