30 - Dermatology (Skin Disorders)
- If generalized, symmetrical, small, painless lymph nodes and the patient’s general condition is not bad, just do nothing. This condition is common for the "last step HIV patient". Drugs often give more symptoms than the lymph nodes... And patients have often to take too many drugs already.
- If generalized, symmetrical, small PAINFUL lymph nodes, and/or a bad general condition without known cause, try fluconazole 200mg 1tab 2x/day after meal or other general anti mycotic drug. If not better, consider erythromycin 500mg 1tab 4x/day or cloxacillin 500mg 1tab 4x/day
- Single cold abscess - pxx004- pxx222 anywhere on the body obligates consideration of TB... But if it has existed for many years, do nothing (seborrhetic abscess). Look for other typical TB symptoms (loss of weight, typical fever...) see "31-TB".
- Single hot abscess anywhere on body, with or without general signs, must first think about bacterial infection (often staphylococcus). Sometimes such abscesses are superficial - ptx008 - but can also be deeper in the derma or be a former infected lymph node. Start with cloxacillin 500mg 1tab 4x/day or erythromycin...
- If small "abscesses" already "connected" with the skin and with sticky pus that refuse to be expressed... (pxx088- axx015 -pxx090-) consider furunculosis. Treat with erythromycin 500mg 1tab 4x/day. It is probably more active than Cloxa... In dangerous areas (close to nose, eyes...) Consider genta 3-4mg/kg//day directly...
See "Erythroderma" below.
See specific protocol "5-Bedsore"
See "38-unknown disease "
Difficult subject: the word "cochon" is French for pig, and this name implies a hotchpotch of unidentified skin lesions of various origins, including fungal, bacterial, viral, allergic, misuse of topical medications, etc. See specific article "15-Genital Cochonoma"
Papular eruption. Usually involves the face and extremities. Sometime there is a mild depression on top of the papule making confusion with molluscum contagiosum easy except that molluscum is usually only on one area of the body (no symmetrical distribution as in crypto) Treat with fluconazole 200mgx2. See also "30-Moluscum". Because infection involve the brain and can be an emergency see article about neuro: "19-Neuro Crypto"
One or more areas of body are affected but not symmetrical distribution (unlike penicilliosis or PPE or psoriasis or...) The lesion starts with a little vesicle or papule. Strepto or staphylo is often the cause... responding to erythro.
"Eczema" means a sterile inflammatory condition of the skin with vesiculation in the acute stage. After acute stage, typically erythematous, edematous, papular, and crusting eruption followed by lichenification and scaling. Usually, pruritus is present. Cause can be an allergy to a drug as well as disease, especially a skin infection (Scabies or Tinea are common cause of allergic exzema...). It is why we must always examine the entire skin surface, including genital and anal areas before thinking that a drug is the cause of allergy. Treat as an allergy... meaning suppress the cause and local corticoids. If severe, general corticoids (predni or even dexa) can be used if no other contraindication (CMV...)
Intense and widespread reddening of the skin associated with exfoliation. In HIV ward the 2 main causes are "acquired erythroderma" (= "acquired ichthyosis") and "erythrodermic psoriasis". Both can be induce by a drug (including antiviral treatment) but; in practice there is one important difference: unlike "acquired erythroderma"; "erythrodermic psoriasis" will relapse often over a lifetime, even if you stop the drug that originally induced the problem.
Treatment of both diseases are basically the same in a poor hospice... dexamethasone high dose for a short time. If it is erythrodermic psoriasis, it is useless to try to obtain "perfect skin". Patient will relapse often... (Dexa during long period is more dangerous than psoriasis for HIV patient: CMV, crypto...)
Generalized infected "erythrodermic psoriasis / acquired erythroderma" is an emergency! (pxx022... ) Patients are often sent to the hospice because of alarming looking skin diseases (severe generalized skin edema, fissures of skin because edema, pus...). Confusion is possible with erysipelas but history of the disease will help: Erythroderma is a generalized disease and had a specific look before the secondary infection). Those patients often still have a high CD4 count and could potentially live for many more months/years. Treat with dexamethasone IM (4cc morning + 2cc midday + gentamycin 160mg IM daily (+ fluconazole 200 2x/day for prevention of fungal infection if patient is able to take it) pxx022... //pxx241 //
See "erythroderma" (up) & See "26-Psoriasis"
See "erythroderma" (up) & See "26-Psoriasis"
See 30- Abscess
Gonococcal septicaemia, gonococcal infection can affect skin. "...The skin lesions, found mainly on the extremities, have a reddened surrounding areola and evolve through macular (1-2 mm in diameter), vesiculopustular, haemorrhagic, and necrotic stages. They are virtually pathognomonic of disseminated gonococcal infection (...) There are usually between four and ten lesions, not particularly painful (...). Frankly haemorrhagic bullae and erythema nodosum-like lesions have been described...” (From "Oxford textbook")
See also 15-Genital because usually gono affect genital area first...
Calamine +/- chlorpheniramine 1-2 tabs 4x/day. If this is not enough, try chlorpromazine.
Try to find and treat cause… Treat as scabies if itching increases at night without any obvious cause - especially for clean patients! See "28-Scabies"
Rare in Thailand. We do not have the technology in our hospice to do anything for this condition.
Addendum of Dr M. Catton (about black patients in Africa)
afr pxx 001... Various typical lesions of Kaposi Sarcoma - diagnostic of HIV, and difficult to treat.
Nothing specific for HIV. Drugs are free in many countries. We recommend to visit other website on the subject.
"White net" on violet papules. Pruritus is not constant. Confusion possible with psoriasis...
Treat with local corticoids. Sometimes we have to use dexamethasone a few days only (as for severe psoriasis). But dexa is always more dangerous than lichen for such patients...
Usually benign tumor, flabby, not painful... nothing to do.
Without lab it is always conjecture... Not responding to antibiotics nor antimycotics... Sometimes, confusion is possible with psoriasis (both diseases respond to corticoids).
Looks like a second degree burn. Can involve a very large area of skin. Main danger is secondary infection and septicemia (ptx017). Treat with strong preventive (cloxa500mg 4x/day + fluconazole 200mg 1x/day) + Dexamethasone 3cc every morning till it looks less dangerous (dry)(pxx009) (pxx007). Stop Bactrim/sulfadiazine if you do not find another cause. We feel it is possible to avoid the "full-blown disease" if we stop Bactrim immediately when we see the beginning of bullous lesions (pxx010) on "abnormally black" skin/lips (pxx005) (bxx008). The lesions become dry immediately when the causative factor has been removed (pxx007), and do not need any treatment... (Must be confirmed). See also "6-Allergy"
(Common if CD4<100)
Don't do anything (treatment is bloody and unnecessary). Umbilicated or non-umbilicated papules without inflammation of the underlying skin... Asymmetrical distribution of papules, usually on one limited area only. Generalized disease (symmetrical distribution) often suggests cryptococcosis... or end of life. See "Cryptococcosis"
Dry moult of skin ("dry Lyell"). Large areas of skin peel off.
In the "moult syndrome", the face is never affected while the palms of hands and soles of feet are always involved. Distribution of lesions is always symmetrical. Unlike erythroderma, not all areas of the body are affected. Crusts are thicker than with erythroderma. General conditions are not affected (no fever, nor other infectious signs...). Disease resolves without specifical treatment and relapse often... Males are more affected than females..
Dermatologists say that the cause of disease could be a soft species of staphylococcus (SSSSS). BUT our recent experience causes us think that this common syndrome (in our ward) can also be an allergic reaction (We had a patient who developed the "moult syndrome" two times, each time a few days after a massive allergic reaction...) It is why we prefer to use 2 different names.
Usually the psoriasis can be seen on other areas besides the nails which is helpful for differential diagnosis... In HIV hospice, it is useless to try to treat terminal patients since treatment need many weeks to be effective (both Mycose and psoriasis) See also "26-Psoriasis"
Only occurs in South-East Asia. Rare out of the rainy season. Papules/vesicles/central hemorrhage/necrosis. Central hemorrhage/necrosis and inflamed underlying skin allows differential diagnosis with molluscum contagiosum & skin cryptococcosis, but also the symmetrical distribution of lesions suggests penicilliosis (Crypto is symmetrical as well but molluscum are usually in a limited area) In penicilliosis, all the steps of skin lesions are present on the patient. Distribution of lesions: more on the upper part of the body (including face). Itraconazole100mg 2tabs 2x/day (as long as possible, for at least a few weeks after symptoms cease).
Penicilliosis can be symptomatic when CD4 are high (700!) even if average CD4 of infected patients are bellow 40. The disease is still not totally described. See the special profile of pxx445-453 (a slow progressor patient that webmaster met in Chiangmai (north of Thailand)
No treatment, or use anti-mycotic cream (Don't confuse with leprosy in endemic zones: see "Leprosis")
Chronic disease marked by a persistent eruption of papules that itch intensely and, often, have a mild secondary infection. If only on both legs (very common for terminal HIV patients in South-East Asia) we call it "Pruritic Papular Eruption". If generalized, it is better to use the classic "prurigo" name.
Treatment: chlorpheniramine+bethazone cream (If severe, use clobetazole with precaution. and for pruritus we have sometimes to use chlorpromazine....)
If secondary infection, add topical antibiotics cream...or cloxa 500mg 4x/day)...
See "5- Bedsore"
See specific article about "28-Scabies".
(Common if CD4<500)
Symmetrical keratotic eczema (often vesicles are not visible) + mild local pruritus, on border of scalp, limits of nose… Confusion is easy with dry mycosis or psoriasis, location and symmetry help. Betamethasone+vaseline+clotrimazole cream. If you are sure there is no fungal infection, Dermovate cream acts faster.
Often an injectable drug addict patient using dirty needles/syringes/drugs. Disseminated purulent patches on the skin... Internal organs can be infected as well (neurological signs, focal pneumonia...)
STEVENS JOHNSON/ERYTHEMA MULTIFORME versus HERPES STOMATITIS
See also "6-Allergy"
"SSSSS" = "Superficial Staphylococcal Scalded Skin Syndrome" versus< "Moult Syndrome"
See "Mould Syndrome" up.
Give anti-mycotic creams 4x/day or, if necessary, fluconazole 200mg 1-2x/day.
If you hesitate (for a still "strong" patient only...) give Dermovate cream 3x/days 2 days on one limited area of skin... If worse, it is Tinea (and not psoriasis or lupus or allergy...) If better, it is not Tinea but psoriasis or lupus or allergic eczema or....
(Common if CD4<400)