Skin Problems Paediatric Palliative Care For Home Based Carers Funded by British High Commission, Pretoria Small Grant Scheme 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 Itchy skin Painful sores Dry skin Slow Healing Boils or abscesses Drug reactions 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 1
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 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 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 2
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 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 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, pusfilled patches Common and highly infectious CDC Dr Georg 3
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!) 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 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) CDC/J.D. Millar Much more severe than usual chicken pox 4
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 Complications of Chicken pox Complications may occur Secondary bacterial infections Haemorrhagic chickenpox Pneumonia Encephalitis Refer to Clinic/Hospital depending on presence of danger signs 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 5
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) Common in all children Scabies 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 Abscesses Children with HIV commonly get abscesses Any child with an abscess must be referred for investigation and treatment 6
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 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 Skin Breakdown Children with HIV are are more likely to get skin breakdown Due to: Malnutrition Immobility Skin infections Picture of Skin Breakdown This can be prevented through: Good nutrition Regular turning and good skin care for immobile, bed ridden children Treatment of skin infections 7
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 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 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 8
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 9