Skin cancer in HIV
Cutaneous oncology in people living with HIV; HIV-related skin cancer; "AIDS-defining and non-AIDS-defining cancers" of skin
People living with HIV have a substantially elevated risk of multiple skin cancers โ both AIDS-defining malignancies (Kaposi sarcoma, certain non-Hodgkin lymphomas, cervical / anal SCC) and non-AIDS-defining malignancies (cutaneous SCC, BCC, melanoma, Merkel cell carcinoma). The introduction of effective antiretroviral therapy (ART) has dramatically reduced the incidence of AIDS-defining cancers โ particularly Kaposi sarcoma โ but the lifetime cancer risk in people with HIV remains elevated due to a combination of (1) chronic immune activation despite virological suppression; (2) ageing of the HIV cohort; (3) high-risk co-infection with oncogenic viruses (HPV, EBV, KSHV/HHV-8, hepatitis B/C); and (4) lifestyle co-factors (tobacco, UV exposure). Comprehensive skin cancer surveillance โ full skin examination, anogenital examination, cervical cytology, anal cytology / HRA in high-risk subgroups โ is now embedded in UK BHIVA / NHS HIV-care pathways. Treatment generally follows standard skin oncology principles with consideration of immunosuppression, drug interactions and immune reconstitution syndrome.
Kaposi sarcoma โ AIDS-defining
- HHV-8 (KSHV) co-infection drives AIDS-related Kaposi sarcoma โ the prototypical AIDS-defining cancer.
- Incidence dramatically reduced by effective ART; remains over-represented in late presenters and patients with persistent immune dysregulation despite virological suppression.
- Cutaneous patches / plaques / nodules; oral mucosal involvement; visceral KS (lung, GI) in advanced disease.
- First-line treatment โ optimisation of ART; localised disease may regress with immune reconstitution. Systemic therapy (liposomal doxorubicin, paclitaxel, pomalidomide) for visceral / progressive disease โ see monograph.
HPV-driven anogenital and oral cancers
- Substantially elevated risk of HPV-driven SCC and pre-malignant intraepithelial neoplasia at all squamous mucosal sites:
- Anal SCC and AIN โ particularly in MSM with HIV; the ANCHOR trial 2022 supports active treatment of anal HSIL โ see AIN.
- Cervical SCC and CIN โ annual cervical cytology in HIV-positive women.
- Vulval / vaginal SCC and VIN โ see VIN.
- Penile SCC and PeIN โ see erythroplasia of Queyrat.
- Oropharyngeal / oral cavity SCC.
- Conjunctival SCC โ particularly in equatorial Africa.
- HPV vaccination should be offered to HIV-positive patients up to age 45.
- Active screening programmes โ cervical, anal (HRA in high-risk), oral.
Non-melanoma skin cancer (NMSC)
- Cutaneous squamous cell carcinoma โ lifetime risk 2โ5ร higher in HIV; behaviour more aggressive (multifocal, faster growth, higher metastatic risk) than in immunocompetent patients; particularly in late presenters with prolonged immunosuppression. Treatment per cSCC monograph with consideration of cemiplimab for advanced disease (used cautiously given underlying immune dysregulation but generally well tolerated).
- Basal cell carcinoma โ incidence increased; behaviour generally not more aggressive; Mohs micrographic surgery for facial / high-risk lesions.
- Field damage โ multiple actinic keratoses and Bowen's disease; aggressive field treatment.
Melanoma
- Incidence modestly increased (~1.5โ2ร general population).
- Stage at presentation tends to be more advanced โ likely a combination of behavioural and surveillance factors rather than HIV-specific biology.
- Treatment โ standard surgical management; checkpoint inhibitor immunotherapy (anti-PD-1 ยฑ anti-CTLA-4) is increasingly used in HIV-positive patients with metastatic melanoma; small but growing evidence base supports comparable safety and efficacy to HIV-negative patients on stable ART with CD4 >200.
Cutaneous lymphoma in HIV
- Aggressive cutaneous T-cell lymphomas โ over-represented; particularly the aggressive cytotoxic CTCL variants (ฮณฮด TCL, CD8+ Berti) โ see ฮณฮด-TCL and CD8+ Berti.
- HHV-8-driven lymphoproliferative disorders โ primary effusion lymphoma, multicentric Castleman disease.
- EBV-driven lymphoma โ diffuse large B-cell lymphoma (often with cutaneous involvement), plasmablastic lymphoma.
Management principles
- Multidisciplinary care โ HIV / GUM specialist, dermatology, oncology, gynaecology, ENT, plastic surgery, palliative care.
- Optimise ART โ virological suppression and immune reconstitution are the foundation of all cancer prevention and treatment in HIV-positive patients.
- Skin cancer surveillance:
- Annual full skin examination from age 30 (earlier if photodamage); 6-monthly if previous skin cancer.
- Lower threshold for biopsy.
- Annual cervical cytology (women).
- Annual anal HRA in MSM with HIV (consider in other high-risk groups).
- Annual oropharyngeal examination.
- Conjunctival examination.
- Photoprotection โ daily SPF 50+; sun-protective clothing.
- Smoking cessation โ smoking is the leading modifiable risk factor for non-AIDS-defining cancer in HIV-positive patients.
- HPV vaccination for HIV-positive patients up to age 45.
- Vaccination against hepatitis B; manage hepatitis C.
- Drug interactions โ careful review of ART and any chemotherapy / targeted therapy / hormone therapy for skin cancer (CYP3A4 interactions with protease inhibitors, NNRTIs, integrase inhibitors).
- Immune reconstitution inflammatory syndrome (IRIS) โ Kaposi sarcoma can paradoxically worsen following ART initiation in patients with low CD4; monitor closely.
References
- Silverberg MJ et al. HIV infection, immunodeficiency, viral replication, and the risk of cancer. Cancer Epidemiol Biomarkers Prev; 2011.
- BHIVA / BASHH / Faculty of Sexual & Reproductive Healthcare guidelines on cancer surveillance in HIV.
Spot a correction?
If any clinical statement, citation or link on this page needs updating, please email admin@skinoncology.net with the page name, the proposed correction and the supporting source.