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Common Dermatologic Problems in Older Patients Return to Medscape coverage of: American Academy of Nurse Practitioners 16th Annual National Conference Common Dermatologic Problems in Older Patients
Introduction
Robert Norman, DO,[1] from Tampa, Florida, was practicing as a family physician when he recognized the extent of dermatologic problems in elderly individuals. He recognized these conditions were especially prevalent in long-term care facilities. He returned to complete a dermatology residency, and is now jointly boarded in both specialties. Along with a staff of nurse practitioners, he provides dermatology care in more than 400 nursing homes, long-term care facilities, and retirement communities. During the annual AANP conference, Norman provided an overview of the effects of aging on the skin, and of the most common dermatologic problems encountered in older adults. Aging Skin
The overall functions of skin, the body's largest organ, decrease with age. Decline is noted in cell replacement, sensory perception, thermal regulation, and chemical clearance. Decreases in sweat, sebum, and vitamin D production also occur.[2] Immune response is lessened; the incidence of neoplasms increases, and there is greater susceptibility to skin infections. Wounds heal more slowly due to a combination of decreased immune and inflammatory response, collagen degradation, and decreased synthesis, and a 30% to 50% decline in epidermal turnover that takes place between the third and eighth decade of life.[3] Other normal changes and potential implications of skin aging include: z Flattening of the dermal-epidermal junction, causing a decrease in the contact surface between the dermis and epidermis. This change may compromise communication and nutrient transfer between skin layers. z Increased dermal separation that may cause increased blistering or tearing. z Decrease in epidermal filaggrin (a protein required to bind keratin filaments into macrofibrils) that contributes to dryness and flaking of skin. z Decline of enzymatically active melanocytes (about 10% to 20% each decade) that contributes to increased sensitivity to ultraviolet (UV) radiation. z Decline of DNA repair; in combination with loss of melanin, this increases the risk of http://www.medscape.com/viewarticle/420852?src=search Common Dermatologic Problems in Older Patients z Decrease in vascular responsiveness due to involution of dermal vascular bed, contributing to decreased temperature, impaired thermoregulation, and skin pallor. z Decrease in subcutaneous fat and changes in distribution that may limit conductive heat loss and decrease protective ability in bony areas such as the ischial tuberosities. z Delayed recovery of the stratum corneum's function as a barrier, which may increase the penetration of certain types of topical medications, leading to systemic absorption.[3] Alterations in the skin's appearance may be due to intrinsic or extrinsic factors. Intrinsic changes (true aging) occur with the passage of time. Extrinsic alterations, most commonly called photoaging, are primarily caused by UV exposure from sunlight. Chronic sun exposure is responsible for increases in irregular mottled pigmentation, lentigines (brown macules), coarse wrinkling, and telangiectasis.[3,4] Norman emphasized the importance of prescribing sun protection for any aged individual. Although it is preferable to begin protection at as young an age as possible, UV radiation continues to damage skin of any age. With every attack on the dermis (ie, severe sunburn), the collagen layer decreases by 4%. Once the collagen layer has been destroyed, it cannot be replaced. Purpura, the purple discoloration of skin commonly seen in the elderly, is related to the destruction of the collagen layer. Common Skin Problems in the Elderly
Norman and associates recently collected data from nursing home patient visits to determine dermatologic conditions most frequently seen in this population. Xerosis and pruritus were the most common complaints encountered, with xerosis being the most frequent cause of pruritus. An overview of these and other common skin problems seen in the elderly was provided. Xerosis, or dryness, is a common characteristic of older skin. Xerotic skin may also be rough and scaly. Dryness occurs most often over the lower legs, hands, and forearms.[5] Although it may be triggered by drugs or physical health problems (eg, hypothyroidism), it is usually not associated with a dermatologic or systemic disease.[4] Treatment consists of increasing water intake and the moisture of the skin. Nonscented emollients, such as white petrolatum, applied frequently and liberally over skin immediately after bathing may be helpful. The indoor environment should be humidified, and the individual's exposure to cold temperatures and wind limited when possible. Use of products that may further dry the skin, such as alcohol, strongly scented soaps, or detergents, should be discontinued. It is also helpful to limit bathing to once a day, using tepid or cool water.[5] Pruritus
Pruritus is a sensation of intense itching that instinctively triggers an attempt to rub or scratch.[5] In the elderly, this generalized itching is also referred to as senile pruritus. As previously stated, xerosis is the most common reason for pruritus. However, systemic disorders can be implicated 10% to 50% of the time. These disorders include liver disease, iron deficiency anemia, uremia, polycythemia vera, parasitosis (usually of the gastrointestinal tract), and leukemias and lymphomas. If the onset of pruritus is sudden and severe, and no obvious skin disorders are present, systemic disease should be considered. It can also be drug-induced. Most drug reactions have an accompanying rash but some drugs, such as opioids, may not be associated with visible skin changes.[5] http://www.medscape.com/viewarticle/420852?src=search Common Dermatologic Problems in Older Patients Low humidity and cold temperatures exacerbate pruritus. Scratching can cause excoriations, which may progress to secondary eczema or become infected. Treatment is aimed at correcting any existing xerosis; antihistamines or tranquilizers may be prescribed. However, Norman noted that the elderly often have adverse reactions to antipruritic medications. Psychogenic Disorders
Psychogenic disorders are self-induced. Areas of the body that can't be reached by the patient are not affected. For example, if marks or other skin changes are not present on skin on the middle of the back, this would perhaps point to a psychogenic origin. Lichen simplex chronicus. This "leatherlike" condition is caused by chronically scratching the
skin. It is especially common on the ankles and feet, where a person may repeatedly rub their heels
against their legs, or in other easy to reach areas. It may affect those with an obsessive personality
at a higher rate. An atopic history may also be associated with this condition. Norman mentioned
that often patients with Alzheimer's or Parkinson's diseases appear to get increased pleasure from
scratching.
Lesions appear as scaling, lichenified plaques that are hyperpigmented. Psoriasis, fungal infection, or mycosis fungoides must be considered in the differential diagnosis of lichen simplex chronicus.[4] Therapy is aimed at breaking the habitual scratching pattern. High-potency topical corticosteroids may be tried initially. Doxepin cream may also provide relief from pruritus.[6] If there is no response to topical therapy, Norman frequently tries oral doxepin (Sinequan), a drug with both antianxiety and antipruritic effects. He begins with a 10-mg-per-day dose, and then advances to 25 mg after a few days if patient is not responding. The dose could be increased to 50 mg per day, depending on the size of the patient. This is a much lower dose than is typically used for treatment of psychiatric problems (usually a 100-mg to 200-mg dose) Since as many as 50% of long-term care patients may be taking psychotropic medications, care should be taken not to overlap with other medications. Several newer medications, including olanzapine (Zyprexa) can also be effective in small doses. Neurotic excoriations. This condition is caused when an individual compulsively "picks" his/her
skin. Sometimes the excoriations are preceded by a focal pruritus but usually there is no underlying
dermatologic condition. The self-inflected lesions, which may include ulcerations, nodules, or atopic
scars, will be seen in all stages of development. This is in contrast to a typical rash, where
appearance is more uniform. The excoriations can become secondarily infected and require
treatment with antibiotics (Figure 1).
Figure 1. Neurotic excoriations.
Treatment with topical corticosteroids, antipruritics, or antihistamines is typically ineffective.[7] In patients identified with an obsessive-compulsive disorder, tricyclic antidepressants or selective http://www.medscape.com/viewarticle/420852?src=search Common Dermatologic Problems in Older Patients serotonin reuptake inhibitors have been used.[8,9] A small amount of evidence also supports the use of fluvoxamine.[10,11] Infections
Candidiasis. Most commonly caused by the yeast fungus Candida albicans, this condition is linked
to decreased salivary function, nutritional factors, and recurrent use of antibiotics in the elderly.
Decreased immune function, heat, moisture, occlusion, and compression of previously inflamed
skin are also conditions that contribute to colonization.[12] Diabetes mellitus is also a predisposing
condition for candidiasis (Figure 2).
Figure 2. Candidiasis.
This condition usually consists of extremely red, weeping areas, often with satellite pustules. In older adults, the groin, axillae, and inframammary folds are common sites. Toe webs are also frequently involved. Norman emphasized that the feet of all diabetic patients should always be carefully examined for the presence of this infection. Treatment may be either topical or oral -- both are effective. Antifungal powder may be more useful than cream or ointment in moist or macerated intertriginous areas.[12] In elderly patients, Norman typically prescribes a short course of systemic therapy using fluconazole. Miliary rubra (also called "prickly heat"). Miliary rubra is caused by occlusion of sweat glands.
Tiny papulovesicles appear, usually caused by lying in 1 position for a prolonged period of time.
Distribution is most common on upper back and upper arms. Treatment includes keeping the
patient clean and dry, and using antibacterial soap. Frequent turning is also important. Scented
powders and soaps can be irritating, and should be avoided.
Herpes zoster. Herpes zoster is an acute condition caused by reactivation of latent varicella virus.
The peak incidence of herpes zoster occurs between 50 and 70 years of age. The decreased
cellular immunity seen in older individuals may be a factor for this risk.[5] Herpes zoster is
particularly significant in the elderly because postherpetic neuralgia is a leading cause of
intractable, debilitating pain.[13] It has been estimated that more than half of infected patients over
the age of 60 years will develop this problem, which tends to persist for a longer period of time.[14,15]
Postherpetic neuralgia has been associated with a high rate of suicide in older chronic pain patients
(Figure 3).[13]
http://www.medscape.com/viewarticle/420852?src=search Common Dermatologic Problems in Older Patients Figure 3. Herpes zoster.
Grouped vesicles appear along dermatomes, most often T5-T9. The outbreak of lesions may be preceded by dermatome paresthesia or neuralgia, or by other systemic symptoms. Herpes simplex can mimic herpes zoster, but unilateral distribution is key to diagnosis. If the outbreak is on the face, especially if around the eyes or nose, an ophthalmology consultation should be obtained. Since zoster can also be a skin manifestation of an underlying systemic disease, further evaluation should be considered if the case is severe. Until the lesions dry, they are infectious to individuals who have never had varicella. However, isolation of the patient is not generally helpful. Treatment is usually with oral antiviral medications (acyclovir, valacyclovir, famciclovir); dosage is reduced in patients with renal insufficiency. Systemic cortisone may decrease the duration of acute neuralgia. Analgesia is given for pain, using medication ranging from acetaminophen to opioids.[5] Beginning treatment early is important, although the effect of antiviral medication on the incidence and duration of postherpetic neuralgia has not been well established. Individuals with herpes zoster are prone to secondary infections, but the most significant consequence is postherpetic neuralgia, which is frequently difficult to treat. Topical or oral monotherapy with antidepressants, anticonvulsants, or opioids has limited success. Results of treatment with topical agents, including capsaicin, lidocaine, diclofenac, doxepin, and aspirin/diethyl ether, have been recently reported.[16] Tinea capitis. Tinea capitis is an infectious disorder of the scalp, most commonly caused by the
organism Trichophyton tonsurans. Although commonly associated with children, tinea capitis is
becoming increasingly prevalent in older adults. It should be ruled out in any patient with a scalp
condition unresponsive to treatment. Asymptomatic carriers, usually children, can colonize adults.
[17]
Norman recommended that treatment of tinea capitis be aggressive. Although griseofulvin has been the standard therapy, the duration of treatment needed with this medication may be difficult for older adults. The newer antifungal medications fluconazole, itraconazole, and terbinafine have all been used successfully.[14] Autoimmune Disorders
Bullous pemphigoid. This condition is characterized by eruption of tense bullae, most frequently
on the flexural areas of the extremities and lower abdomen.[4] The bullae are chronic and recurrent.
It is a condition that primarily occurs in the elderly population, and is very common in long-term care
(Figure 4).
http://www.medscape.com/viewarticle/420852?src=search Common Dermatologic Problems in Older Patients Figure 4. Bullous pemphigoid.
Bullous pemphigoid has been associated with low protein levels, so a dietary consultation is recommended. Even though mild conditions may be controlled with topical steroids, most cases require oral treatment with oral tetracycline, an antibiotic with anti-inflammatory properties. The conditions described in this report are just a few of the common dermatologic problems encountered in older adults. Other conditions discussed during the presentation included inflammatory disorders, infestations, vascular disorders, and neoplasia. The impact of these conditions on the elderly may be significant, extending beyond the effects suffered by younger individuals. It is important that nurse practitioners be able to recognize and adequately treat or quickly refer older patients who have dermatologic problems. References
Norman RA. Ten common dermatological problems in geriatrics. Program and abstracts of the American Academy of Nurse Practitioners 16th Annual National Conference; June 28-July 1, 2001; Orlando, Florida. Yaar M, Gilchrest BA. Aging skin. In: Freedberg IM, Eisen AZ, Wo HK, et al, eds. Dermatology in General Medicine, 5th edition. New York: McGraw-Hill; 1999:1697-1706. Gilchrest BA, Chiu N. Aging and the skin. In: Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. Chapter 122. Whitehouse Station, NJ: Merck and Co, Inc; 2000. Available at: http://www.merck.com/pubs/mm_geriatrics/sec15/ch122.htm. Accessed July 19, 2001. Moschella SL. Skin diseases of the elderly. In: Norman RA, ed. Geriatric Dermatology. Chapter 3. New York: The Parthenon Publishing Group; 2001:17-34. Gilchrest BA, Chiu N. Common skin disorders. In: Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. Chapter 123. Whitehouse Station, NJ: Merck and Co, Inc; 2000. Available at: http://www.merck.com/pubs/mm_geriatrics/sec15/ch123.htm. Accessed July 19, 2001. Drake LA, Millikan LE. The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Doxepin Study Group. Arch Dermatol. 1995;131:1403-1408. Weintraub E, Robinson C, Newmeyer M. Catastrophic medical complication in psychogenic excoriation. South Med J. 2000;93:1099-1101. Harris BA, Sherertz EF, Flowers FP. Improvement of chronic neurotic excoriations with oral doxepin therapy. Int J Dermatol. 1987;6:541-543. Kalivas J, Kalivas L, Gilman D, et al. Sertraline in the treatment of neurotic excoriations and related disorders. Arch Dermatol. 1996;132:589-596. Arnold LM, McElroy SL, Mutasim DF, et al. Characteristics of 34 adults with psychogenic http://www.medscape.com/viewarticle/420852?src=search Common Dermatologic Problems in Older Patients excoriation. J Clin Psychiatry. 1998;59:509-514. Simeon D, Stein DJ, Gross S, et al. A double-blind trial of fluoxetine in pathologic skin picking. J Clin Psychiatry. 1997;58:341-347. Glick BP, Zaiac M, Rebell G, Zaias N. Superficial mycoses in the elderly. In: Norman RA, ed. Geriatric Dermatology. Chapter 6. New York: The Parthenon Publishing Group; 2001:83-93. Hess TM, Lutz LJ, Nauss LA, Lamer TJ. Treatment of acute herpetic neuralgia. A case report and review of the literature. Minn Med. 1990;73:37-40. Roberts JL. Geriatric hair and scalp disorders. In: Norman RA, ed. Geriatric Dermatology. Chapter 4. New York: The Parthenon Publishing Group; 2001:35-64. Gerson AA. Epidemiology and management of post herpetic neuralgia. Semin Dermatol. 1996;15(suppl 1):8-13. Medline Abstracts. Treatment of neuropathic pain using topical agents. Medscape, 2000. Williams JV, Honig PJ, McGinley KJ, Leyden JJ. Semiquantitative study of tinea capitis and the asymptomatic carrier state in inner-city school children. Pediatrics. 1995;96:265-267. Copyright 2001 Medscape Portals, Inc. • About Medscape • Privacy & Ethics • Terms of Use • Help • W
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