The incidence of skin diseases in people with HIV has declined significantly over the past decade, but some patient groups remain at a higher risk, particularly for cutaneous malignancies (CM), according to a longitudinal study of a predominantly Black population of people with HIV.

The study, published online in the Journal of the American Academy of Dermatology, included 11,738 adults enrolled in the DC Cohort, a longitudinal study of people with HIV in Washington, DC, between 2011 and 2023. This is “the first longitudinal study to report declining incidence” of major dermatologic diseases in a predominantly Black HIV cohort, according to the study authors, led by Yagiz Matthew Akiska, BSE, a fourth-year medical student at George Washington School of Medicine and Health Sciences, Washington, DC.

The median age of participants was 46.9 years; almost two thirds (62.7%) were Black non-Hispanic, 71.3% were cisgender males, and 61.1% were treated primarily at community sites. The median time since they had been diagnosed with HIV was 9.5 years.

In the study, 49.4% of participants had at least one dermatologic diagnosis, but from 2011 to 2024, the incidence of dermatologic disease per 1000 persons declined across all dermatologic disease categories. During this period, the incidence of infectious dermatologic conditions dropped from 463 to 41 per 1000 persons, inflammatory dermatologic diseases dropped from 306 to 62 per 1000 persons, and malignant skin conditions dropped from 31 to 6 per 1000 persons (P < .0001 for all).

“The decline in new dermatologic diagnoses reflects major advances in HIV management,” although despite improvements, the results also show that “nearly half of people with HIV continue to experience at least one skin condition,” Akiska told Medscape Dermatology.

Senior author Adam Friedman, MD, professor and chair of dermatology at the George Washington University, Washington, DC, noted that the study is one of the largest evaluations of dermatologic disease in people with HIV in the era of modern antiretroviral therapy (ART). “Prior work was smaller, older, or single condition,” Friedman told Medscape Dermatology. “This study links longitudinal HIV care data to broad dermatologic outcomes at scale.”

He attributed the decline in the incidence of dermatologic diagnoses among people with HIV over the past decade to several factors, including earlier diagnosis, sustained viral suppression, and immune reconstitution with modern ART, “all of which reduce opportunistic and infectious dermatoses,” Friedman said. “It’s a real-world signal that HIV care advances translate to fewer new skin problems, while still reminding us that overall prevalence remains high.”

Types of Dermatologic Conditions

Among the types of skin diseases reported in study participants, infectious conditions were the most prevalent, affecting 41.5%. The most common infectious disease was dermatophytosis (19.9%), followed by herpes simplex virus (13%), viral warts (12.3%), and candidal infections of the skin and nails (7.7%).

Inflammatory dermatosis affected 28.2% of the patients in the study; the most frequent manifestations were rash and nonspecific eruptions in 18.8%. CM was reported in 5.8% of participants, with human papillomavirus-associated squamous cell carcinoma the most common malignancy (2.8%).

Among the patients with dermatologic diagnoses, 60.2% had infectious conditions only, while 17.3% had combined infectious and inflammatory conditions. People who only had inflammatory conditions had the highest CD4 count at diagnosis: a median of 607 cells/mm³. The use of ART was lowest among those with CM and infectious conditions (65%) and was highest among the patients with inflammatory-only skin conditions (77.9%).

Where people received care also seemed to factor into dermatologic diagnosis patterns, the study found. Those who received care at academic centers had about 20% lower odds of being diagnosed with infectious or inflammatory skin conditions than those treated at community centers. Compared with those who had private insurance, those with public insurance were about 30% more likely to develop infectious conditions and 45% more likely to have inflammatory skin conditions.

Those trends point to “structural barriers — specialty access, referral pathways, social determinants — rather than biology alone,” Friedman said.

With regard to risk for CM, odds were increased for cisgender females (adjusted odds ratio [aOR], 6.57) and people with opportunistic infections (aOR, 2.51). Higher risks for CM were also found in older patients per 10-year increments (aOR, 1.15) and those whose HIV transmission risk factor was male-to-male sexual contact (aOR, 1.52).

“Older adults with HIV also deserve attention given cumulative ultraviolet exposure and aging-related risks observed in other datasets,” Friedman commented. “We need to prioritize proactive screening and streamlined dermatology access for publicly insured and community site patients and keep a low threshold to evaluate chronic/atypical lesions in older people with HIV.”

Lower odds for CM were found among Black non-Hispanic individuals (aOR, 0.40) and Hispanic (aOR, 0.25) individuals and those with a nadir CD4 count greater than 500 cells/mm³ upon enrollment (aOR, 0.61).

Clinical Implications

“Even in 2025, when ART is highly effective, skin disease remains common in people with HIV, and who you are and where you get care matters,” Friedman said. “We saw a marked decline in new dermatologic disease diagnoses over time, but a persistent, inequitable burden concentrated in patients seen in community settings and those with public insurance.”

The study underscores that dermatology must be integrated into HIV care “with deliberate attention to access and equity,” he said.

For dermatologists, the study carries two key messages, Akiska added. “One, screen broadly, not selectively. Skin disease remains common even among virally suppressed patients,” and all people with HIV should have routine, comprehensive skin assessments, not only those with advanced disease, he said. “Many conditions in the ART era can still occur despite immune recovery.”

Dermatologists also need to think beyond opportunistic infections, Akiska said. “Chronic inflammatory and neoplastic/malignant skin conditions are prominent and deserve proactive management within HIV clinics,” he added. “As people with HIV live longer with effective viral suppression, dermatologists should anticipate a shifting burden toward age-associated skin conditions and ensure surveillance and prevention are integrated into long-term HIV care.” 

As the population of people with HIV ages, Akiska added, “dermatologic surveillance and access must evolve in parallel, integrating more dermatology pathways, such as teledermatology and colocated care models, to reduce gaps for publicly insured and community-managed patients.”

Strengths of the study, Friedman said, are its large, real-world, longitudinal cohort; linkage to routine HIV care across a city; and its ability to compare community vs academic settings and payer type.

He acknowledged limitations of the study, including its reliance on electronic health records/claims-style data, which, he said, are “only as good as the practitioners’ coding and capture.” Other limitations included the potential for dermatology encounters outside participating sites being missed in the data and the nature of its observational design that could not prove a cause behind the declining incidence of dermatologic disease in people with HIV.

Asked to comment on the results, Claire Hannah, MD, assistant professor of dermatology, University of Pennsylvania, Philadelphia, who was not an investigator, said that the study provides “timely, contemporary data” on dermatologic disease in people with HIV, an area where information in the modern ART era is still surprisingly limited. “Skin disease continues to contribute significantly to morbidity and quality-of-life concerns for people living with HIV, so updated epidemiology is essential to ensure dermatology remains a central part of comprehensive HIV care,” she told Medscape.

“Importantly, this study includes a predominantly Black population and examines malignancy and inflammatory disease in skin of color, an area where there are critical knowledge gaps and well-known diagnostic challenges,” she added. “That representation makes the findings more generalizable to the communities most affected by HIV in the United States and highlights the need for equitable access to dermatologic care” for these patients. 

For people with HIV, “prioritizing dermatologic care is an essential and often overlooked aspect of improving long-term outcomes,” Hannah said. “Continuing to research and publish in this space reinforces that comprehensive HIV care must include the skin, and ensures dermatologists remain active partners in improving outcomes for this population.”

She noted that she was struck by how common dermatophyte infections were in the study cohort, an important reminder to maintain vigilance for fungal disease when evaluating people living with HIV. “While I certainly see these in practice, I would not have expected them to be among the most frequent skin infections in this population,” she added.

Akiska and Friedman reported having no relevant financial relationships. No study funding was mentioned, but the DC Cohort study was supported by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. Hannah had no disclosures.

Richard Mark Kirkner is a medical journalist based in Philadelphia.