Skin Problems

Problems and possible causes

Skin problems in people with AIDS are common and unfortunately tend to be chronic. They can be controlled with the right treatment, but rarely completely cured. The following skin problems occur more often in people who have AIDS than in those who do not:

· rashes
· itching skin
· painful sores on the skin
· increased dryness of the skin
· slow healing of wounds
· boils and abscesses.

The most common causes of some of these problems include:

· yeast infections (thrush, candidiasis)
· other fungal infections (e.g. ringworm)
· bacterial infections
· shingles (herpes zoster)
· poor hygiene
· allergic reactions to medicines or skin irritants
· bed sores (caused by lying in one position in bed)
· eczema
· Kaposi sarcoma.

What to do at home

As a general rule, cleaning the skin frequently with soap and water and keeping it dry between washing will prevent the most common problems.

Almost all skin problems involve the sensation of itching. Scratching the itching skin with fingernails can make things worse, either by breaking the skin or by introducing or spreading infection. This can be avoided by keeping nails short. Try to encourage people not to scratch any type of skin lesion or sore. However, rubbing with the flat of the fingers or gentle slapping can give some relief.

Itching can be reduced in a number of ways, including the following:

· cooling the skin with water or fanning it
· applying lotions such as calamine that are soothing and prevent the skin from becoming too dry
· not letting the skin get hot and not applying warmth to itching areas
· using effective traditional remedies that are available locally from a herbalist.

If people have trouble with very dry skin, they may have to avoid soaps and detergents and use bath oils and skin creams as much as possible. Vaseline, glycerine, and vegetable or plant oils can be as effective as the more expensive oils and creams sold in the shops.

To prevent babies, or someone who is confused, from scratching themselves, cut their fingernails very short or put gloves or socks over their hands.

For children in nappies who have diarrhoea or yeast infections, the buttocks area will need special care. For example people should:

· leave the baby's bottom exposed to air as much as possible

· soak the baby's bottom with warm water between nappy changes

· not let the child remain in wet nappies or cloths but remove or change them as soon as they become soiled

· avoid wiping the buttocks area; instead squeeze water from a wash cloth or pour water over the area and then pat dry

· use simple lotions provided by a health care worker or pharmacist - this may help cure rashes in the nappy area, particularly if they are treated early

· not forget to wash their hands afterwards!

Treatment of wounds

Wounds (including open sores and ulcers) which are not infected:

· Wash the affected areas with clean water - preferably water which has been boiled and cooled - mixed with a little salt (one tea-spoonful of salt to one litre of clean water) or gentian violet solution (one teaspoonful of gentian violet crystals in half a litre of clean water).

· Protect by covering with clean gauze bandages or cloth, wrapped loosely.

· Put warm compresses of weak saltwater on the area four times a day (one teaspoonful of salt to one litre of clean water).

· If the wound is on the legs or feet, raise the affected area as high and as often as possible. During sleep it should be on pillows. During the day, try to raise the foot for 5 minutes in every 30 minutes. Walking helps the circulation, but standing in one place or sitting with the feet down for long periods is harmful.

Closed wounds (including abscesses and boils) which are infected:

Boils - and some abscesses - are red, raised painful lumps on the skin. They are most common on the groin, buttocks, armpits, back and upper legs. They may start as single lumps under the skin or in groups. They quickly become more painful as they increase in size. Once someone notices a red lump under the skin they should start using warm compresses over the area for 20 minutes four times a day. The warmth of the compresses will help the boil or abscess "mature" or to form and harden and drain its contents. If they are having a great deal of pain and the boil or abscess continues to get bigger without draining (i.e. opening out onto the skin) they should seek help. The wound may require drainage and treatment with antibiotics.

Figure

Open wounds (including abscesses that are actively draining) which are infected:

If wounds are not cared for properly they can become infected. A wound is infected if:

· it becomes red, swollen, hot, and painful
· it has pus either draining from it or visible under the skin
· it begins to smell bad.

The infection is spreading to other parts of the body if:

· it causes fever
· there is a red line above the wound
· the lymph nodes under the skin in the neck, armpits or groin become swollen and tender.

People should attend to infected wounds with one of the following:

· a salt wash (one teaspoonful of salt in one cupful of clean water)
· hot compresses over the wound for 20 minutes, four times a day.

If there is pus or dead tissue, you should show the person how to dean it away.

Figure

Advise people to treat infected wounds as follows:

· Use a gentian violet solution on the wound before applying dressings.

· If the wound is on a hand or foot, soak it in a bucket of hot water with soap or potassium permanganate (one teaspoonful of potassium permanganate to a bucketful (4-5 litres) of clean or boiled water - do not exceed the recommended amount; if the solution is too concentrated it can bum or irritate the skin). Be sure that any compress or water applied to the wound is not too hot, since damaged skin can easily bum.

· When it is not being soaked, keep the infected part at rest and elevated (raised above the level of the heart).

· If there is dead tissue, hydrogen peroxide can be used to rinse the wound.

Advice on washing or cleaning an infected wound and applying dressings

· Use gloves, plastic bags, or a big leaf when handling cleansing cloths or dressings to avoid touching blood from the wound, and wash your hands afterwards with soap and water.

· Wash around the edge of the wound first, then wash from the centre out to the edges using separate little pieces of clean cloth for each wipe if possible.

· Cover the area with a dean piece of cloth and bandage if the wound has pus or blood. If the wound is dry it can be left exposed to the air - it will heal quicker this way.

Dressings are used to cover wounds to prevent them from becoming infected, to protect other people from infection, to keep medicines in place or to avoid painful contact with the environment.

· Never apply a dressing tightly.

· Make sure dressings are dean.

· Change the dressing at least once a day. Be sure to look for signs of infection.

· After changing the dressing, rinse the soiled cloth and bandages in water and soap and put them in the sun to dry or put them in boiling water for a short period and hang them to dry. If the dressings are not to be reused, always dispose of them properly by burning them or putting them in a pit latrine.

If soil or dirt gets into the wound it can become infected with the bacteria that cause a serious disease called tetanus (lockjaw). You should therefore ensure that people are fully immunized against tetanus. Even if they have been immunized for tetanus before, they may still need further immunization. Advise people who are not immunized against tetanus to seek medical help immediately if they are wounded or develop open sores.

Shingles

Figure

Shingles (herpes zoster) is a viral infection which used to be seen only in older people or in those with weakened immunity for various reasons. Now shingles is very common in people with AIDS and it may be one of the first symptoms they have of HIV infection or AIDS.

Shingles begins as a painful rash with blisters, usually on the face, limbs or trunk. Shingles on the face may affect the eyes, causing pain and blurred vision. The blisters often combine, resulting in a large eroded or broken area, and there may be an intense burning feeling in the affected area. Healing takes place over several weeks and leaves discoloured areas on the skin.

The following measures may be helpful:

· Applying calamine lotion twice daily to relieve pain and itching and promote healing.

· Keeping the sores dry and not letting clothes rub on them if possible.

· Wearing dean, loose-fitting, cotton clothing.

· Relieving pain with aspirin or paracetamol, but sometimes the pain maybe so severe as to require stronger prescribed medicines, including pain killers and sedatives at night. For additional measures to control pain, see the section on pain in Chapter Seven.

· Preventing infection by bathing the sores with warm salt water three or four times a day or applying gentian violet solution once a day, or antibiotic skin creams or ointments if available.

· Watching for signs of infection of the shingles sores such as redness or pus. If infection occurs treat as indicated for infected wounds above.

The pain usually diminishes after three or four days. Unfortunately some people develop a persistent pain and scarring over the affected area. Rubbing creams on the scars or painful areas may help; medicines for pain such as aspirin or paracetamol may also be needed.

Allergic reactions

Allergic reactions to medicines are more common in people with AIDS. These often appear suddenly and start as skin rashes, redness, and itchy skin. If people think they may be having a reaction to a medicine they should immediately go to see the health care worker who prescribed it. Medicines that commonly cause reactions in people with AIDS include:

· anti-tuberculosis medicines
· antibiotics
· anti-cancer medicines.

See Chapter Seven for further details of possible reactions to anti-tuberculosis medicines.

Kaposi sarcoma

Kaposi sarcoma is a cancer of the cells in the blood vessels or lymph system. The cancer may begin as:

· discoloured (brown or purple) areas on the skin or in the mouth
· enlarged lymph glands which are not painful.

Both of these are a type of external cancer (affecting the outside of the body) and are mostly a problem for cosmetic reasons, but the cancer may go on to affect internal parts of the body causing the enlargement of internal organs or bleeding from the lungs or digestive tract. How Kaposi sarcoma will appear in a specific person and what its course will be are very difficult to predict. Some people have only mild complaints arising from the appearance of the lesions; others may become very ill as a result of the cancer.

Because of the variety of ways in which Kaposi sarcoma may appear and because of the numerous parts of the body that may be affected, this disease can be mistaken for many others. Once the diagnosis of Kaposi sarcoma is made, it indicates that the person has AIDS.

The specific care needed for the problems caused by Kaposi sarcoma will depend on where the cancer is situated and on what type of problems it is causing.

Bed sores

It is very important to prevent infections resulting from sores of any type that do not heal adequately. Included in this category are "bed sores" or sores caused by breakdown of the skin due to pressure. These chronic open sores appear in people who are so ill that they cannot roll over in bed, especially those who are very thin and weak. The sores form over bony parts of the body where the skin is pressed against the bedding. They are most often seen on the buttocks, back, hips, elbows and feet.

Figure

To prevent bed sores in sick people you should advise them to:

· get out of bed as much as possible

· change position, when lying down, every two hours from one side onto the back, from the back onto the other side, and so on in order to prevent prolonged lack of circulation to any one area of the body; this is particularly important if an area of skin is already affected - the person may need help with this in the home if they are very weak

· use soft bed sheets and padding, which should be hung to air daily and changed each time the bedding is soiled with urine, stools, vomit or sweat. Straighten the bedding often as lying on wrinkled bedding can hurt the skin

· put cushions under the body in such a way that the bony parts rub less (see illustration below)

· eat as well as possible; extra vitamins may help.

A bedridden child who has a severe chronic illness should be held often on someone's lap.

When sick people and their families must seek help

· If pus, redness or fever (indicating infection) accompany the skin problem.

· If the wound has a bad smell, if brown or grey liquid oozes out, or if the skin around it turns black and forms air bubbles or blisters - this might be gangrene, a very dangerous condition. Medical help must be sought very quickly.

· If there is severe pain from a skin problem, like shingles, and the sick person is unable to sleep or function during the day.

· If shingles affects the eyes.

· If there is an allergic skin reaction to a medicine.

· If the sick person is wounded or develops an open sore and they are not fully immunized against tetanus.

Notes on skin problems
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