Download Module 4 - 4.05 MB

THE SKIN SHOW
“Critters
VS
the Hide
Module #4
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
402-559-7512
All photos were reprinted with permission from the American Academy of
Dermatology. All rights reserved.
Slides adapted with permission from GRS 5th edition: Dermatologic diseases and disorders
PROCESS
Series of 4 modules and questions on
Etiologies, Evaluation, & Management
Step #1 Power point module with voice
overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or
take a break
Objectives
Upon completion the learner will be able to
1. Identify common infectious dermatologic
diseases in the elderly.
2. List treatment modalities for common
infectious dermatologic diseases in the
elderly
What’s this?
Candidiasis
( intertrigonal)
Intertrigonal: commonly found in
the web space between the 4th
and 5th toes.
Moist erythema, maceration and
superficial erosion is apparent.
More common in older adults
because of increased skin
folds from decreased dermal
elasticity
Often associated with secondary
candidal or mixed bacterial
colonization
TREATMENT OF
INTERTRIGO
• Keep area dry, open to air
• Use topical antifungal powder or
lotion (eg, 2% miconazole powder or
1% clotrimazole lotion)
• Use mild topical corticosteroid
occasionally to reduce inflammation
What’s this?
Answer:
Candidiasis
• rash may resemble
intertrigonal but have
peripheral satellite papules
and pustules
• At risk: older persons with
decreased mobility, increased
skin moisture or friction, poor
hygiene, diabetes mellitus
• Oral thrush may develop in
those on corticosteroid
inhalers, antibiotics,
immunosuppressants, or with
concomitant illness (diabetes)
CANDIDIASIS
• Diagnosis: KOH preparation reveals
spores and pseudohyphae
• Treatment:
• Keep skin dry
• Improve hygiene
• Use topical or oral anticandidal agents
(1% clotrimazole lotion, nystatin,
ketoconazole)
What’s wrong with the
nails?
Answer:
Onychomycosis
often yellow, thickened, and
friable, with yellow-brown
debris under the nail plate.
Causes: dermatophytes,
yeasts, and
nondermatophytic molds
Often preceded by or
concomitant with tinea pedis
Diagnose by KOH preparation
or fungal culture
TREATMENT OF
ONYCHOMYCOSIS
For cosmetic concerns, comorbidities (diabetes), or pain
•
• Topical agents not usually effective
• Oral griseofulvin: poor absorption, side effects, and drug
interactions limit adherence and efficiency
• Oral terbinafine: only orally active fungicidal agent, may
interact with tricyclic antidepressants
• Oral fluconazole: safe and useful for candida, well
tolerated
• Oral itraconazole: potential for drug interactions
(cytochrome P-45O)
• Treatment may take 3 to 4 months
• Relapse rate is high
What’s this?
Answer:
HERPES ZOSTER
• Prodrome: pain, burn, itch,
dull ache
• Grouped clusters of vesicles
and pustules on an
erythematous base involving
a dermatome.
• More than 2/3 of cases occur
in persons aged 50 or older
• Incidence is 20 to 50 times
higher among
immunosuppressed patients
Ddx: -Herpes simplex;
-Dermatitis herpetiformis
-Allergic contact dermatitis
HERPES ZOSTER
• Most important reason for varicella
zoster virus (VZV) reactivation is
senescence of the cellular immune
response to VZV with increasing age
• Reactivation also associated with
HIV, malignancy, use of
immunosuppressive drugs
COMPLICATIONS OF ZOSTER
• Involvement of ophthalmic branch of trigeminal nerve
• Requires careful ophthalmic monitoring
• Hutchinson’s sign: vesicles on the tip of the nose represents
involvement of nasociliary branch
• Ramsay-Hunt syndrome (involvement of facial or auditory
nerves)
• Presents as herpes zoster of external ear or tympanic
membrane
• Leads to facial palsy with or without tinnitus, vertigo, and
deafness
• Pain can precede, co-exist, or persist after rash
• Post-herpetic neuralgia: pain that persists or appears after
rash has healed > 30 days after onset of rash
• Occurs in 70% of those ≥ 70
• Prevention and education more effective than treatment
DIAGNOSIS OF HERPES
ZOSTER
• Tzanck smear from base of vesicle
shows multinucleated giant cells and
epithelial cells containing intranuclear
inclusion bodies
• Smear can be sent for direct fluorescent
antibody staining
• Definitive diagnosis by viral culture
TREATMENT OF HERPES
ZOSTER
• If intact immunity, herpes zoster is usually self-limited
• Treatment should start within 72 hours of rash
• Acyclovir 800 mg, 5x / day for 7 to 10 days
• Valacyclovir ( Valtrex) 500 mg tid X 10 days
• Famciclovir (Famvir) 500 mg tid x 7 days
• Early treatment: 1)halts progression of disease,
2) increases rate of clearance of virus from vesicles,
3) decreases incidence of visceral and cutaneous
dissemination, 4) decreases ocular complications
when eye is involved, may decrease pain and
incidence of post-herpetic neuralgia
• Wet compresses(Burrow’s)/topical antibiotics can treat
secondary bacterial infection
TREATMENT OF POSTHERPETIC NEURALGIA
• No definitive therapy
• Antidepressants, anticonvulsants
Narcotics, epidural injection of local
anesthetics, capsaicin, acupuncture
• Corticosteroids may decrease acute
neuropathic pain and reduce pain
medicine requirements
What’s this?
77 yo male
homeless with
diffuse
pruritus,
erythematous rash
with scabs.
Answer;
SCABIES
Symptoms include severe
pruritus (esp. of hands,
axillae, genitalia, and periumbilical region),
Signs: erythematous, crusted
papules, and linear burrows
• Infestation of mite
Sarcoptes scabiei
• Common in institutionalized
older persons; epidemics
occur in long-term-care
facilities
• Eradication can be difficult
• Spread by person-to-person
contact
Ddx; - Lichen simplex chronicus
-Atopic dermatitis
-Flea or insect bites
-Pruritus of systemic disease
SCABIES
• Diagnosis: scraping of suspected lesion (mite
excreta, eggs or mite may be seen)
• Treatment often initiated when clinical
suspicion of infestation is strong
• Treatment:
• Topical permethrin 5% or lindane ( Kwell) 15 cream
• Re-treat in 1 week if itching and lesions persist
• Launder bed linens and clothing in hot water
• May use topical corticosteroids for pruritus
• Pruritus may persist for weeks to months
The End
of
“Skin Show”
Module Four
Thank you for Your kind Attention !!
Ed Vandenberg MD CMD
Section of Geriatrics
981320 UNMC
Omaha NE
68198-1320
[email protected]
Web: geriatrics.unmc.edu
post-test
• A 74-year-old man with diabetes mellitus and
hypertension has onychomycosis of most nails
on each foot confirmed by potassium hydroxide
(KOH) staining and fungal culture of nail
scrapings. In addition to having cosmetic
concerns, the patient finds that the crumbling,
thickened nails are causing discomfort and
difficulty in his routine foot care. His current
medications are glyburide 10 mg twice daily and
enalapril 5 mg daily.
• What is the most appropriate therapy for this
patient?
What is the most appropriate therapy for this
patient?
A. Griseofulvin 500 mg daily
B. Ketoconazole 200 mg daily
C. Itraconazole 200 mg daily
D. Terbinafine 250 mg daily
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY
Answer:D. Terbinafine 250 mg daily
The most appropriate treatment for this patient is
terbinafine, a fungicidal agent especially useful for
onychomycosis. Terbinafine is an orally active allylamine
derivative with a high potency against dermatophytes. It
is well absorbed from the gastrointestinal tract and
metabolized in the liver. Its effect is cytochrome P-450independent. Terbinafine is generally well tolerated, with
occasional gastrointestinal side effects and the rare
serious skin reaction. The treatment is with one tablet
daily for 6 weeks for fingernail infections and for 3
months for toenail infections. Recurrence rates are
below 10%.
• Itraconazole is also effective against
dermatophytes and is likewise readily absorbed
from the gastrointestinal tract. Daily doses of
200 mg of itraconazole for 6 to 8 weeks for
fingernails and 3 to 4 months for toenail
mycoses have cure rates of 80% to 90%.
Recurrence rates are below 10%. Itraconazole
does affect drugs metabolized by the
cytochrome P-450 3A system and can cause
severe hypoglycemia in patients who are taking
oral hypoglycemic agents, as is the case with
this patient, for whom terbinafine would thus be
a better choice.
• Ketoconazole, the first orally active broadspectrum antimycotic drug, has been
abandoned for this indication because of
idiosyncratic hepatic side effects.
Griseofulvin is a safe systemic treatment
for onychomycosis but has very low cure
rates, about 50% to 60% for fingernails
and 20% for toenails. Recurrence rates
with use of griseofulvin approach 100%.
end