The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 9: Dermatologic ProblemsTreatmentImpetigo26 picasMupirocin 2% (Bactroban) ointment or cream tid-qid until clear. This isusually effective in treating mild and localized disease. Systemic therapy isindicated in cases of bullous impetigo, extensive disease or with regionallymphadenopathy. The preferred treatment for nonbullous impetigo is eitherpenicillin VK 250-500 mg PO q6-8h x 7d, penicillin G-benzathine 1.2 million UIM x 1, amoxicillin 250-500 mg PO q8h or 500-875 mg PO q12h x 7d, orampicillin PO q6h x 7d. For bullous impetigo or culture-proven Staphylococcalimpetigo either cephalexin 250-500 mg PO q6h x 7d, cefadroxil 500 mg-1gPO q12h x 7d, or dicloxacillin 500 mg PO q6h x 7d. In addition to theaforementioned antibiotic regimens, practitioners should soften the crustswith clean Vaseline or Bacitracin ointment several times per day, wash theindividual lesions with antibacterial soap or antiseptic solution and water,trying to gently remove crusts twice a day, instruct the patient not to touch thelesions and to wash hands frequently, and clip fingernails short to decreaserisks of excoriation, self-inoculation, and contagion.CellulitisWhile penicillin is, in most cases, appropriate for the treatment of uncomplicatedstreptococcal cellulitis, the problem of resistance is very real. Keepingthis in mind, a penicillinase-resistant penicillin (e.g. dicloxacillin 250-500 mgPO qid) or first generation cephalosporin (e.g. cephalexin 250-500 mg PO qid)may be used. These also should be kept in mind for Staphylococcal genera.However, mild cases of non-resistant Streptococcal cellulitis may be treatedwith penicillin V 500mg PO q6h x 10d or penicillin G benzathine 1.2 mil U IMx1. If penicillin allergic, then Erythromycin 250-500mg PO q6h or 333mg POq8h x 7-10d or azithromycin 500mg PO x1 followed by 250mg PO qd x 4d orclarithromycin 250mg PO q12h x 7-10d. For severe cases, penicillin G 2-4mil UIM or IV q4-6h (maximum 24mil U/day) is suggested.Other interventions besides antibiotics include immobilization and elevationof the affected area, moist heat compresses, and debridement and drainagewhen bullae, abscess or necrosis is present.IXViral InfectionsViral infections tend to run rampant in patients with advanced HIV disease. Not only areHerpes simplex infections the most commonly seen in this setting, but Varicella zoster virusreactivation as well as poxviruses and human papillomavirus infection are all especially common.Clinical PresentationHerpes simplex virusHerpes labialisHerpes labialis often begins with a prodrome of pain or burning on the lipprior to eruption of a tender, vesicular, erythematous lesion that crusts in a fewdays. In advanced HIV infection, the lesions may be chronic, difficult toeradicate, often resistant to standard antiviral therapy, and may become moreU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 189