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: RashesSlow Healing Itchy skinBoils or abscesses Painful soresDrug 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

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

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