Vesicles and pustules

INFECTIONS

R23.8/L08.9

See: Varicella (chickenpox) and Zoster.

SKIN AND MUCOSAL DISORDERS IN HIV

Skin and mucosal disorders are more severe in immune suppressed (HIV-infected) patients and may be worsened by IRIS. HIV may present initially with skin or mucosal lesions, or these lesions may develop during the course of the illness.

Lesions respond to antiretroviral therapy together with treatment for the specific skin and/or mucosal disorder. Skin eruptions or rashes are relatively common in HIV patients and may be due to antiretroviral and other medicines.

Conditions that are more common in patients with HIV, and may be present atypically include:

  • Papular pruritic eruption.
  • Kaposi sarcoma.

HIV PAPULAR PRURITIC ERUPTION

T78.4

DESCRIPTION

Chronic itchy condition with a relapsing course. In HIV-infected patients, insect bites may be severe and recalcitrant with post inflammatory pigmentation and scarring.

DIAGNOSTIC CRITERIA

  • Initial lesion is a pruritic urticarial spot with a central red punctum.
  • Lesions progress to pruritic papules with or without blisters. Scratching lesions may cause inflammatory changes, erosions, crusts or scabs with secondary infection.
  • Post inflammatory pigmentation and scarring are common.

GENERAL AND SUPPORTIVE MEASURES

  • Prevent insect bites with use of, insect repellents. Eradicate fleas and other insects.

MEDICINE TREATMENT

  • Calamine lotion, topical, applied as needed.

AND

  • Chlorphenamine, oral, 0.1 mg/kg/dose 6 hourly.

AND

  • Betamethasone 0.1%, topical, applied 12 hourly for 3 days.

THEN, until pruritus subsides:

  • Face: Hydrocortisone 1%, topical applied 12 hourly.
  • Body: Betamethasone 0.1%, topical applied 12 hourly

Treat secondary infection with an appropriate antibiotic, if indicated.

Treatment of HIV. See: Human immunodeficiency Virus Infections.

REFERRAL

  • No response to treatment.

KAPOSI SARCOMA

C46.9

DESCRIPTION
Kaposi sarcoma is a vascular tumour that can present anywhere on the skin and oral mucosa. Lymph nodes and internal organs, primarily lungs and gastrointestinal tract, may also be involved.

It is associated with human herpes virus 8 and occurs most commonly in immunocompromised HIV-infected patients.

It can be asymptomatic and indolent or aggressive, characterised by explosive growth and death.

DIAGNOSTIC CRITERIA

  • Presents with skin lesions on the limbs particularly the lower leg and foot, but may occur anywhere on the body.
  • Lesions (skin and mucosal) may be bruise-like patches, purple or purple-red plaques, subcutaneous papules or nodules.
  • Lymphoedema, ulceration and secondary bacterial infection may occur.

GENERAL AND SUPPORTIVE MEASURES

  • Counselling to assist patient in dealing with the condition.

MEDICINE TREATMENT

REFERRAL

  • All suspected cases for initial diagnosis.
  • Kaposi sarcoma cases unresponsive to ART.
  • Extensive progressive disease.

WARTS

B07

MEDICINE TREATMENT

Common warts

  • Salicylic acid 25% ointment, applied under plaster nightly.
    • Protect surrounding skin with petroleum jelly.
    • Repeat until the wart falls off.

Genital warts

  • Podophyllin resin 20%, applied under plaster nightly.
    • Protect surrounding skin with petroleum jelly.
    • Repeat until the wart falls off.

REFERRAL

  • Extensive warts involving the face.
  • Genital warts: Refer to STI clinic.

IMPETIGO

L01

Refer to the Primary Healthcare Standard Treatment Guidelines and Essential Medicines List, 2014:

CUTANEOUS HAEMANGIOMAS

D18.0

DESCRIPTION

Benign tumours of the vascular endothelium that may be classified as either congenital or infantile. They are characterised by abnormal proliferation of endothelial cells and abnormal blood vessel architecture.

  • Congenital haemangiomas: fully grown at birth, and are either rapidly involuting or non-involuting.
  • Infantile haemangiomas: Usually appear before 4 weeks of age and continue to grow until 5 months.

DIAGNOSTIC CRITERIA

  • Most haemangiomas can be diagnosed clinically.

GENERAL AND SUPPORTIVE MEASURES

  • Counselling to assist patient in dealing with the condition.

REFERRAL

  • Life-threatening haemangiomas (airways), function-threatening haemangiomas, ulcerating lesions; for consideration of propranolol.
  • Diagnostic uncertainty.
  • Failure to respond to therapy.
  • Peri-ocular haemangioma.
  • Suspected airway haemangioma.
  • Large segmental haemangioma on face, neck, or vital organ for echocardiogram.
  • Propranolol pre-treatment evaluation reveals cardiac or pulmonary abnormalities.
  • Multiple haemangiomas (> 5 lesions).