Dermatological Findings in the Aging Population Dr

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Jonathan A. Dyer, MD Associate Professor of

Dermatology and Child Health University of Missouri

Dermatological Findings in the Aging Population

Acknowledgements

• Dr. Kristen Heinz Fernandez

Geriatric Dermatology: What’s all the fuss about? Geriatric Dermatology: What’s all

the fuss about?

“The great majority of persons over 70 have at least one, often two or three, skin conditions which would benefit from the attentions of a knowledgeable doctor..” Albert M. Kligman, MD, foreword to Skin and Aging Processes, Barbara Gilchrest, MD

Changes in skin with aging

•  Senescence related

•  Environmental •  Internal/ External

•  Actinic purpura

•  Skin fragility

•  Stellate pseudoscarring

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Most Common Dermatological Diagnoses: Geriatric Dermatology

•  Unpublished data - University of Iowa Dermatology Clinic –  January-December 2008

•  Most common diagnoses patients >65 y/o 1.  Actinic keratoses 2.  Other dermatoses 3.  Basal Cell Carcinoma or Squamous Cell Carcinoma 4.  Benign neoplasm


•  Nursing home dermatology diagnoses (n=1,556)

Diagnosis N Mean age (years)

Scabies 220 78.0 (14.7) Contact dermatitis and other eczema 218 77.1 (14.3) Erythematosquamous dermatitis 216 75.6 (16.5) Disorders of the sweat glands 166 78.3 (14.0) Nonthrombocytopenic purpura 145 84.8 (8.0) Stasis dermatitis with varicosities 135 81.3 (11.3) Candidiasis 80 80.5 (13.3) Cellulitis, unspecified site 77 79.3 (14.1) Dermatophytosis 71 78.4 (14.4) Other hypertrophic and atrophic conditions of the skin 47 83.9 (18.1)

NormanR, ed. Geriatric Dermatology. New York: Parthenon, 2001: 5–16.

U. of Iowa Dermatology Clinic Nursing Home Visits

•  Actinic keratoses •  Other dermatoses •  Basal or squamous cell

carcinoma of the skin •  Benign neoplasm

•  Pruritus and other related diseases

•  Diseases of the sebaceous glands (xerosis)

•  Other dermatoses •  Basal or squamous cell

carcinoma of the skin

















Most Common Dermatological Diagnoses: Geriatric Dermatology Agenda

•  “Other dermatoses” – Xerosis

•  Asteatotic eczema •  Nummular eczema

– Pruritus – Causes of itch* •  Bullous pemphigoid •  Actinic keratoses and Skin Cancer

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Xerosis •  Ranges from dry skin to true dermatitis:

– Asteatotic eczema – Nummular eczema

Asteatotic Eczema •  Pruritic, dry, cracked, polygonally fissured

skin with irregular scaling –  Shins –  Elderly patients –  May occur on the hands and trunk

•  Appears similar to: –  cracked porcelain –  dried-up riverbed

•  Pathogenesis: 1.  The elderly have decreased sebaceous and

sweat gland activity 2.  Loss of stratum corneum lipids = increased

transepidermal water loss 3.  Stratum corneum loses water = cells shrink =

fissures 4.  Fissures rupture dermal capillaries, causing

clinical bleeding Emedicine.com

Nummular Eczema •  Nummular ="coin-shaped“ •  Round/oval erythematous

plaques •  Mostly arms and legs •  Early lesions may be

studded with vesicles containing serous exudate

•  Very pruritic •  Peaks in 6th-7th decade

Asteatotic and Nummular Eczema: Treatment

•  Rehydrate skin and repair epidermal lipid barrier à Emollients – Use BID, especially after

bathing/showering – Creams or ointments

preferable to lotions •  “Scoop not pump”

•  Reduce inflammation à topical steroids when inflamed

Asteatotic and Nummular Eczema: Repair of Epidermal Barrier

•  Lukewarm/ cool bath/showers daily –  Decrease itching - helps rehydrate skin –  MUST follow with moisturizers/ topical medications to seal in.

•  Soak and Smear: (handout) –  20-minute plain water soak qHS then steroid ointment/ petrolatum

to wet skin –  Soap only to the axilla/ groin –  >90% response in 27/28 pts with refractory chronic pruritic

eruptions when used as directed3

•  Wet wraps: –  Dampen skin with lukewarm water until well hydrated (~10 min) –  Petrolatum/ steroid ointment applied liberally, then occlude for 1

hour with damp pajamas •  May use plastic wrap for occluding small areas

–  May repeat 5-6 times a day with petrolatum –  Caution using with prescription steroids –striae/ atrophy

Stasis Dermatitis •  Due to underlying

venous stasis – Cyclical edema

•  Triggers inflammation – Often symmetric

•  Lower extremities –  “bilateral cellulitis”

•  Treat: topical antiinflammatory + compression

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Contact Dermatitis Allergic contact dermatitis

•  Due to type IV hypersensitivity reaction to external allergen

•  Clinical –  Patterned rash –  Itchy –  Chronic

•  Patch testing can identify allergen

•  Poison Ivy is classic

example

Irritant Contact Dermatitis •  Repeated exposure of

skin to irritants – Hand dermatitis from over

washing –  Incontinence related

dermatitis •  Not a true allergy •  Avoidance of irritant is

key to successful treatment

Irritant Contact Dermatitis

•  Incontinence related dermatitis – Control incontinence – Frequent changing of pads/absorptive device – Barrier. . . Barrier. . . .Barrier

•  Zinc Oxide paste •  Stoma barrier creams

–  Ilex barrier paste –  SensiCare barrier cream

•  Cavilon barrier films

Scabies •  Infestation with Sarcoptes

scabiei •  Itch is due to immune

reaction to mite •  Typical clinical sites:

–  Umbilicus –  Web spaces –  Under nails –  Wrists –  Axilla –  Areolae –  Palms/soles in infants

•  Nodular lesions may be occur –  Genitalia

Crusted scabies

•  Massive infestation with mites

•  Debilitated patients •  Often secondary

infection •  Oral therapy

–  Ivermectin •  Topical

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Scabies

•  Mineral oil scrape –  Mites –  Eggs –  Feces (scyballa)

•  Transmission –  Close personal

contact •  Most infested adults

have < 10 mites –  Crusted = Teeming

Scabies •  Treatment

–  Topical •  Permethrin

–  Repeat in 1 week to treat unhatched eggs

–  Oral •  Ivermectin

–  Hot water wash and/or heated drying of clothes, sheets, towels

•  If not possible – seal tightly in plastic bag for 1 week

–  Fumigation is unecessary •  Thorough vacuuming is

enough

•  All at risk family members/ care providers must be treated at same time

•  Nursing Home: –  Roommates –  Wings –  Units –  Staff

•  Symptoms may persist after treatment –  Until immune reaction calms

Seborrheic keratoses

Can be quite pruritic!

Herpes zoster •  AKA “Shingles” •  May start with itch;

“burning” pain •  Typically follows

dermatome –  May be multidermatomal –  Ocular involvement can

= loss of vision •  Can be systemic •  Treatment

–  Watchful waiting –  Oral anti-viral therapy

Pruritus in the Elderly

Sometimes associated with dermatitis, but not always

•  International Forum for the Study of Itch (IFSI) Classification of Pruritus5

1.  Pruritus on diseased skin 2.  Pruritus on non-diseased skin 3.  Chronic scratch lesions


Sometimes associated with dermatitis, but not always

•  IFSI Classification of Pruritus5

1.  Pruritus on diseased skin: asteatotic and nummular eczema

2.  Pruritus on non-diseased skin 3.  Chronic scratch lesions

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Pruritus in the Elderly •  Pruritus on non-diseased skin

•  Metabolic problems –  Renal disease, cholestatic pruritus, hematologic pruritus,

endocrine pruritus, pruritus related to malignancy –  CBC/ CMP –  +/- CXR –  Treatment:

»  Address underlying disease »  Symptom relief:

»  Sarna lotion: menthol (0.5%) and camphor (0.5%) »  Cool compresses »  Antihistamines: be careful of sedation in the elderly!

»  Case-by-case basis

•  Neuropathic itch

Pruritus in the Elderly •  Pruritus on non-diseased skin

•  Neuropathic itch –  Degenerative joint disease or spinal injury predispose the

elderly –  Pruritus sometimes has burning quality –  Often involves a neurocutaneous dermatome

Brachioradial pruritus Notalgia paresthetica


•  Pruritus on non-diseased skin •  Neuropathic itch

–  Therapeutic treatment ladder »  Capsaicin cream – as tolerated »  Topical steroids »  Gabapentin »  Pregabalin

Pruritus in the Elderly •  Chronic scratch lesions

– A secondary process… – Lichen simplex chronicus

•  Thickened skin with pronounced skin lines

– Prurigo nodularis •  Excoriated thick nodules •  Often intermixed with scarring

– Treatment: Break itch/scratch cycle

•  Potent topical steroids +/- occlusion; NAC?

Systemic Medications and Eczema/Pruritus

•  Chronic use of CCB (>3 months) associated with eczematous dermatitis in the elderly4

•  Stopping CCB = resolution of eczematous dermatitis in 68% of patients – Took up to 1 year to see improvement in some

•  Statins could decrease SC lipids… – Mostly taken up by the liver after absorption

Agenda




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Bullous Pemphigoid •  Chronic, autoimmune

blistering skin disease – Widespread, tense bullae

•  May favor sites of trauma –  +++pruritus –  Bullae may develop after

persistent urticarial lesions •  Elderly patients

–  Avg 65 y/o •  Most treated patients remit

in 1.5-7 years

Bullous Pemphigoid

Bullous Pemphigoid: Pathophysiology

•  IgG autoantibodies specific for the hemidesmosomal bullous pemphigoid antigens BP230 and BP180

Bullous Pemphigoid: Treatment Typically NOT fatal

(In contrast to pemphigus vulgaris)

•  Goals of therapy – Decrease blister formation – Promote healing of blisters/ erosions – Determine the minimal dose of medication

necessary to control

Treatment of Bullous Pemphigoid

Therapeutic Ladder of Treatment •  Topical steroid

– Class 1 or 2 – clobetasol/fluocinonide

•  Tetracycline antibiotic – Minocycline or doxycycline

•  Oral prednisone +/- immunosuppression

Agenda




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Actinic Keratoses •  Elevated, rough patches-

sun-exposed areas (face, bald scalp, lips, and the back of the hands)

•  Most red/pink, occ. Tan/ skin colored

•  Prevalence of 75% in those 80 to 89 years of age2

•  “Pre-skin cancers” –  Only 5-8% progression to

SCC over a period of 10 years

–  “Sun-damage spots” http://doctorsgates.blogspot.com/2011/07/photo-illustration-of-actinic-keratosis.html

Actinic Keratoses •  Elevated, rough patches-

sun-exposed areas (face, bald scalp, lips, and the back of the hands)

•  Most red/pink, occ. Tan/ skin colored

•  Prevalence of 75% in those 80 to 89 years of age2

•  “Pre-skin cancers” –  Only 5-8% progression to

SCC over a period of 10 years

–  “Sun-damage spots” http://doctorsgates.blogspot.com/2011/07/photo-illustration-of-actinic-keratosis.html

Actinic Keratoses: Treatment •  No pain, no gain… •  Cryotherapy

– ~99% effective – Best for a limited number

of lesions •  Painful •  Significant irritation •  Risk of scarring

www.webmd.com

Only 5-8% progress to SCC over 10 years

Actinic Keratoses: Treatment •  Cryotherapy

– Method: •  1-2 cycles (15-30 second

freeze/thaw cycles), depending on thickness

•  Hold cryac container perpendicular 1-2 cm from the lesion

•  Must get a 1-2 mm border

Actinic Keratoses:Field Therapy

•  Best for multiple lesions (>15)

•  Fluorouracil 5% cream –  Targets actinically damaged cells –  2-4 weeks of home treatment –  Significant irritation

•  Varies depending on patient

•  Imiquimod 5% cream –  Immunomodulator

•  On head and neck, can cause flu-like symptoms

•  Chemical peels –  35% Tricholoracetic acid (TCA) –  Applied in office –  7-10 days of erythema/peeling –  Best for thicker skin

•  Scalps, foreheads, arms

•  Photodynamic Therapy (PDT)

–  Topical photosensitizing agent (5-aminolevulinic acid) applied to lesions then area exposed to light to activate 5-ALA

Actinic KeratosesField Therapy

•  Chemical peels –  35% Tricholoracetic acid

(TCA) –  Applied in office –  7-10 days of erythema/peeling –  Best for thicker skin

•  Scalps, foreheads, arms

•  Photodynamic Therapy (PDT) –  Topical photosensitizing agent

(5-aminolevulinic acid), is applied to the lesions, then the area is exposed to strong light that activates 5-ALA.

•  Best for multiple lesions (>15)

•  Fluorouracil 5% cream –  Targets actinically damaged

cells –  2-4 weeks of home treatment –  Significant irritation

•  Varies depending on patient

•  Imiquimod 5% cream –  Immunomodulator

•  On head and neck, can cause flu-like symptoms

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Actinic Keratoses: Treatment •  Use:

– SUNSCREEN – SUNSCREEN – SUNSCREEN

•  SPF >50 •  Reapplying every 2 hours

with sun exposure

Actinic cheilitis •  High metastatic rate

of SCC of lip (16%) •  Low threshold for bx •  Tx

–  LN2 –  Topical retinoid –  Efudex –  CO2 ablation

Non-melanoma Skin Cancer •  Total incidence greater than all other cancer

dx combined •  20% lifetime risk •  45-52% chance of 2nd NMSC within 5 yrs.

after 1st

•  BCC-75-80% of NMSCa’s, 0.05% mortality –  intermittent light exposure or severe sunburn

before age 18 •  SCC-0.7% mortality, 5% metastatic risk

–  related to cumulative sun exposure

Basal cell carcinoma •  Smooth, translucent (pearly), papule with

rolled border and telangiectasia •  Ulceration - “rodent ulcer” •  Superficial - red, scaly plaque

– Differential: dermatitis/fungus/Bowen’s dz •  Morpheic – indurated/ scarlike •  Basosquamous – features of BCC &

SCC

BCC - nodular BCC - superficial

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BCC – Morpheic/Infiltrative Squamous cell carcinoma

•  Usually hyperkeratotic, scaly papules or plaques – UV-induced – head/neck/arms – Arsenic – palms/soles –  Ionizing radiation – border of field

•  Can look like AK’s- close f/u of treated lesions (usually thick/indurated)

•  Arising in chronic wounds/burns – “Marjolin’s Ulcer”

SCC SCC

Melanoma •  70% - de novo •  Upper back in men / legs in women •  Risk factors: a. Numerous nevi b. Family history c. H/O blistering sunburns DEPTH is key! Breslow’s and Ulceration – most

important prognostic indicators

Melanoma - subtypes

•  Superficial spreading – most common •  Nodular – no radial growth phase •  Lentigo maligna melanoma – face of

elderly; large lentigos •  Acral lentiginous melanoma – dark skin,

worse prognosis

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Melanoma Melanoma

Lentigo Maligna Melanoma Acral Lentiginous Melanoma

Treatment

•  Early surgical intervention has largest benefit – Melanoma in situ – 0.5cm margins – < 2 mm depth – 1.0 cm margins – 2-4 mm depth – 2.0 cm margins – > 4 mm depth – no randomized studies

•  Sentinel lymph nodes for staging

References 1.  Book chapter – nursing home 2.  Engel A, Johnson ML, Haynes SG. Health effects of sunlight

exposure in the United States. Results from the first National Health and Nutrition Examination Survey, 1971–1974. Arch Dermatol. 1988;124:72–9.

3.  Gutman AB, Kligman AM, Sciacca J, James WD. Soak and smear: a standard technique revisited. Arch Dermatol. Dec 2005;141(12):1556-9.

4.  Joly et al. Chronic eczematous eruptions of the elderly are associated with chronic exposure to calcium channel blockers: results from a case-control study. J Invest Dermatol. 2007 Dec;127(12):2766-71. Epub 2007 Aug 23.

5.  Acta Derm Vener 2007;87:291 6.  Pillemer K, Finkelhor D. The prevalence of elder abuse: a

random sample survey. Gerontologist 1988;28:51-7.

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Thank you for attending!

Jonathan A. Dyer, MD Associate Professor of Dermatology and Child Health

University of Missouri - Columbia 1 Hospital Drive; Room MA111

Columbia, MO. 65212 phone: 573-882-3142 fax: 573-884-5947

E-mail: [email protected]

Please contact me should you have any questions

Documents

Dermatological Findings in the Aging Population Dr