Here's How Hair, Skin, and Nails Can Be Affected By HIV Medications

By Emily Rekstis

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When someone is diagnosed with human immunodeficiency virus, or HIV, they may notice flu-like symptoms and other persistent health concerns due to the virus' attack on the immune system. This attack can also wreak havoc on one's hair, skin, and nails. "The body's immune system is compromised so the hair, skin and nails are more vulnerable to infections," Rhonda Q. Klein, MD, board-certified dermatologist and co-founder of Modern Dermatology in Westport, Connecticut. Even though people typically are able to eliminate these symptoms through treatment, the treatment itself may also cause some hair, skin, and nail concerns.

Thanks to clinical research and medical breakthroughs, HIV has become highly manageable. Even though there is still no cure for the virus, which attacks the body's immune system, new treatment regimens can allow people living with HIV to live longer, healthier lives while also lowering the risk of passing HIV to someone else. These regimens, which are a combination of different medicines, are more commonly referred to as an antiretroviral treatment, or ART. It's important to note that the only way to receive these HIV treatments is to get tested to confirm an HIV diagnosis.

Though the appearance of one's hair, skin, and nails side effects may seem minute in the grand scheme of HIV's effects, they can have a direct effect on any person's quality of life. And when you’re fighting to be your healthiest self, these physical side effects can be more than just frustrating — they even can be debilitating. Here, we checked in with experts to get their take on how to handle the symptoms that affect the hair, skin, and nails.

As of 2022, HIV is treated using a combination of medications, which are mostly administered using pills and often in a combination tablet. Some of the most well-known are dolutegravir, bictegravir, and darunavir, but there are dozens of medications that can be combined to build a person's treatment plan.

"[This regimen] works to interrupt viral replication by inhibiting steps in the viral life cycle," says Monica Gandhi MD, MPH, Professor of Medicine and Associate Division Chief of the Division of HIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital. "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."

The goal of these medicines is to help patients reach undetectable status, which means the virus can no longer be detected on an HIV viral load test. Not only does this improve the health of the individual, but it also means there's little to no risk of transmitting HIV to HIV-negative partners through sex. This is why HIV testing is so vital: according to the Centers for Disease Control and Prevention (CDC), every person between the age of 13 and 64 should get tested for HIV as a part of their regular health care routine. For people with certain risk factors such as men who have sex with other men, having sex with more than one partner since the last HIV test, or sharing needles or syringes with other people, the CDC recommends getting tested once a year.

Hair loss has long been associated with HIV, but beyond the virus' effect on hair, there have been a substantial number of cases of antiretroviral-related alopecia. In 1999, a French study first confirmed that hair loss was a side effect of men using the protease inhibitor Crixivan (indinavir). A 2008 article appearing in HIV & AIDS review, the official journal of the Polish AIDS Research Society, noted that while most cases of hair loss in men were related to indinavir, there were also several other reports that show drugs such as lopinavir and ritonavir used in conjunction with saquinavir could be related to hair loss. However, results were too inconclusive to definitely confirm hair loss as a side effect. "We cannot establish whether generalized hair loss in our patient was due to lopinavir or saquinavir alone or both drugs used simultaneously,]" the article reads. "Although generalized hair loss after PIs [protest inhibitors] use is rare, clinicians should be aware of this side effect."

Fortunately, it's been generally accepted that newer antiretrovirals are less likely to cause hairs loss. "Older HIV medications such as AZT, Crixivan, and Atripla, were frequently associated with medication-induced alopecia," says Jason Miller, MD, a board-certified dermatologist at Schweiger Dermatology Group in Freehold, New Jersey, says. "Newer antiretroviral therapies are less likely to lead to hair loss." He continues to note that there are still cases of telogen effluvium, which is when stress causes hair follicles to go into a resting phase. This causes hair to thin and possibly fall out after a couple months. "There are still some cases of telogen effluvium seen with acute HIV or with therapy," he says. "However, these are generally self-limiting."

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Miller says patients who see early hair loss might want to opt for mild shampoos and conditioners. This means no irritants, such as fragrance, and clarifying shampoos should be avoided. To keep things easy, Miller recommends drugstore-favorite Free & Clear.

Skin rashes are a common possible side effect in many medications used in antiretroviral therapy. Although these rashes can appear differently in different people — some may blister while others may take the form of other skin conditions like psoriasis — the most common is a morbilliform drug eruption, according to Dr. Miller: "This is when itchy, red patches develop symmetrically over the trunk and extremities." He notes that less common rashes one may see include localized plaques or those that resemble other diseases such as psoriasis.

"Rashes from ART treatment are common, but typically not dangerous and can be managed for comfort with hydrocortisone cream and medications can be adjusted to avoid further flares," says Dr. Klein. "There are a few rare, but serious, rashes associated with ART drugs, most notably Stevens-Johnson Syndrome (SJS) and hypersensitivity reactions that can be life threatening and may require hospitalization." Stevens-Johnson Syndrome is a rare disorder of the skin and mucous membranes that starts with flu-like symptoms and then a painful rash that blisters and spreads, causing the top layer of skin to die and before healing over several days. SJS is about 100 times more likely to occur in people with HIV than among the general population, so if you develop a painful rash that blisters and spreads, Dr. Klein says you should go to the emergency room for immediate assistance.

Regardless of how mild or severe a rash may seem, always consult with a doctor if you start to see these types of side effects. "These rashes should be examined by your doctor to determine the underlying cause," Dr. Miller says. "Some may be treated symptomatically with topical creams, while more severe rashes may require cessation or change in HIV medication."

If you do experience any flare-ups or skin reactions to the medications, board-certified dermatologist and co-founder of Modern Dermatology in Westport, Connecticut, Deanne Mraz Robinson, MD recommends using gentle products that are great for sensitive skin. This means avoiding irritants such as fragrance, alcohols, and any chemical or physical exfoliants. "Overall I advise my HIV patients to stick with simple, [simple] skincare." Dr. Robinson says. "I like the Vanicream line of products, as well as CLn BodyWash, which is antimicrobial and antifungal but still gentle on the skin."

Just like the hair and skin, nails can be a window into one's health — and if nails begin to change in color or texture, it could provide valuable information for your doctor. One 1998 study found that over two thirds of patients with HIV experienced changes in the nails, mostly caused by fungal infections.

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Changes in the nails can also be a side effect of the medications used in ART. The most common of which is melanonychia, which is a brown-black discoloration on a nail plate that presents itself in a vertical dark line going up the center of the nail. "This can be caused by both the HIV virus itself as well as many of the medications used in ART, which is why it's the most common nail abnormality associated with the virus," Dr. Robinson says. "This nail abnormality is not dangerous and can be associated with other conditions; on its own, it is not indicative of HIV." Even though melanonychia may be persistent, Dr. Miller notes that it usually is temporary and does not require any treatment. However, you should still visit a dermatologist to identify the underlying cause for the pigment discoloration.

Dr. Miller says that other changes in the nails due to medications could include dystrophia (a thickening of the nail plate), nail thinning, clubbing, or loss of the lunula, which is the white moon shape at the bottom of the nail. He says the best way to minimize or avoid these types of nail issues is by avoiding nail traumas such as gel manicures or picking and peeling off layers. He also recommends using nail treatments such as Olive & June Nail Strengthener to treat brittle, thin nails.

Healthy hair, skin, and nails are a factor when it comes to the quality of life for people living with HIV, but it's also important to remember that the medications being prescribed are life-saving. "Do not be worried about occasional changes in the hair and skin with HIV medications, as there are remedies for those," says Dr. Gandhi. In fact, she says she helps many of her female patients who need help strengthening their hair and nail follicles using different products. "I have treated HIV for more than 20 years and have seen only subtle changes in hair and nail thinning that we can easily combat," Dr. Gandhi explains. "If your HIV medications are causing you any concerns about hair and skin, we have a number of treatment options in 2022, and please ask your doctor about a change in medication if needed."

By Gabi Thorne

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No matter what medications are needed, the only way to receive them is to get tested. You can ask your healthcare provider for an HIV test or visit gettest.cdc.gov to find a testing site near you.

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