Bibliographic Source(s)

• New York State Department of Health. Dermatologic manifestations. New York (NY): New York State Department of Health; 2004. 15 p. [14 references]

Guideline Status

This is the current release of the guideline.

Guideline Category

Diagnosis
Evaluation
Management
Treatment

Intended Users

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Public Health Departments

Guideline Objective(s)

To develop guideline for diagnosis and management of dermatologic manifestations of human immunodeficiency virus (HIV) infection

Target Population

Human immunodeficiency virus (HIV)-infected children and infants

Interventions and Practices Considered

Diagnosis/Evaluation

Bacterial Infections

1. Culture of purulent fluids
2. Blood culture
3. Skin biopsy

Fungal Infections

Candidiasis

1. Identification of clinically distinctive lesions

Dermatophyte Infection

1. Clinical appearance
2. Verification by potassium hydroxide preparation or fungal culture

Viral Infections

Herpes Simplex and Herpes Zoster

1. Clinical appearance
2. Culture or immunofluorescent antibody of the lesion if uncertain

Molluscum Contagiosum

1. Clinical appearance

Human Papillomavirus Infection

1. Clinical appearance
2. Confirmation by whitening of the mucosa when acetic acid is applied

Parasitic Infections (Scabies)

1. Scraping burrows and looking for mites or feces

Inflammatory Dermatoses

Seborrheic Dermatitis

1. Clinical presentation

Atopic Dermatitis

1. Clinical presentation
2. Family history of atopy
3. Progression of rashes from flexural intertriginous to extensor part of the body

Cutaneous Manifestations of Drug Reactions

1. Clinical presentation

Treatment/Management

Bacterial Infections

1. Empiric antibiotic therapy (first-generation cephalosporins anti-staphylococcal penicillins clindamycin)
2. Antibiotic adjustment based on culture results
3. Incision and drainage

Fungal Infections

Candidiasis

1. Fluconazole or mycostatin for oral candidiasis
2. Mouth washing and sterilization of bottles bottle nipples and pacifiers for oral candidiasis
3. Mycostatin or imidazole topical cream for cutaneous candidiasis (alternatives: ciclopirox and terbinafine)
4. Frequent diaper changes and keeping the affected area open to air as much as possible

Dermatophyte Infection

1. Imidazole cream in tinea corporis (alternatives: ciclopirox and terbinafine creams)
2. Oral griseofulvin in tinea capitis (alternatives: fluconazole and itraconazole)
3. Selenium sulfide shampoos topical imidazole gel and lotions or single-dose itraconazole in tinea versicolor (alternatives: topical ciclopirox or terbinafine or oral itraconazole or fluconazole)

Viral Infections

Herpes Simplex

1. Oral or intravenous acyclovir
2. Note: Guideline developers discuss but do not make recommendations on valacyclovir famcyclovir and foscarnet

Herpes Zoster

1. No treatment or oral or intravenous acyclovir depending on severity of the varicella and the severity of immune deficiency (Famcyclovir or valacyclovir are alternatives in older children.)
2. Note: Guideline developers discuss but do not offer recommendations on foscarnet and cidofovir

Molluscum Contagiosum

1. Treatment of HIV infection with standard regimes of anti-retroviral medications.

Human Papillomavirus Infection

1. Salicylic acid or cryotherapy imiquimod cream podophyllotoxin gel or solution tretinoin or fluorouracil cream cantharidin
2. Oral cimetidine
3. 20% podophyllum resin
4. Cryosurgery or surgical excision

Parasitic Infections (Scabies)

1. 5% permethrin cream
2. Laundering of all clothing and bedding at the time of treatment
3. Prophylactic treatment of all household members at the same time from the neck down
4. Head treatment in infants

Inflammatory Dermatoses

Seborrheic Dermatitis

1. 1% or 2.5% hydrocortisone cream
2. Ketoconazole cream or shampoo

Atopic Dermatitis

1. Emollients antihistamines non-fluorinated topical steroid ointments tacrolimus pimecrolimus
2. Avoidance of harsh soaps and detergents wool clothing and bathing too frequently
3. Dermatology consult

Cutaneous Manifestations of Drug Reactions

1. Considering discontinuation of suspected medication
2. Symptomatic treatment including antipruritics (benadryl ativan) and topical preparations

Major Outcomes Considered

• Effectiveness of treatment
• Side effects of treatment

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV Specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care including infectious diseases family medicine obstetrics and gynecology among others. Generally committees meet in person 3 to 4 times per year and otherwise conduct business through monthly conference calls.

Committees meet to determine priorities of content review literature and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member reviewed and modified by the committee edited by medical writers and then submitted for peer review.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

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

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

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

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

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)

* 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

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

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

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

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

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

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.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not stated.

Potential Benefits

Appropriate diagnosis and management of dermatologic manifestations

Potential Harms

• Development of acyclovir-resistant strains of varicella has been reported.
• In immunodeficient children treatment of oral candidiasis with mycostatin is associated with high failure rate.
• Penicillins and cephalosporins may result in exanthems

Description of Implementation Strategy

Following the development and dissemination of guidelines the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases such as diagnostic screening or oral health delivery however barriers emerge which prevent effective implementation. Strategies to promote implementation such as through quality of care monitoring or dissemination of best practices are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines New York State Department of Health; 2003) which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below.

• Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience
• Define target audience (providers consumers support service providers).
  • Are there groups within this audience that need to be identified and approached with different strategies (e.g. HIV Specialists family practitioners minority providers professional groups rural-based providers)?
• Define implementation methods.
  • What are the best methods to reach these specific groups (e.g. performance measurement consumer materials media conferences)?
• Determine appropriate implementation processes.
  • What steps need to be taken to make these activities happen?
  • What necessary processes are internal to the organization (e.g. coordination with colleagues monitoring of activities)?
  • What necessary processes are external to the organization (e.g. meetings with external groups conferences)?
  • Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion?
• Monitor progress.
  • What is the flow of activities associated with the implementation process and which can be tracked to monitor the process?
• Evaluate.
  • Did the processes and strategies work? Were the guidelines implemented?
  • What could be improved in future endeavors?

Implementation Tools

Personal Digital Assistant (PDA) Downloads
Quick Reference Guides/Physician Guides

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness

Bibliographic Source(s)

• New York State Department of Health. Dermatologic manifestations. New York (NY): New York State Department of Health; 2004. 15 p. [14 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

New York State Department of Health

Guideline Committee

Committee for the Care of Children and Adolescents with HIV Infection

Composition of Group that Authored the Guideline

Committee Chair: Jeffrey M. Birnbaum MD MPH Assistant Professor of Pediatrics SUNY Health Sciences Center at Downstate Brooklyn New York Director HEAT Program Kings County Hospital

Committee Vice Chair: Geoffrey A. Weinberg MD Director Pediatric HIV Program Strong Memorial Hospital Rochester NY Associate Professor of Pediatrics Division of Infectious Diseases University of Rochester School of Medicine and Dentistry

Committee Members: Jacobo Abadi MD Assistant Professor of Pediatrics Albert Einstein College of Medicine Bronx New York Jacobi Medical Center; Saroj S. Bakshi MD Associate Professor of Clinical Pediatrics Albert Einstein College of Medicine Bronx New York Chief Division of Pediatric Infectious Diseases Bronx-Lebanon Hospital Center; Howard J. Balbi MD Associate Professor of Pediatrics SUNY at Stony Brook School of Medicine Director Pediatric Infectious Diseases Good Samaritan Hospital Medical Center; Joseph S. Cervia MD Associate Professor of Clinical Medicine and Pediatrics Albert Einstein College of Medicine Bronx New York Director The Comprehensive HIV Care and Research Center Long Island Jewish Medical Center; Aracelis D. Fernandez MD Assistant Professor of Pediatrics Albany Medical College; Ed Handelsman MD Assistant Professor of Pediatrics SUNY Health Sciences Center at Downstate Assistant Medical Director of Pediatrics Office of the Medical Director AIDS Institute; Sharon Nachman MD Chief Pediatric Infectious Diseases Professor of Pediatrics SUNY at Stony Brook; Natalie Neu MD Assistant Professor of Pediatrics Division of Pediatric Infectious Diseases Columbia University; Catherine J. Painter MD PhD Assistant Professor of Clinical Pediatrics College of Physicians and Surgeons Columbia University New York New York Medical Director Incarnation Children's Center; Roberto Posada MD Assistant Professor of Pediatrics Division of Pediatric Infectious Diseases Mount Sinai School of Medicine New York New York Director Pediatric HIV Program Mount Sinai Hospital; Michael G. Rosenberg MD PhD Associate Professor of Clinical Pediatrics Albert Einstein College of Medicine Bronx New York Pediatric Consultation Services Jacobi Medical Center; Pauline Thomas MD Assistant Professor Dept. of OB/GYN and Women's Health Dept. of Preventive Medicine and Community Health New Jersey Medical School; Barbara Warren BSN MPH PNP Assistant Director Bureau of HIV Ambulatory Care Services AIDS Institute New York State Department of Health

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.

Print copies: Available from Office of the Medical Director AIDS Institute New York State Department of Health 5 Penn Plaza New York NY 10001; Telephone: (212) 268-6108

Availability of Companion Documents

The following are available:

• Dermatologic manifestations. Tables and recommendations. New York (NY): New York State Department of Health; 2004 Mar. 11 p. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.
• HIV clinical practice guidelines. New York (NY): New York State Department of Health; 2003. 36 p. Electronic copies: Available from the New York State Department of Health AIDS Institute Web site.

Print copies: Available from Office of the Medical Director AIDS Institute New York State Department of Health 5 Penn Plaza New York NY 10001; Telephone: (212) 268-6108

This guideline is available as a Personal Digital Assistant (PDA) download from the New York State Department of Health AIDS Institute Web site.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on January 14 2005. This summary was updated by ECRI on January 31 2006 following release of a public health advisory from the U.S. Food and Drug Administration regarding the use of Elidel Cream (pimecrolimus) and Protopic Ointment (tacrolimus).

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is copyrighted by the guideline developer. See the New York State Department of Health AIDS Institute Web site for terms of use.

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.