Geriatric Dermatology

Geriatric DermatologyThe Pharmacists RoleObjectivesAt the end of this session the participant will be able to:Describe the dermatological changes that occur as we ageList some of the common disorders that are prevalent in an older populationDescribe the risk factors and consequences of decubitus ulcersDescribe treatment options for Xerosis

Skin ChangesIn the ElderlyEtiologyIntrinsic: occurs in everyone and is related to genetic changes in cell processesExtrinsic: produced by external causes (e.g. UV exposure, smoking, environmental pollutants)Age related skin disorders are related to:Decreased mobilityInnate cutaneous age-related changesDrug induced disordersChronic Diseases (e.g. CAD, Diabetes, CHF, HIV)Cellular changes in the epidermis & underlying structuresCellular changes in aging skin:Altered lipid metabolism impaired ability to recover from injurySluggish keratinocytes impaired ability to recover from injuryDecreased melanocyte density decreased protection from UV raysDecreased Langerhans cells density decreased immune functionLoss of collagen and elastic tissues wrinkles and skin fragilityDecreased function of cutaneous nerves, microcirculation and sweat glands poor thermoregulation and increased risk of burningDecreased subcutaneous fat in distal extremities less padding to protect from trauma

All these factors lead to increased risk of:Fragile skin (skin tears, abrasions, cuts)Traumatic purpura (bruises)Ischemia (cell death, decubiti)Xerosis (dry skin)Infections Skin cancersDecubitus UlcersStage III Decubitus Ulcer with necrosis on sacrum

Decubitus UlcersUsually occur over bony prominencesCaused by ischemia, which leads to cell death and tissue damageRelated to the forces of:PressureShearFrictionFrequently complicated by secondary infection, leading to:CellulitisOsteomyelitisSepsis

High Risk PatientsElderly patients, especially those in LTC facilities & hospitalsCritical care patientsOncology patientsDiabeticsEnd stage renal, heart or liver disease patientsPatients with femoral fracturesIncontinent patientsPatients with impaired mental statusPatients with impaired nutritional status

Stages of Decubitus UlcersStages of Decubitus UlcersStage INonblanching erythema of intact skin

Stage IISuperficial to partial thickness involvement of the epidermis or dermis

Stage IIIDeep necrosis with full-thickness skin loss that may extend down to, but not through, underlying fascia

Stage IVExtensive necrosis to underlying fascia, possibly extending into muscle, bone, and supporting structures

Treatment of Decubitus UlcersStage-dependentRanges from cleansing and application of protective ointments and specialized dressings to surgical debridement of necrotic tissue.The pharmacist should be aware of any topical agents and specialized dressings being used and encourage compliance to any ordered regimen.The pharmacist may recommend nutritional, vitamin, and mineral supplements, after consultation with a nutritionist, when wound healing is delayedThe pharmacist may recommend appropriate pain management for pain related to dressing changes and chronic pain which may be decreasing mobilitySecondary infection should be treated with systemic antibiotics, NOT topical formulations

Treatment of Decubitus UlcersAppropriate treatment should be determined by a wound care specialist, as use of inappropriate dressings may cause harm (e.g. occlusive dressings over an infected wound may lead to sepsis and debriding dressings used on granulating wound beds may delay healing)Wound dressings may be combined in different ways by different practitioners dependent on the individual case and prior experience

Treatment of Decubitus UlcersAppropriate wound dressings should:Maintain a moist wound bedControl moisture levels on healthy wound margins (to avoid maceration)Permit gas exchange (oxygen required for healing)Provide thermal insulationPrevent secondary infection and decrease colonization of wound bedAdhere to body to maintain good wound-dressing contact without damaging healthy skin when removedAvoid over-adherence to wound bed to prevent trauma on removal (unless debridement is needed)Fill wound cavities to promote healing by primary intention

Treatment of Decubitus UlcersDressings which may be used for outpatient treatment may includeGauze (wet to dry dressings)mechanical debridementmust be done at least TID (to avoid over-drying)stop once wound bed is mostly clean or granulation tissue will be removedSimple occlusive dressings (e.g. Opsite)Useful to prevent skin breakdown in vulnerable areas, or prevent further breakdown in Stage I areasSemipermeable allows gas exchange and keeps out microbialsAllows visual inspection of wound area through dressingChange PRN Gentle on healthy skin when removed correctlyNever use on an infected wound

Treatment of Decubitus UlcersHydrocolloid dressings (e.g. Duoderm)Keep wound bed moistOffer some absorption for wounds with minimal exudateOffer some thermal protectionMay be changed infrequently depending on wound (q2days q7days)Semipermeable allow gas exchange and keep microbials outDifferent shapes available for different body parts (i.e. Sacrum)Adhesive is gentle to healthy skin when removedDo not use on infected wounds

Treatment of Decubitus UlcersImpregnated dressings (e.g. Mesalt,)Exert osmotic pressure and dissolve necrotic tissue using the bodys own fluidsProvide an environment which discourages bacterial growth in the wound bed (high salt content)Pack the wound to heal by primary intentionShould only be used in wounds with large amounts of exudate (in order to avoid drying the wound bed)Change at least BIDMay be used on infected wounds

Treatment of Decubitus UlcersAbsorbent dressings (e.g. foam, calcium alginate)Highly absorbent materials to control wound exudateCome in various forms and can be used to pack wounds and/or as an outer layerProvide thermal protection to the woundAllow dressings on clean wounds to be changed less frequently Frequently used in conjunction with impregnated dressings to control moisture

Treatment of Decubitus UlcersTopical treatments may include:Saline Used to cleanse the wound and debride necrotic material (wet-to-dry, syringe irrigation)Commercial wound cleansers (instead of saline)Hydrogels/XerogelsKeep dry wound beds moist to promote healingAllow longer periods between dressing changesAct as gentle packing to encourage healing by intention

Treatment of Decubitus UlcersTopical treatments may include:Silver sulfadiazine creams/gels/solutionsSome antibacterial properties to wound colonization (biofilm theory)May reduce odour in infected woundsMay alleviate some pain in wound bedHelp to keep the wound bed moistSulfa based antibiotic creamsAntibacterial properties to wound colonization (not used for true wound infections)Help to keep the wound bed moistOther antiseptics (e.g. Dakins Solution, Chlorhexadine) may be ordered but do not offer any advantage over saline, do not promote wound healing and should be avoided

Prevention is keyThe pharmacist should support the efforts of the healthcare team to prevent decubitus ulcers and encourage caregiver compliance with preventative strategiesEncourage mobility as appropriate (manage pain)Turning schedules for bedbound patients (q2h)Pressure reducing mattresses and wheelchair cushions (egg crates and sheepskin are comfort measures only; they do not reduce pressure)Keep skin dry and clean(control wound drainage, incontinence and other sources of moisture)Minimize physical restraint useAssess skin daily and keep intact skin in good condition using barrier creams, moisturizers and emollients

Xerosis

XerosisXerosis (dry skin) is characterized by:Pruritus (itchiness)DrynessCracksFissures (like cracked porcelain)Occurs mostly on the legs (but sometimes hands and trunk)Excoriation (from scratching) leading to infection or dermatitis

Causes of xerosisDry air e.g. low winter humidity Exposure to the wind Over-washing Reduction in production of natural moisturisers (sebum) in old age Diuretic medications Underactive thyroid gland Inherited factors A skin condition such as atopic dermatitis (eczema), psoriasis or ichthyosis Any combination of these

Treatment of XerosisOcclusive moisturizers and emollientsOils, lotions, creams and ointmentsHumectants, keratolytics and keratoplasticsUrea, ammonium lactate, and alpha hydroxy productsNon-pharmacologic management

Occlusive moisturizers & emollientsOils of non-human origin, either in pure form or mixed with varying amounts of water through the action of an emulsifier ,to form a lotion or cream.Provide a layer of oil on the surface of the skin to slow water loss and thus increase the moisture content of the stratum corneum.Should be used liberally and frequentlyUnscented, nonallergenic is preferablePreferably applied when skin is dampNo EBM comparing different moisturizers.There is no 'right moisturiser for all patients: the most suitable one often having to be found by trial and error.

FormulationsBath oil deposits a thin layer of oil on the skin upon rising from the water. Lotions are more occlusive than oils. These are best applied immediately after bathing, to retain the water in the skin, and at other times as necessary. Creams are more occlusive again. Thicker barrier creams containing dimeticone are particularly useful for those with hand dermatitis. Ointments are the most occlusive, and include pure oil preparations such as equal parts of white soft and liquid paraffin or petroleum jelly.

Which formulation?The choice of occlusive emollient depends upon the area of the body and the degree of dryness and scaling of the skin:Lotions are used for the scalp and other hairy areas and for mild dryness on the face, trunk and limbs. Creams are used when more emollience is required on these latter areas. Ointments are prescribed for drier, thicker, more scaly areas, but many patients find them too greasy.

Humectants, keratolytics & keratoplasticsHumectant: a substance that promotes retention of moisture Keratolytic: a substance that softens keratin and improves the skin's moisture binding capacityKeratoplastic: substances which normalize keratinizationMany products have more than one of these propertiesAll or some of these may not be tolerated by patients due to stinging and irritationUreaHydrating effects urea is strongly hygroscopic (water-loving) and draws and retains water within skin cells Keratolytic effects urea softens the horny layer so it can be easily released from the surface of the skin Regenerative skin protection urea has a direct protective effect against drying influences and if used regularly improves the capacity of the epidermal barriers for regeneration Irritation-soothing effects urea has anti-pruritic activity based on local anaesthetic effects Penetration-assisting effects urea can increase the penetration of other substances, e.g. corticosteroids as it increases skin hydration

Ammonium Lactate & Alpha Hydroxy Acid ProductsSymptomatic relief of dry skin by increasing moisture capacity of stratum corneum. Have also been shown to reduce excessive epidermal keratinization in patients with hyperkeratotic conditions. Loosen the glue-like substances that hold the surface skin cells to each other, therefore allowing the dead skin to peel off.The mechanism of action of topically applied neutralized lactic acid is not yet known.

Adverse ReactionsPossible adverse reactions of both occlusives and humectants/keratolytics include:Irritation (burning sensation, stinging) usually caused by an ingredient in the cream or lotion baseAllergy - true allergies are rareFolliculitis - Over-occlusive emollients can result in blocked hair follicles and painful pustules (folliculitis) or boils

Nonpharmacologic ManagementReduce washing to every second day, or less often, although the body folds may be sponged daily if desired. Baths or showers should be kept as brief as possible. Water should be lukewarm. Minimise the use of soap and avoid harsh cleansers. Use a mild soap or better still, a detergent-based cleanser. Cleansers that have the same pH as the skin (5.5) may be advantageous. Reduce the need for bathing by keeping as clean as possible Humidify air in dry environments

Skin InfectionsSkin infections are common in elderly patients due to frequent skin trauma, dermatitis, and impaired immunity, and may be:Bacterial (e.g. impetigo)Viral (e.g. varicella, herpes simplex)Fungal (e.g. seborrheic dermatitis, candida, tinea)

Impetigo

ImpetigoUsually found near the mouth or nares, but may be anywhere on the bodyMay be bullous (staphylococal) or nonbullous (streptococcal)Treated with oral and topical prescription antibiotics OTC preparations are not effectiveEncourage good hygiene to avoid contact spreadConfused elderly should be kept isolated until 48 hours of treatment has elapsedVaricella (Herpes) Zoster

Varicella (Herpes) ZosterVaricella or herpes zoster, also known as shingles, results from reactivation of the dormant varicella zoster virus in adults, the same virus that causes chickenpox in children.Vesicles usually appear along one dermatome (nerve path)rarely cross the midlinemay crust over after several daysusually dry out over 2-3 weeksPost herpetic neuralgia may last from months to years after the rash is goneOTC therapy will not treat the virus but may assist with symptom management OTC use in ShinglesNSAIDs may be helpful in pain management in milder casesAntihistamines may be helpful to alleviate itching of the rashHydrocortisone cream may be helpful to alleviate itching of the rashAntipruritic lotions (e.g. calamine) may also help to alleviate itchCapsaicin cream (e.g. Zostrix) may help with pain once the vesicles have crusted over and also with post herpetic neuralgiaEnsure that the patient has sought medical treatment for the virus itself and that OTC treatments are not contraindicated by other medications or pre-existing disease

Fungal Infections Dermatological fungal infections are highly prevalent in the elderly and include:Seborrheic dermatitisCandidaTinea Pedis (Athletes Foot)Tinea Cruris (Jock Itch)Onychomycosis (Tinea Unguium nail infections)

Seborrheic dermatitis

Seborrheic dermatitisCaused by a combination of an over production of skin oil and irritation from a yeast called malassezia.Usually found in sebaceous areas Scalp (called cradle cap in infants)EyebrowsNasolabial foldsEarsChestPresents a reddened patches or plaque with greasy scalesMay be pruritic (itchy)May be related to nutritional deficiencies or disease states (eg. Parkinsons, HIV)

42Seborrheic dermatitisGenerally managed with OTC productsSelenium sulfideZinc pyrithioneCoal tarKetoconazole 2%Low potency topical steroids may be used in more severe cases

Candida

CandidaFound mostly in skin folds where there is warmth, moisture and skin to skin contact:InguinalBetween the fingersPerianalUnder the breastsAppears as a demarcated beefy-red eruption with satellite pustulesCandidaOften related to: Obesity DiabetesImmunosuppressionChronic debilitationOcclusion under incontinence productsSystemic antibiotic therapyCandidaOTC Treatments may includeExposure to airUse of desiccants (Burrows solution, Castellanis paint)Zinc oxide (topically)Topical azole antifungal agents BIDMiconazoleEconazoleKetoconazoleCiclopirox Antifungal powders may be used to dry the skin and prevent macerationTerbinafine cream is NOT effective against Candida.Tinea pedis (Athletes Foot)

Tinea pedis (Athletes Foot)Caused by dermatophytes Presents with erythema, scaling and maceration3 types:Interdigital dry scaling between toesMoccasin-type involves entire sole and sides of footVesiculobullous plantar surface; usually the arch

Tinea pedis (Athletes Foot)Usually treated with topical azole antifungals:ClotrimazoleKetoconazoleEconazoleTerbinafineCiclopiroxSystemic treatment reserved for extensive/persistent infections Oral treatment may be used for elderly patients who would have difficulty seeing or reaching their feet to apply cream

Tinea pedis (Athletes Foot)Prevention is key:Dry feet thoroughly after washing (especially between toes)Avoid walking barefoot in public placesWear cotton socksIntermittent application of antifungal creams, powders or sprays may help prevent recurrences

Tinea Cruris (Jock Itch)

Tinea Cruris (Jock Itch)Presents as an itchy, red rash in the groin areaMen are more likely to acquire this infectionTreatments include:Reduce and control moistureTopical antifungalsSevere or resistant cases may benefit from oral treatmentOnychomycosis

OnychomycosisFungal nail infections usually caused by dermatophytesTrichophytons rubrumTrichophytons mentagrophyteVery few cases caused by Candida or moldsPrevalence increases with age (nearly 20% of patients over 60 are infected)Predisposing factors:TraumaPeripheral vascular diseaseImmunosuppressionDiabetesContiguous spread of tinea pedisCannot be treated with OTC products

Blistering Diseases

Blistering DiseasesBlistering diseases in the elderly are rare and may be immune-mediated, drug-induced, or secondary to systemic illness. It can be fatal, even when treatedCannot be treated with OTC therapiesPharmacists should be aware that blistering diseases may be drug-induced. Medication classes associated with blistering diseases include AntibioticsDiureticsbeta-blockersmedications containing a thiol group (captopril, penicillamine, piroxicam)

Nutritional DeficienciesDeficiencies in certain vitamins and minerals may present with skin findings, and the elderly are at greater risk of poor nutrition due to:Chronic diseasePhysical limitations which hamper food preparationPoor food choices due to economic restrictionsDelayed gastric emptyingSlowed intestinal motilityDry mouthChanges in taste perceptionAltered dentition

Vitamin C DeficiencySkin manifestations of vitamin C deficiency may be related to defective collagen production. Common dermatologic concerns include:perifollicular hemorrhage gingival hypertrophy altered wound healing Systemic findings may include fatigue, anemia, and joint swelling. Symptoms related to vitamin C deficiency may present after 3 months without vitamin C intake.

Zinc DeficiencyIn the elderly, malabsorption or malnutrition may lead to zinc deficiencyHighest risk is found in those withLong term parenteral nutritionAlcoholicsPatients with cirrhosisZinc deficient patients will present with perioral or perianal erythematous, scaling plaquesNonhealing leg ulcersHair loss

Vitamin B DeficienciesSkin findings may present when a patient is deficient inRiboflavin (B2)Niacin (B3)Pyridoxine (B6)Riboflavin (B2) DeficiencyPatients with Riboflavin deficiency may present withAngular cheilitis (Inflammation, burning, redness, and ulceration or cracks at the corner of the mouth)Stomatitis (inflammation of the mouth lining)Seborrheic dermatitis

Niacin (B3) DeficiencyPatients with Niacin deficiency may present with dermatitisThose at risk for niacin deficiency include:AlcoholicsPatients taking chronic antibiotic therapyPatients with cirrhosisPatients with carcinoid syndrome (Carcinoid syndrome is a group of symptoms associated with carcinoid tumors -- tumors of the small intestine, colon, appendix, and bronchial tubes in the lungs.)

Pyridoxine (B6) DeficiencyPatients with Niacin deficiency may present with seborrheic dermatitis and photosensitivityRisk factors include:AlcoholismCirrhosisDrug therapy: isoniazid, penicillamine & L-dopa

Skin CancersMore than 50% of skin cancer-related deaths occur in persons over 65 years of age.Photocarcinogenesis due to sun exposure is a continuous and cumulative processDecreased melanocyte density decreased protection from UV raysDecreased Langerhans cells density decreased immune function

Skin CancersCan be divided into two main typesNon-melanomasRarely fatal but cause tissue damage and may become invasiveUsually caused by UV radiation, sunlight, and HPVMelanomasMost lethal skin cancerRates increasing dramaticallyNon-MelanomasMost common types areBCC (basal cell carcinoma)Most common type of skin cancerDo not metastasizeUsually treated with surgery SCC (squamous cell carcinoma)Untreated may progress and become invasiveCan metastasize to lymph nodesUsually treated surgically

MelanomaMost lethal skin cancerRates increasing dramaticallyFour main types:Superficial spreading (most common)NodularLentigo (occurs only in the elderly)Acral lentiginousEarly excision is the only curative management

MelanomaAll members of the health-care team, including pharmacists should be aware of the ABCDEs of melanoma recognition.How to recognize a melanoma (ABCDE)AAsymmetrical in shapeBBorder is irregularCColour is not uniform; may have different shades of black, brown, gray, red or whiteDDiameter >6 mm (pencil eraser)EEvolution of colour, shape, elevation, or size in recent months

Skin Cancer PreventionInconclusive evidence that sunscreen protects against skin cancer use it, but dont rely on itthis may be partly related to poor application or the fact that people feel protected, so they stay out in the sun longerIntermittent exposure to sun seems to be the biggest risk factor (ie. Weekend exposure after working inside all week)The most effective preventative measures are to minimize sun exposure (avoid sunburn and tanning) -- especially during peak UV-B hours; seek out shade and cover up with hats, long sleeves, and long pants

The Pharmacists RoleThe pharmacist has an important role in Geriatric DermatologyStress the importance of non-pharmacological management for prevention of decubitus ulcers, xerosis, and fungal infectionsInclude all OTC and topical medications in medication assessmentsEvaluate and recommend appropriate drug therapy (both prescription and OTC)Monitor for drug-drug/drug-disease interactionsMonitor for known dermatological side effects of drug therapyConsider additive effects of combined topical and oral corticosteroid therapy

ReferencesSep 4, 2009By: Cristina E. Bello-Quintero, MD, PharmDDrug TopicsOverview of geriatric dermatology:ImpetigoTreatment & ManagementAuthor: Lisa S Lewis, MD; Chief Editor: Russell W Steele, MD Medscape Reference: Drugs, Diseases and ProceduresDermNet NZFacts about skin from the New Zealand Dermatological Society Incorporated. http://www.dermnetnz.orgThe Good, the Bad, and the Ugly of SunscreensM BerwickClinical Pharmacology & Therapeutics 89, 31-33 (January 2011)Skin Cancer in the ElderlyKONSTANTINOS N. SYRIGOS1, IFIGENIA TZANNOU1,NIKOLAOS KATIRTZOGLOU1 and EVANGELLOS GEORGIOU2in vivo 19: 643-652 (2005)National Center for Biotechnology InformationPubMed HealthA.D.A.M. Medical Encyclopedia.http://www.ncbi.nlm.nih.gov/pubmedhealth/National Quality Measures ClearinghouseManagement of Pressure Ulcers: Guideline SynthesisRegistered Nurses' Association of Ontario (RNAO). Assessment and management of stage I to IV pressure ulcers. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2007 Mar. 112 p. [118 references]Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence Nurses Society (WOCN); 2010 Jun 1. 96 p. (WOCN clinical practice guideline; no. 2). [341 references]

Decubitus UlcersTreatment & ManagementAuthor: Don R Revis Jr, MD; Chief Editor: John Geibel, MD, DSc, MA Medscape Reference: Drugs, Diseases and Procedures