Guidelines on skin and oral HIV-associated conditions in children
and adults
WHO Department of Maternal, Newborn, Child and Adolescent
Health
Department of HIV/AIDS
Mucocutaneous manifestations in HIV
Common
High morbidity & mortality
Could be an indicator disease
Objectives
…to provide a summary of key evidence and practice
recommendations on
treatment of the main skin and oral conditions
in HIV-infected adults and children
What are these guidelines about?
Criteria for selectionBurden of diseaseSeverityImpact on prognosis of HIV
Marker of low CD4 initiation of ART
Applicability for primary health care levels in resource-poor settings
What are these guidelines about?
Who is the target audience?
Health proffesionals Policy makers Managers of HIV/AIDS control programmes
in settings with HIV infection, primarily where resources are limited.
Kaposi SarcomaSelection of patients for chemotherapy
No standardized criteria presently
Extent of tumour alone may be insufficient
Categorization of KS into mild/moderate & severe symptomatic based on the original ACTG tumour extent criteria
* Pending approval by the WHO guideline Review Committee
Kaposi Sarcoma
Recommended Regimens*
Rationale
Vincristine with Bleomycin and Doxorubicin (ABV)
Bleomycin with Vincristine (BV)
(When available or feasible)Liposomal anthracyclines (doxorubicin or daunorubicin)
Though Liposomal anthracycline treatment is the standard of care, they are:
• Expensive• not widely available• remain under patent• require cold storage
Kaposi Sarcoma
* Pending approval by the WHO guideline Review Committee
Recommended Regimens
Disease Pending Recommendation*
Rationale
Mild SD Topical ketoconazol
2%
2-3 times / week for four weeksmaintenance treatment once / week as needed
• Evidence for treatment of SD in HIV very limited
• Evidence is strongest for Ketoconazole
• General concensus that combination of antifungals and corticosteroids is effective
• Potential side effects with topical corticosteroids
• Quality of evidence for ART alone is limited & of very low quality
Severe SDTopical antifungals (e.g. ketoconazole 2%) and topical corticosteroids
* Pending approval by the WHO guideline Review Committee
Seborrheic dermatitis
Pending Recommendati
on*
Rationale
ART should be considered as the primary treatment
Evidence for treatment of PPE in HIV very limitedSome evidence is available for resolution of PPE with ART
General concensus: ART initiation, with or without symptomatic therapy, as the best option
Additional symptomatic therapy
Antihistamines Topical corticosteroids
* Pending approval by the WHO guideline Review Committee
Pruritic papular eruption
Pending Recommendation* Rationale
ART should be considered as the primary treatment
Evidence base for all of the interventions was of very low quality
Expert opinion and general concensus: ART as the primary treatment
Should not discontinue the ART
Additional symptomatic therapyoral antihistamine if no adequate response, add:topical corticosteroids / oral itraconazole /permethrin 5% cream
* Pending approval by the WHO guideline Review Committee
Eosinophilic folluculitis
Disease type
Pending Recommendatio
n*
Rationale
TineaNot extensive
Topical terbinafine 1% Topical miconazole 2%
No evidence to determine if one class of antifungal is superior
Terbinafine, Miconazole • In“WHO essential medicine list” • widely available• Terbinafine offers shorter
duration of therapy
For extensive tinea:Expert panel favoured griseofulvin rather than terbinafine because of the latter’s higher cost
TineaExtensive, hair/nail involvement
Oral griseofulvin
If there is no response:Oral terbinafine or itraconazole
* Pending approval by the WHO guideline Review Committee
Tinea
PendingRecommendation*
Rationale
Acyclovir(at any time in the course of the disease)
Acyclovir, famciclovir and valaciclovir are all effectiveThe safety profiles of all three drugs similar
Acyclovir • Better availability• Costs less
* Pending approval by the WHO guideline Review Committee
Herpes zoster
Disease Pending Recommenda
tion*
Rationale
Classical scabies
1st line:Permethrin 5% 2nd line:Oral ivermectin
Permethrin appears to be the most effective treatment for scabies
The limited data on crusted scabies in HIV-infected patients suggest a good effect of oral ivermectin
Crusted scabies
1st line:Oral ivermectin *2nd line:Permethrin 5%
*avoid in children <15kg
Scabies
* Pending approval by the WHO guideline Review Committee
* Pending approval by the WHO guideline Review Committee
Molluscum contagiosum
PendingRecommendati
on*
Rationale
Oral fluconazoleWhen fluconazole is not available or contraindicated:nystatin suspension or pastilles, or clotrimazole troches
ketoconazole, fluconazole, itraconazole and clotrimazole are all effective
Oral fluconazole • Highly effective• Single dose• Better bioavailability• Less toxicity• Less drug interaction
* Pending approval by the WHO guideline Review Committee
Oropharyngeal Candidiasis
Pending Recommendati
on*
Rationale
Suspected causative drug should be promptly discontinued and supportive therapies should be offered
Absence of good evidence to support the use of oral steroids, immunoglobulins or cyclosporine-A
Steroids may:• Decrease survival in the
paediatric group• Place the HIV-infected
patient at risk for OI / sepsis
Stevens-Johnson Syndrome
* Pending approval by the WHO guideline Review Committee
Tool to aid in diagnosis of skin conditionsAfter input from dermatologists in the field, the tool was refined to include better diagnostic criteria, additional diagnoses of relevance, additional pictures of children and of skin diseases in diverse subjects.
The research gaps
Common to all conditions…
Research in HIV infected Research in Children Standardized outcome measures Well designed prospective,
randomized double blind studies with adequate power
Effect of ART … does it manifest as an IRIS
Contributors to the GRADE systematic reviews and supporting evidenceEsther Freeman (Harvard Medical School, USA), Toby Maurer (University of California, USA), Oluwatoyin Gbabe (Stellenbosch University, South Africa), Charles L. Okwundu (Stellenbosch University, South Africa), Miriam Laker (University of California, USA), Philippa J. Easterbrook (World Health Organization, Switzerland), Jeffrey Martin (University of California, USA), Martin Dedicoat (Birmingham Heartlands Hospital, United Kingdom).Andrew Anglemyer (University of California, USA), Anurag K. Agarwal (Baylor College of Medicine, USA), George W. Rutherford (University of California, USA).John Stephen (St. John's Medical College, India) Tony Raj (St. John's Medical College, India), Kedar Radhakrishna (St. John's Medical College, India), Tinku Thomas (St. John's Medical College, India).Ser Ling Chua (University Hospital Birmingham, United Kingdom), Kedar Radhakrishna (St. John's Medical College, India), John Stephen (St. John's Medical College, India), Mike Zangenberg (World Health Organization, Switzerland).Mamaduo O. Diallo (Centers for Disease Control and Prevention, USA), Magdy El-Gohary (University of Southampton, United Kingdom), Esther J. van Zuuren (Leiden University, Netherlands), Hana Burges (University of Southampton, United Kingdom), Liz Doney (University of Nottingham, United Kingdom), Zbys Fedorowicz (Cochrane Collaboration Awali, Bahrain), Michael Moore (University of Southampton, United Kingdom), Paul Litle (University of Southampton, United Kingdom).Dunja Vekic (St. Vincent’s Hospital, Australia), Lisa Abbot (St. Vincent’s Hospital, Australia), Emily Asher (University of California, USA), Margot Whitfeld (Skin and Cancer Foundation, Australia). Elissa M. McDonald (University of Auckland, New Zealand), Johannes de Kock (Wanganui Hospital, New Zealand), Feliz S.F. Ram (Massey University, New Zealand), Cristina C. Chang (Monash University, Australia), Vivek Naranbhai (Doris Duke Medical Research Institute, South Africa), Allen C. Cheng (Monash University, Australia), Monica Slavin (Peter MacCallum Institute, Australia), Abijeet Waghmare (St. John's Medical College, India).Paul Harris (London School of Hygiene & Tropical Medicine, United Kingdom)Elizabeth D. Pienaar (Medical Research Council, South Africa), Taryn Young (Medical Research Council, South Africa), Haly Holmes (University of Western Cape, South Africa). WHO Staff and Consultants Lulu Muhe, Philippa Easterbrook, Mike Zangenberg, Elizabeth, Frank Lule, Kasonde Mwinga, Meg Doherty, Rajiv Bahl, Wilson Were, Peggy Henderson,
Thank you!
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