Primary care clinicians should refer human immunodeficiency virus (HIV)-infected children to a dermatologist when they cannot determine the etiology of a skin lesion based on clinical evaluation.
Bacterial Infections
| Presentation |
- Redness, warmth, and swelling
- +/- purulent drainage or nodule
- +/- fever or leukocytosis
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| Diagnosis |
- Culture of purulent fluids
- Blood culture
- Consider skin biopsy if empiric treatment fails
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| Treatment |
- Empiric antibiotic therapy (first-generation cephalosporins, anti-staph penicillins, clindamycin)
- Adjust antibiotics based on culture result
- Decide exposure level of antibiotics (topical versus oral versus intravenous) based on type of infection and severity of immune compromise
- Consider incision and drainage
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Diagnosis
The clinician should attempt to identify bacterial pathogens by culture of purulent fluids.
The clinician should perform a blood culture in patients with cellulitis
Treatment
In patients with cellulitis, impetigo, and abscesses, the clinician should immediately initiate empiric antibiotic therapy (e.g., first-generation cephalosporins, anti-staph penicillins, clindamycin) that covers Staphylococcus aureus and beta hemolytic streptococci. Antibiotics should be adjusted based on culture result.
In an immunocompetent patient, the clinician should treat mild, localized impetigo with topical antibiotics that are effective against both staphylococci and streptococci. A child who has more severe impetigo or who is more severely immunocompromised will require systemic treatment.
Fungal Infections
Candidiasis
| Presentation |
- White, curd-like material that can be wiped off revealing an erythematous mucosa
- Pink, slightly raised rash in intertriginous areas with satellite lesions
- Candidal diaper rash is a pink rash, sometimes slightly raised, that can involve the skin folds and often contain small satellite lesions outside of the affected area
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| Diagnosis |
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| Treatment |
- Oral candidiasis: fluconazole or mycostatin
Mouth washing and aggressive sterilization of all bottles, bottle nipples, and pacifiers
- Diaper candidiasis: Mycostatin or imidazole topical cream
- Alternatives: ciclopirox and terbinafine
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Diagnosis
Diagnosis of candidiasis should be made by the identification of clinically distinctive lesions.
Treatment
The clinician should treat oral candidiasis with fluconazole (3 to 6 mg/kg/day) or mycostatin (lozenges or oral suspension).
The clinician should advise the caregiver to regularly wash the mouth of younger children and sterilize all bottles, bottle nipples, and pacifiers to prevent recurrence of oral candidiasis.
Mycostatin or imidazole topical cream should be used to treat candidal infection of the skin.
Dermatophyte Infection
| Presentation |
- Tinea corporis: single or several scaly oval patches, often hyperpigmented, with a raised outer rim
- Tinea capitis: area of flaking within the scalp, with or without hair loss, or a weeping or crusting kerion or diffuse flaking throughout the scalp
- Tinea versicolor: many small hypopigmented lesions, often on the shoulders, neck, and face
- Onychomycosis: yellowed, darkened, thickened, or pitted nails
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| Diagnosis |
- Clinical, verified by potassium hydroxide preparation or fungal culture
|
| Treatment |
- Tinea corporis: imidazole cream twice a day
Alternatives: ciclopirox or terbinafine creams
- Tinea capitis: a 4- to 6-week course of oral griseofulvin (10 to 20 mg/kg/day) or fluconazole (3 to 6 mg/kg/day)
- Tinea versicolor: selenium sulfide shampoos, topical imidazole gel and lotions, or single-dose itraconazole
Alternatives: topical ciclopirox or terbinafine, or oral itraconazole or fluconazole
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Diagnosis
Diagnosis of dermatophyte infections should be made on a clinical basis and can be verified by the presence of fungal organisms on potassium hydroxide preparation or fungal culture.
Treatment
The clinician should treat tinea corporis with application of an imidazole cream twice a day. Topical ciclopirox or terbinafine creams are alternative treatment options.
Tinea capitis should be treated with a 4- to 6-week course of oral griseofulvin (15 to 20 mg/kg/day). Possible alternatives include fluconazole (3 to 6 mg/kg/day) and itraconazole (5 mg/kg/day).
The clinician should treat tinea versicolor with selenium sulfide shampoos, topical imidazole gel and lotions, or single-dose itraconazole. Topical ciclopirox and terbinafine and oral itraconazole and fluconazole are alternative treatment options.
Viral Infections
Herpes Simplex
| Presentation |
- Crusting erosions of the lips, gums, and tongue
- Vesicular and ulcerative lesions of the fingers
|
| Diagnosis |
- Clinical
- Culture or immunofluorescent antibody of the lesion if uncertain
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| Treatment |
- Mild Herpes Simplex Virus (HSV) infection and good immune function: oral acyclovir 40 to 80 mg/kg/day divided into 3 doses (every 8 hours), maximum of 1,200 mg/day for 7 to 10 days
- Severe mucocutaneous HSV infection or severe immune deficiency: intravenous acyclovir 15 to 30 mg/kg/day divided into three doses (every 8 hours), given over 1 hour for 7 to 14 days
- Chronic suppressive therapy: oral acyclovir 40 to 80 mg/kg/day divided into 2 to 3 doses (max 1,200 mg/day)
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Diagnosis
The clinician should perform culture or immunofluorescent antibody testing for the presence of HSV for any chronic ulcer of the mouth or skin.
Treatment
The clinician should treat children with mild HSV infection and good immune function with oral acyclovir (see the Table above for dosages).
The clinician should treat children with severe mucocutaneous HSV infection or severe immune deficiency with intravenously administered acyclovir (see the Table above for dosages).
Herpes Zoster (Varicella-Zoster Virus)
| Presentation |
- Varicella zoster (or chickenpox): vesicular and ulcerative lesions all over the child's body in multiple different stages
- Herpes zoster (or shingles): painful or pruritic blistering lesions, usually in a single dermatome on one side of the body.* At the time of presentation, it may look more ulcerative
- Chronic varicella: following an episode of chickenpox or shingles, vesicular and ulcerative lesions, often expanding in diameter, each with a "dry" central core and a wet, active outer ring
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| Diagnosis |
- Physical examination for classical lesions
- Culture or immunofluorescent antibody if uncertain
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| Treatment |
- Chickenpox or zoster and good immune function: no treatment
- Moderate disease and mild immune deficiency: oral acyclovir 80 mg/kg/day (maximum 3,200 mg/day) divided into 4 to 5 doses/day
- Severe disease or severe immune deficiency: intravenous acyclovir 30 mg/kg/day or 1,500 mg/m2/day divided every 8 hours
- Chronic varicella: intravenous acyclovir 30 mg/kg/day or 1,500 mg/m2/day divided every 8 hours
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* Occasionally, in children with immune deficiency, shingles can affect multiple dermatomes and/or both sides of the body.
Diagnosis
Diagnosis of chickenpox, shingles, or chronic chickenpox should be based on the appearance of classical lesions noted on physical examination. If the diagnosis is unclear after physical examination, diagnosis should be made by culture or fluorescent antibody of the lesions.
Treatment
Treatment of all forms of varicella zoster should be dependent on the extent and severity of the varicella and the severity of immune deficiency of the child. Most HIV-infected children with normal immune function will not need treatment for chickenpox.
Clinicians should treat children with mild immune deficiency with oral acyclovir and those with severe immune deficiency with intravenous acyclovir.
Clinicians should treat HIV-infected children with shingles with oral or intravenous acyclovir, depending on the severity of immune deficiency and number of lesions. Multidermatomal lesions or recurrent lesions should be treated with intravenous medication.
Chronic varicella is indicative of severe immune deficiency and should be treated with intravenous acyclovir.
Molluscum Contagiosum
| Presentation |
- Pearly, flesh-colored, umbilicated papules containing caseous material, often on the face, shoulder, or back
|
| Diagnosis |
- Clinical appearance
- Can be confirmed by clusters of large clear cells on potassium hydroxide
|
| Treatment |
- Treatment of HIV infection
|
Diagnosis
Molluscum contagiosum should be diagnosed by its characteristic appearance.
Treatment
Clinicians should treat patients with widespread molluscum contagiosum lesions with standard regimens of anti-retroviral (ARV) medications.
Human Papillomavirus Infection
| Presentation |
- Verruca vulgaris: widespread flat warts and condylomata acuminata
- Verrucae: thickened keratotic papules
- Flat warts: thin discrete papules
- Condylomata: filiform or hyperkeratotic papules on the mucous membranes
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| Diagnosis |
- Clinical appearance
- Confirmed by whitening of the mucosa when acetic acid is applied
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| Treatment |
- Initial therapy not always necessary
- Severe or refractory cases: either daily application of salicylic acid or cryotherapy
Additional options: imiquimod cream, podophyllotoxin gel or solution, tretinoin or fluorouracil cream, and cantharidin
- Extensive lesions unresponsive to topical therapy: oral cimetidine 40 mg/kg/day divided every 12 hours
- Small condylomata acuminata: 20% podophyllum resin washed off thoroughly after 2 hours
- Large condylomata acuminata: cryosurgery or surgical excision
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When prepubescent children beyond infancy present with anogenital warts, clinicians should consider the possibility of sexual abuse.
Diagnosis
Diagnosis of anogenital warts should usually be made by clinical presentation and, in mucosal cases, can be confirmed by whitening of the mucosa when acetic acid is applied.
Treatment
If ordinary warts persist for an extended amount of time, the clinician should treat with daily application of salicylic acid or cryotherapy (refer to the original guideline document for additional options).
Small condylomata acuminata should be treated with 20% podophyllum resin, which should be washed off thoroughly after 2 hours.
A multidisciplinary approach, including consultation with a gynecologist, should be used to treat female patients with large lesions of condylomata acuminata.
Parasitic Infections
Scabies
| Presentation |
- Punctate, itchy papules on the hands, feet, arms, legs, periumbical area, face, or scalp; may be somewhat disguised by self-inflicted scratch marks
- Crusted or "Norwegian" scabies: widespread eczematous eruption, no characteristic papules and burrows
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| Diagnosis |
- Scraping burrows and looking for mites or feces
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| Treatment |
- Single application of 5% permethrin cream
- Laundering of all clothing and bedding at the time of treatment
- Treatment of all household members at the same time from the neck down
- For infants: the head should also be treated
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Diagnosis
Diagnosis of scabies should be made by scraping burrows and looking for mites or feces.
Treatment
Clinicians should treat children with scabies with a single application of 5% permethrin cream. In infants, the head should also be treated.
The clinician should advise the caregiver to launder, in hot water, all bedding and clothing that was worn next to the skin during the 4 days prior to treatment initiation.
The clinician should provide prophylactic treatment for household members. All household members should be treated at the same time to prevent reinfestation.
Inflammatory Dermatoses
Seborrheic Dermatitis
| Presentation |
- Erythema and scaling of the scalp, skin behind the ears, and nasolabial folds in areas with maximal numbers of sebaceous glands, including the scalp, ears, T zone of the face, chest, and genital areas
|
| Diagnosis |
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| Treatment |
- 1% or 2.5% hydrocortisone cream and/or ketoconazole cream or shampoo
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Diagnosis
Seborrheic dermatitis should be diagnosed by clinical presentation.
Treatment
The clinician should treat seborrheic dermatitis with 1% or 2.5% hydrocortisone cream and/or ketoconazole cream or shampoo.
Atopic Dermatitis
| Presentation |
- Erythematous, flaky skin
- In infants: involves the face and extensor surfaces and often spares the diaper area
- In children: involves the flexural surfaces
|
| Diagnosis |
- Clinical presentation
- The clinician should ask for a family history of atopy (i.e., asthma, urticaria, hay fever)
- Progression of rashes since childhood from flexural intertriginous to extensor parts of the body is also indicative of atopic dermatitis
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| Treatment |
- Emollients, antihistamines, non-fluorinated topical steroid ointments, or immodulatory topical treatments (tacrolimus and pimecrolimus)
- Avoidance of provocative factors such as harsh soaps and detergents, wool clothing, and bathing too frequently
- Dermatology consult in severe cases
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Diagnosis
Atopic dermatitis should be diagnosed by clinical presentation.
The clinician should ask for a family history of atopy (i.e., asthma, urticaria, hay fever).
Treatment
The clinician should treat atopic dermatitis with emollients, antihistamines, nonfluorinated topical steroid ointments, or immodulatory topical treatments (tacrolimus and pimecrolimus).
The clinician should advise the caregiver to avoid provocative factors, such as using harsh soaps and detergents, dressing children in wool clothing, and bathing children too frequently.
The clinician should consult with a dermatologist in severe cases.
Cutaneous Manifestations of Drug Reactions
| Presentation |
- Most common: simple, morbilliform rash
- Less common: diffuse redness, papules, or targetoid lesions
- Rare: blisters, skin desquamation, erythema multiforme, Stevens-Johnson syndrome, or toxic epidermal necrolysis
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| Diagnosis |
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| Treatment |
- Consider discontinuing suspected medication, depending on severity of rash and urgency of causative medication
- Symptomatic treatment, including antipruritics, such as benadryl or ativan, and topical preparations
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Diagnosis
Clinicians should suspect drug reactions as the cause of a rash in any patient who develops a rash while he/she is on medication. Antibiotics should be suspected first when drug reaction is being considered.
Treatment
The decision to discontinue drug therapy in a child with a rash should be individualized and based on the severity of cutaneous disease and the availability of treatment alternatives.
When abacavir is stopped, it should NEVER be restarted.
