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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