Guidelines for treatment of skin diseases in children with HIV infection

Abstract

Bacterial infection. Bacterial skin infections, including impetigo, ecthyma, and cellulitis, may occur in the child with HIV infection. Most skin lesions are caused by infection with staphylococci or streptococci; if there is doubt as to the cause of the skin infection, a skin biopsy specimen should be taken for both culture and histologic examination. Obvious impetigo may be treated with appropriate oral antibiotics effective against both staphylococci and streptococci; most HIV-infected children will require hospitalization and intravenous antibiotic therapy effective against staphylococci and streptococci for therapy of more involved skin infections. Candidiasis. Oral thrush and recalcitrant monilial diaper dermatitis are the most common mucocutaneous manifestations of HIV infection in children. Monilial infection also may involve intertriginal areas (axilla, neck folds) and the proximal nail folds (paronychia). In addition to topical therapy, a therapeutic regimen for these infections may include oral therapy to eradicate a gastrointestinal source of the fungus. The first line of therapy for oral thrush during infancy consists of nystatin solution (100,000 U/ml) in a dose of 1 to 2 ml four times per day. In older children clotrimazole troches may be more effective. For infants who do not respond to nystatin, these troches also may be inserted into a plastic nipple and used four times a day as a pacifier. Ketoconazole at 5 to 10 mg/kg /day or fluconazole (not licensed for use in children) at 3 to 6 mg/kg /day may be required for the treatment of oral thrush that does not respond to these measures. The development of feeding difficulty or dysphagia in the child with oral thrush may signal the presence of candidal esophagitis. Topical nystatin or an imidazole cream are effective in treating candidal infection of the skin. Dermatophyte infection. Children with HIV infection may develop severe or widespread tinea corporis or tinea capitis. The presence of fungal infection should be verified by either a potassium hydroxide preparation or a fungal culture. Tinea corporis may be treated with twice daily application of an imidazole cream. Tinea capitis will not respond to topical antifungals and requires a 4to 6-week course of oral griseofulvin 10 to 20 mg/kg/day. Viral infection Herpes simplex. Severe, chronic, or recurrent infection with herpes simplex virus is a complication of HIV infection in children. The most common presentation is the development of severe and persistent erosions of the lips and tongue. However, vesicular and ulcerative lesions of the fingers and other cutaneous surfaces sometimes are seen. Any chronic ulcer of the mouth or skin should be cultured for herpes simplex.