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By :Dr .Pawana Kayastha SKIN CHANGES IN OLD AGE •Typical changes: include atrophy, laxity, wrinkling, dryness, irregular pigmentation and sparse grey hair. •changes are brought about by: age-related alterations in structure and function of the skin •cumulative effects of environmental insults, especially ultraviolet radiation •cutaneous consequences of disease in other organ systems •Immunity: alterations in immune surveillance and antigen presentation, and reduced cutaneous vascular supply which lead to decreases in the inflammatory response, absorption and cutaneous clearance of topical medications. •Consequences: these changes make the skin less durable, slower to heal, and more susceptible to damage and disease. COMMON SKIN DISEASES IN OLD AGE •Prevalence: about 40% of individuals over the age of 60 years have significant dermatological problems. •Diseases: the most common in this age group are: • skin cancers • leg ulcers, a major cause of morbidity in the elderly • blistering disorders • herpes zoster (shingles) and post-herpetic neuralgia inflammatory skin diseases, e.g. asteatotic, gravitational and seborrhoeic eczema, . psoriasis lichen sclerosus et atrophicus scabies lymphoedema pruritus of old age drug-related rashes Long standing pigmented spot. The principal clinical concern is to distinguish correctly between benign pigmented lesions and melanoma. The situation is complicated by the fact that any one of a number of changes in a pigmented lesion is highly sensitive as a marker of melanoma, specificity is low. ABCDE FEATURES OF MALIGNANT MELANOMA Asymmetry Border irregular Colour irregular Diameter often greater than 0.5 cm Elevation irregular (+ Loss of skin markings) Determine the precise nature of the change. Is it due to the development of itch, inflammation, bleeding or ulceration, or does it relate to the colour, size, shape or surface of the lesion? Subtle changes:plucking hair,shaving,irritants Is the patient worried about change in one or many moles? Positive family history of melanoma. Fewer than 10% of melanomas occur in individuals with a strong family history but in some of these families up to 50% of individuals may develop melanoma. Examine the pigmented lesion carefully. Look at the morphology of the melanocytic naevi at other sites. magnifying glass or dermatoscope whether the lesion is a benign melanocytic naevus or a malignant melanoma Before trying to answer this, the clinician needs to exclude the possibility that it is another type of pigmented lesion: Lentigo (a benign proliferation of melanocytes) Freckle (ephelis, a focal overproduction of melanin,) Seborrhoeic wart (basal cell papilloma, a benign keratinocyte tumour) Dermatofibroma. This lightly pigmented firm dermal nodule is common on extremities in young adults. It feels larger than it looks. There is dimpling when the skin is squeezed on both sides (positive Fitzpatrick sign). Pigmented basal cell carcinoma : This lesion is usually found on the face of the elderly and is slow-growing. It has a blue-brown hue with an opalescent look. There may be a rolled edge around an ulcer. Subungual haematoma Any changing lesion which is suspected of being a malignant melanoma should be excised without delay, with a clear margin. If there is even a low index of suspicion of a malignant melanoma ,then the lesion should be reviewed 1 month and may be 3mths later. Continuing change demands excision. If benign then reassurance but advised to report back without delay if the change and concern continue If in doubt cut out and then check the histology An unpleasant localized or generalized sensation on the skin, mucus membranes or conjunctivae which the patient instinctively attempts to relieve by scratching or rubbing Many Causes, Many Treatments Trivial to Life threatening (mosquito bite) (malignancy) 10-50% of cases with generalized itching have systemic disease Skin diseases associated with generalised pruritus Eczema Scabies Urticaria/dermographism Pruritus of old age and xeroderma Skin diseases associated with localised pruritus Eczema Lichen planus Dermatitis herpetiformis Pediculosis CAUSES OF PRURITUS IN PREGNANCY iin IN PREGNANCYGestation and Condition Obstetric cholestasis features 3rd trimester Associated with abnormal liver function tests Pemphigoid 3rd trimester gestationis Pruritus followed by blistering Starts around the umbilicus Polymorphic 3rd trimester, eruption after delivery (urticarialpapules Polymorphic ) of pregnancy lesions with urticaria Treatment Emollients Chlorphenamine Colestyramine Early delivery Topical or oral corticosteroids Chlorphenamine Prurigo gestationis 2nd trimester Emollients Excoriated papules Topical corticosteroids Chlorphenamine Pruritic folliculitis 3rd trimester Aseptic pustules on trunk Topical corticosteroids Chronic Renal Failure: 25-86% itching (not in acute renal failure) Attrib to accumulation of pruritogens: histamine (mast cells), serotonin Ca, Phos, Mg, Al, vit A also implicated 1/3 uremic patients not on dialysis Maintenance hemodialysis: 70-80% 20-25% janudiced patients with hepatobiliary disease associated with cholestasis 100% primary biliary cirrhosis Viral hepatitis Attrib to bile salts in serum and tissues Begins palms and soles & spreads inward vera (50%) iron def anemia, lymphomas Polycythemia Hodgkins – 30% T-cell: almost all leukemias, plasma cell dyscrasias, mastocytosis Central: CNS abscess, spinal and cerebral tumors (17%), CVAs Attrib to effects on descending pathways which itching Neurogenic Shingles (10-15% in US) Notalgia paresthetica: sensory entrapment syndrome causing neuropathy of T2-6 dorsal spinal nerves Diabetes Thyrotoxicosis,Hypothyroidism Generalised due to dry skin Localised may be due to Candida Myxodema Postmenopausal syndrome Most common trigger: mucocutanious candidiasis HIV Infection, infestation Eosinophilic folliculitis Unknown infection Malignancy Unknown Psychogenic Unknown opioids commonly Direct action on medullary dorsal horn and trigeminal nucleus of medulla – not t/histamine release Spinal anesthesia with lidocaine: 30-100% pruritis Fentanyl: Intrathecal 67-100% Epidural 67% Morphine Intrathecal 62-82% Epidural 65-70% Penicillin: immediate type I hypersensitivity reaction Vancomycin: massive nonimmunologic release of histamine “Red Man Syndrome” (flushing CP, pruritis, muscle spasms, hypotension) Related to rate of infusion Potentiated by muscle relaxants and opioids Attenuated by H1 blockers Rifampin Fentanyl: itching decreased when mixed with bupivicane, increased when mixed with procaine Drug induced cholestasis esp phenothiazenes, estrogens, tolbutamide, anabolic steroids LOOK for skin changes If no skin disease identified then search for systemic diseases by systemic examination Investigation –as per systemic illness Pressure Low-intensity electrical Histamine: acts directly on free nerve endings in skin Histamine Substance Prostaglandins Proteases Leukotrienes Peptides Serotonin Enzymes Acetylcholine Cytokines P Cutaneous (pruritoceptive) Neurogenic Neuropathic Mixed Psychogenic C-Fibers originate @ dermal/epidermal jxn Thin unmyelinated axons, lots of branching Ipsilateral dorsal horn of spinal cord Synapse with itch-specific secondary neurons Cross to opposite anterolateral spinothalamic tract to thalamus Somatosensory cortex of postcentral gyrus SLOW transmission and BROAD receptor field Scratching stimulates large fast-conducting A-fibers adjacent to slow unmyelinated C fibers A-fibers synapse with inhibitory interneurons and inhibit C-fibers Scratching may either–stimulating ascending sensory pathway-inhibit itch at the spinal cord Or,may damage itch fibers directly Painful stimuli (thermal, mechanical, chemical) can inhibit itching Inhibition of pain (opioids) may enhance itching Inhibit mediators of itch: histamine, prostaglandins, substance P, serotonin, cytokines Block chemicals that induce pruritis: opioids, antimicrobials Treat effects of diseases which induce itching: eczema, CRF, LF, heme, neuro, endo cool compresses emollients topical steroids antidepressants anxiolytics antibiotics Tx for uremic itching: renal transplant Effective even when transplant is failing as long as immunosuppresants are given Antihistamines not effective Also effective: moisturizers, UV-B tx (vit A in skin), oral activated charcoal, cholstyramine, naltrexone, ondansterone, topical capsaicin, azelastin, thalidomide, IV lidocaine, erythropoetin, electric needle stim Tx: reverse cholestatis, liver transplant Also helpful: oral guar gum (dietary fiber) binds bile acids; cholestyramine; rifampin! (inhibits bile uptake), opioid antagonists, codeine, propofol, ondansetron,Naltrexone UVB Not helpful: scratching Thyrotoxicosis Lymphoma Iron defn HIV Emollients Cimetidine Iron supplement Treatment of opportunistic infection Local corticosteroids, UVB UVB Pshychogenic Psychotherapy Anxiolytics Antidepressives opioid related pruritis : Diphenhydramine – for systemic opioids For Neuraxial Opioids: Ondansteron Naloxone (1-2mcg/kg/hr) Nalbuphine (10-20 mcg/kg/hr) Propofol (.5-1mg/kg/hr) Lidocaine (2mg/kg/hr) NSAIDs (diclofenac, tenoxicam) Droperidol Penicillin Reaction Diphenhydramine