Sir,

Pruritic papular eruption (PPE) described in HIV is a skin disease often encountered in HIV-positive patients. It is most often a sign of severe immunodeficiency and is commonly reported in African, Southeast Asian, and Indian populations [1,2]. It affects both adult females and males and may also be seen in children. The elementary lesion is a discrete, firm, erythematous, urticarial, very itchy papule of the extremities, face, and trunk, sparing the palms and soles. Painful excoriations in the genital mucosa are sometimes described. The CD4⁺ lymphocyte count (CD4) is usually below 250 cells/mm³. Histopathology reveals a lymphohistiocytic, inflammatory, perivascular, and periannexal infiltrate with a variable number of eosinophils. According to the World Health Organization (WHO), it is recommended to all HIV patients with antiretroviral therapy (ART), regardless of the staging and the CD4 count [3]. However, an elective treatment for PPE has not yet been found. Regression has been noted in some cases after the initiation of antiretroviral therapy. UVB therapy seems to be the most successful method in cases not improving with antiretroviral therapy [4]. Herein, we report the case of a patient who presented with PPE revealing HIV.

A 42-year-old patient presented with itchy, papular eruption persistent for over one year, worsening with topical steroids. A clinical examination revealed erythematous papules and urticarial plaques, some of which were purpuric and located on the trunk, limbs, and face (Fig. 1). Also, the presence of pustules on the nose, forehead, and arms, without palmoplantar involvement was noted. A mucosal examination showed hairy leukoplakia of the tongue (Fig. 2) and two erosions on the penis. The patient also had recurrent episodes of bronchitis and diarrhea. A blood examination was performed, which returned positive for HIV. A skin biopsy was performed showing marked hyperkeratosis with parakeratosis and keratotic, follicular plugs, also mild to moderate inflammatory infiltrates of the perivascular dermis, including eosinophils, lymphocytes, and histiocytes (Fig. 3), confirming the diagnosis of PPE related to HIV. A biological assessment showed a CD4 count of 234, and antiretroviral therapy was initiated.

	Figure 1: Erythematous papule and urticarial plaques of the limbs.
	Figure 2: Hairy leukoplakia of the tongue.
	Figure 3: Marked hyperkeratosis with parakeratosis and keratotic, follicular plugs, also mild to moderate inflammatory infiltrates of the perivascular dermis, including eosinophils, lymphocytes, and histiocytes (H&E; 50×).

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