Skin problems

Refer to Dermatology for impetigo and scabies, which are also very common in HIV.

Herpes Zoster (shingles)

Presentation Differentials Investigations Treatment
Painful vesicular lesionsresting on a red base in a dermatomal pattern
Not crossing the midline		 Herpes simplex
Chickenpox
Impetigo		 Clinical diagnosis
  • Local care (1% GV paint)
  • Pain relief - Amitriptyline 0.2-0.5 mg/kg nocte if Paracetamol or Ibuprofen insufficient
  • If face affected refer to eye specialist as soon as possible
  • Acyclovir*
  • Antibiotics if superinfected

N.B. Herpes Zoster is contagious. This is also important in the case of a parent with shingles. Advise parents to keep the area covered.
In case of facial lesions: no kissing.
In case of herpes zoster on the breast of a breastfeeding mother: expressed breast milk advisable.

Varicella Zoster (chicken pox)

Presentation Differentials Investigations Treatment
Crops of macules, papules and vesicles, followed by crusting. Lesions may often be in different stages simultaneously. May be presceded by or associated with fever, generl malaise and body pains Herpes zoster
Scabies		 Clinical diagnosis
  • Acyclovir*
  • Calamine lotion BD

N.B. Chicken pox is highly contagious!
If patients present in clinic: try to see them as soon as possible (avoid waiting areas), preferably in a separate room.
If patients are admitted, admit them in the isolation room.

* Ideally treat all immunocompromised patients with acyclovir. Acyclovir dose: preferably started within 96 hours. Use IV Acyclovir if available (dose - 10mg/kg/dose TID), if not use PO 20mg/kg/dose QID (max dose 800mg) x 1 week or until all lesions resolve if still present after one week of treatment.

Drug-related skin rashes - mild/moderate

-> Not involving mucous membranes, nor skin blistering and patient clinically stable.

While antimicrobial drugs are commolny implicated, any drug can cause skin hypersensitivity. Suspected drugs should be those started within the last 14 days.

Presentation Differentials Investigations Treatment

Erythematous rash, sometimes urticaria

Causes of drug reactions consider:

  • Co-trimoxazole
  • Nevirapine
 Viral exanthematous rash Clinical diagnosis If very mild: observe with low threshold to admit the patient
Avoid systemic drugs, treat with topicals

Drug-related skin rashes - severe

Presentation Differentials Investigations Treatment
Stevens Johnson syndrome: mucous membranes (eyes, mouth) involved, fever, hypotension

Causes - Drugs:

  • Co-trimoxazole
  • Nevirapine
  • SP
  • Anticonvulsants
  • NSAIDs
  • Varicella
  • Staphylococcal scalded skin syndrome
  • Measles
 Clinical diagnosis Admit the patient
Stop nevirapine, continue the two NRTIs for one week, then stop all drugs until rash is completely settled.
Restart using EFZ instead of NVP.
Supportive care:
  • Careful handling of the skin to avoid denuding the skin further
  • fluids IV or NGT feeds
  • monitor closely for secondary skin infection
  • consult dermatologist
  • consult ophthalmologist
  • Sufficient Analgesia