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“THE SKIN SHOW”
Aging Dermatology and Disease
Module #3
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) List the normal age related skin changes
2) Identify and treat the common skin
disorders of aging
3) Identify malignant versus non malignant
skin conditions in aged
What’s this?
Eighty-year-old
female with persistent
“itchy” feeling in legs.
Answer:
XEROSIS
Dry, erythematous, scaly, fissured, most
commonly on extremities
Diagnosis: history, associated with
generalize dry skin ( “sand paper”).
Causes: reduced water content & reduced
epidermal lipid production
Risk factors:
Decreased skin hydration from low
humidity, diuretics, excessive bathing,
hot water, harsh soaps, incomplete
drying
Differential diagnosis:
Irritant contact dermatitis
Eczemas
Statis dermatitis
Psoriasis
Dermatophyte
TREATMENT OF XEROSIS
• Reduce bathing
frequency, soap to
“critical” areas only
• Moisturizing agents
containing lactic acid or
α-hydroxy acids
• Tepid, not hot, showers
• Mild topical
corticosteroids
episodically for
irritation or
inflammation
• Emollients immediately
after bathing when skin
moist
• Use moisturizer
instead of itching
• Increase humidity and
fluid intake
Avoid:
Bath oils
Systemic anti-pruritics
NEURODERMATITIS
Alias: lichen simplex chronicus
•
Chronic, pruritic conditions of
unclear cause
•
Severe, paroxysmal, before sleep
•
Most common: women, Asian
•
signs of chronic scratching
•
Location: lower extremeties
•
Exclude irritant or allergic contact
dermatitis
•
Treatment:
• Potent topical corticosteroids
(often under occlusion)
• Emollients
• Behavioral modification
Avoid: systemic anti-pruritics
What’s this?
Seventy-seven-year-old
female, non pruritic,
slowly progressive
eruption, surrounding
edema.
Answer:
Stasis dermatitis
Location: lower extremity, associated with
venous insufficiency
Prevention: leg elevation, compression
stockings, muscle contraction, moisturize
skin
Venous insufficiency ulcers:
Debride:
(wet-dry, Hibclens whirlpool, hydrocolloid nonadhesive)
Heal:
Unna boot, change no more than 2x/wk,
Correct associated factors: CHF, malnutrition,
constricting garments,
Evaluate arterial flow (ABI)
What’s in the scalp?
Answer:
SEBORRHEIC DERMATITIS
Common chronic dermatitis
Erythema and greasy-looking scales
Typical locations: hairline,
nasolabial fold, midline chest
Dandruff is often a precursor
More common in men
Cause unclear: normal yeast flora
may cause inflammation
TREATMENT OF
SEBORRHEIC DERMATITIS
• Can be suppressed but not cured
• Mild topical corticosteroids useful for
acute forms (1% to 2% hydrocortisone)
• Once controlled, maintenance with
medicated shampoos that act against
yeast, eg, selenium sulfide,
ketoconazole, tar shampoos
What’s this?
Sorry,
no clues for
you!!
Answer:
Bullous Pemphigoid
Tense, large, clear fluid or hemorrhagic
filled bullaeon an erythematous base
were seen on the trunk and
extremities. Bullae rupture and leave a
scab with crusting.
•
•
Autoimmune
Most often in adults in 60s and 70s
•
Condition may last from months to
years, but often is self-limited
•
Diagnosis by biopsy and
immunofluorescence
TREATMENT OF BULLOUS
PEMPHIGOID
• Dependent on severity
• For localized disease, use topical
corticosteroids
• For more extensive disease, use
• Systemic corticosteroids
• Other immunosuppressant (azathioprine or
cyclophosphamide)
• Tetracycline and niacinamide combination therapy
What’s this?
Answer:
PSORIASIS
Well-demarcated, erythematous
papules & plaques with silverywhite scales. May have pustular
component.
Location: knees, elbows, scalp, back
genitalia, intergluteal folds, nails
Exacerbated by: trauma (physical or
psychological), inflammation of skin,
low humidity, sunburn,
drugs: digoxin, clonidine, lithium,
propranolol, antimalarial drugs
Differential diagnosis:
Tinea corporis
Pityriasis rosea
Nummular eczema
Seborrheic dermatitis
TREATMENT OF
PSORIASIS
• Topical treatments:
• may control mild disease but may be irritating or
messy
• include corticosteroids, vitamin D derivatives
(calcipotriene), topical retinoids (tazarotene),
salicylic acid, tar compounds
• long-term use of topical corticosteroids is limited
by cutaneous atrophy and tachyphylaxis
TREATMENT OF
PSORIASIS
• Systemic treatment:
• if no response to topicals
• phototherapy
• immunosuppressive agents (cyclosporine,
methotrexate)
• UV therapy:
• can be used with topical therapy
• PUVA (psoralen with UVA light) and UVB
• Evaluate risks, benefits of all therapies for older adults
What’s this?
Answer:
ROSACEA
Diffuse erythema, with papules.
Location: cheeks, forehead & chin
Nose: thickended, erythematous
rhinophyma.
Common in fair-skinned persons of all
ages
Common symptom: Recurrent facial
flushing from a variety of stimuli
(sunlight, alcohol, hot beverages,
drugs that cause vasodilation)
Chronic condition with frequent flares
TREATMENT OF ROSACEA
 Avoid skin irritants, strong soaps
 Reduce sun exposure: use sunscreens
 For moderate to severe flares:
oral antibiotics (tetracyclines, eg,
doxycycline, minocycline) or erythromycin
 For mild cases and maintenance:
topical antibiotics (erythromycin,
clindamycin, metronidazole)
TREATMENT OF SEVERE
ROSACEA
• Severe or refractory rosacea:
Oral isotretinoin
• Erythema and telangiectasias:
• Difficult to treat
• Lasers provide option to reduce redness and
improve cosmetic appearance
• Rhinophyma:
• Less common
• Can be treated with surgical excision or CO2
laser ablation
The End of “Skin Show”
Module Three
Post-test
• A 78-year-old man has greasy, yellow
scales over the central chest, nasolabial
folds, scalp, eyebrows, and in the ears.
The rash developed last year, after the
patient was placed in a skilled nursing
facility following a stroke. Which of the
following is the most likely diagnosis?
Which of the following is the most likely
diagnosis?
A. Actinic keratoses
B. Seborrheic dermatitis
C. Psoriasis
D. Scabies
E. Eczema
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:B. Seborrheic dermatitis
Seborrheic dermatitis is a chronic, superficial,
inflammatory process affecting the hair- bearing
areas of the body. It has been associated with
neurologic conditions such as Parkinson’s
disease and as a sequela to stroke with motor
function impairment. It also affects
approximately one third of patients with AIDS. It
is thought to be a reaction to the yeast
Pityrosporum ovale. Therapeutic options include
nonprescription ketoconazole and selenium
sulfide shampoos, as well as 1.0% to 2.5%
hydrocortisone cream.
• Actinic keratoses are precancerous skin lesions
that are erythematous, with a rough surface.
They usually are found in sun-exposed areas.
Typical psoriatic lesions are erythematous
plaques with a silvery-white, micaceous, firmly
adherent scale on extensor surfaces. Scabies
infestation usually is accompanied by severe
itching. Erythematous excoriated papules can be
found on inspection of the nipples, axillae,
genitalia, wrists, and fingers. Burrowing may be
visible, and a black dot, the causative mite, can
be seen. The greasy appearance and
distribution (chest and ears) of this rash make
eczema very unlikely. end