Skin Problems

1. Skin Problems Paediatric Palliative Care For Home Based Carers Funded by British High Commission, Pretoria Small Grant Scheme

2. Skin Problems • Common in children with HIV • Often conditions common in all children but more severe • Often first sign of HIV infection / HIV disease progressing • Include: Rashes Slow Healing Itchy skin Boils or abscesses Painful sores Drug reactions Dry skin

3. Issues for a Child • Hygiene dependent on carer • ‘Pick up’ infections • Distressing symptoms • Secondary infections (scratching, picking) • May infect others • Increased risk of skin infections as HIV disease progresses

4. Preventing Skin Problems • Daily washing with soap and water • Dry skin well • Moisturise skin • Wash nappies and clothes regularly • Keep Nails short and clean • Expose skin to sun and air when possible ©TALC

5. Thrush • Extremely common in children with HIV • Caused by Candida infection • Commonly found in nappy area or skin folds • May be painful for a child • May lead to secondary infection ©TALC

6. Managing Thrush • Expose skin to sun and air • Clean area with water • Gentian Violet or Nystatin • Pain relief (Paracetamol) • Wash nappies and clothes well • Refer for medication if no improvement ©TALC

7. Seborrhoeic dermatitis • Infection/ Inflammation of the skin • Highly suggestive of HIV infection • Thick, yellow scales on scalp, face, nappy area, behind ears • May be itchy and sore • May become secondarily infected ©TALC

8. Managing Seborrhoeic Dermatitis • Ensure child has clean, short nails • Wash skin using aqueous cream • Moisturise skin • Pain relief (Paracetamol) • Refer for Chlorpheniramine maleate • Refer as antibiotics or steroids may be required

9. Fungal Infections • Tinea Infections (e.g. Ringworm) • Flat, round, scaly, dry patches • Commonly found on face, trunk, extremities and head (with loss of hair) • May become severe, large, pus-filled patches • Common and highly infectious ©TALC CDC Dr Georg

10. Management of Ring Worm • Wash infected area with soap and water • Ensure thorough hand washing • Apply Whitfield’s Ointment • Refer for oral Griseofulvin treatment (1-3 months!)

11. Dry Skin and Itching • Extremely common in children with HIV • May be very distressing to child • May lead to skin infections • Avoid use of soaps • Bath child in bath oils • Moisturise skin with emulsifying ointments in stead • South Coast Hospice’s ‘Itch cream’ • Keep child’s nails clean and short

12. Chicken Pox • Caused by Varicella Zoster virus • Rash, developing to crusts • Found all over body, particularly on trunk • Commonly itchy and painful • Highly contagious (spread by contact with sores and secretions) • Much more severe than usual chicken pox CDC/J.D. Millar

13. Managing Chickenpox • Pain relief • Thorough hand washing • Keep child away from young, sick, or elderly people • Acyclovir treatment • Symptom relief with Calamine, Chlorpheniramine maleate • Wash clothes well • Antibiotic treatment if infected

14. Complications of Chicken pox Complications may occur • Secondary bacterial infections • Haemorrhagic chickenpox • Pneumonia • Encephalitis Refer to Clinic/Hospital depending on presence of danger signs ©TALC

15. Shingles (Herpes Zoster) • Child has had chicken pox before • If immune system weakens, the chicken pox virus returns as shingles • Extremely painful blisters, in cluster or line along the line of a nerve • Usually down leg, arm, neck, chest, face, may involve eye • Suggestive of HIV in a child ©TALC ©TALC

16. Management of Shingles • Analgesia (Paracetamol, Codeine) • Oral/IV acyclovir • Isolate child from sick, young, elderly • Hand washing • For itch: Calamine, Chlorpheniramine maleate • If infected: Antibiotic treatment (Amoxycillin / Flucloxacillin)

17. Scabies • Common in all children • Very itchy bumps all over body • Caused by tiny mites which tunnel under the skin • Commonly between fingers and toes, in wrist-folds, around waist, on genitals, palms & soles of feet • Scratching causes infection, producing sores with pus • Symptom relief with Calamine/Chlorpheniramine maleate

18. Abscesses • Children with HIV commonly get abscesses • Any child with an abscess must be referred for investigation and treatment ©TALC ©TALC

19. Molluscum • Flesh-coloured, dome-shaped growths • Vary in size from 3mm – 1cm • Often indicate advanced HIV disease • Commonly occur on the face and can be extremely disfiguring • Refer child

20. Drug Reactions Children with HIV take lots of drugs A child may react to these drugs: • Exfoliating skin rash • Fever • Severe pain • Risk of dehydration and malnutrition More common in infected children: • Taking Co-trimoxazole • Taking anti-TB therapy • Starting ARVs (e.g. Nevirapine, Abacavir)    Refer immediately ©TALC

21. Skin Breakdown Children with HIV are are more likely to get skin breakdown Due to: • Malnutrition • Immobility • Skin infections This can be prevented through: • Good nutrition • Regular turning and good skin care for immobile, bed ridden children • Treatment of skin infections Picture of Skin Breakdown ©TALC

22. Kaposi’s Sarcoma • Most common type of cancer affecting people with HIV • Less common in children than adults but still seen • Pink, red, purple or brown/black, painless, lesions • May start on face, mouth, gums, palate or penis ©TALC

23. Kaposi’s sarcoma May lead to skin infections and painful ulcers May spread to: • GI tract ( assess for blood in stool or abdominal pain) • Lungs (assess for dry, productive cough) Care is usually palliative ARVs may be of benefit

24. Management of Skin Problems • Good Hygiene • Symptom Relief (Paracetamol, Calamine, Chlorpheniramine maleate) • Antibiotic and Antifungal treatment • Prevent secondary infections (short nails, Gentian Violet) • Treatment for secondary infections

25. Summary • Children with HIV commonly get a wide range of skin problems • These can cause intense itching, pain and distress • Preventing skin problems through good hygiene and care is extremely important • Delaying treatment for skin problems makes treatment more difficult and complications may occur