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a;lskdjf > 9 - Geriatric Skin Disorders > Flashcards

9 - Geriatric Skin Disorders Flashcards

1
Q

Normal skin aging

A

o Chronological = physiologic alteration in skin function

o Photoaging = secondary to UV exposure

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2
Q

Decrease in skin lipids with againg leads to

A

dryness

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3
Q

Decreased cell replacement with againg leads to

A

roughness, delayed healing

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4
Q

Decreased DNA repair with againg leads to

A

increased malignancies

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5
Q

Fragmentation of collagen and elastin with againg leads to

A

Wrinkles, increase in ulcers

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6
Q

Reduced connective tissue support of blood vessels with againg leads to

A

increased purpura

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7
Q

Decreased sensation with againg leads to

A

Increased injury

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8
Q

Impaired thermoregulation with againg leads to

A

vulnerability to heat and cold

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9
Q

Reduced function of subcutaneous glands with againg leads to

A

decreased lipids

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10
Q

Reduced function of sweat glands with againg leads to

A

risk of overheating

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11
Q

Decrease in Langerhans cells with againg leads to

A

Delayed healing and increase in infection

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12
Q

Reduced subcutaneous fat with againg leads to

A

increased risk of injury

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13
Q

Flatteneing of DE junction with againg leads to

A

increase risk of skin tears and listers

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14
Q

Reduced linear nail growth with againg leads to

A

Onychogryphosis, longitudinal striations, brittle nails

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15
Q

Decreased melanocytes with aging leads to

A

Increase in malignancies

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16
Q

A patient asks you why their nails are so brittle and why they are susceptible to skin tears when bumped. Your response includes:
o Brittleness is due to the longer time it takes for nails to grow
o Brittleness is due decrease in skin lipids
o Skin tears are due to decreased number of Langerhans’ cells
o Skin tears are due to decreased number of melanocytes
o Skin tears are due to flattening of the DE junction

A

o Brittleness is due to the longer time it takes for nails to grow
o Skin tears are due to flattening of the DE junction

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17
Q

Extrinsic changes due to UV light

A
  • Pruritus
  • Spider veins
  • Age “spots”
  • Easy bruising and skin breaks
  • Increase in malignancy
18
Q

Decubitus ulcer

A
  • Occur over bony prominences
  • Pressure over time leads to ischemia and tissue damage
  • Stages (according to NPUAP)
    o I - non-blanchable erythema
    o II - necrosis with superficial to partial thickness skin loss
    o III - necrosis with full-thickness skin loss to fascia
    o IV - extensive necrosis into muscle and bone
  • Treatment
    o Frequent change of position
    o Use of air, gel, water mattresses
    o Keep ulcer dry
    o Nutritional consult
    o Infection control measures
19
Q

Xerosis

A
  • Cause
    o Due to decrease in lipids combined with impaired epidermal barrier function (greater loss of water from skin)
  • Symptoms
    o Dryness leads to pruritus, rough and scaly skin
    o Exacerbated by soap, hot water, low humidity
  • Similar (synonymous?) to asteatotic eczema
  • Treatment
    o Moisturizers with urea, lactic acid, petrolatum, lanolin
    o Can add low potency steroid ointment (1 % hydrocortisone)
    o Apply after bath  Best time to apply either type of moisturizer is after a bath
    o Hasten moisturizing by applying Saran wrap® over area, cover w/ sock at night
  • NOTE: there are numerous treatments out there because patients respond differently and there is no way to tell which ones
    o Hydrophobic = ointment/Vaseline physically trap water in the skin
    o Hydrophilic = lactic acid, urea, etc. draw water up to the epidermis to increase moisture
  • When you have SERIOUS xerosis  skin is breaking/bleeding down to the dermis, use 40% urea (costs $60 for a jar)
20
Q

Pruritus

with resultant excoriations

A
  • Most commonly caused by xerosis and leads to local excoriations
  • Due to increased touch and pain thresholds and/or systemic disorders (“PHILL”)
    o P = polycythemia vera
    o H = HIV
    o I = iron deficiency anemia
    o L = liver and renal dysfunction
    o L = lymphoma
  • Treatment
    o topical steroid ointments
    o topical Benadryl® (with or without calamine lotion)
    o topical lidocaine
    o topical NSAID’s and moisturizers
21
Q

Stasis dermatitis

A
  • Symptoms
    o Dermatitis may be weepy, dry, scaly, or lichenified
  • Cause
    o Venous hypertension leads to inflammatory reaction accompanied by leukocyte activation and release of red cells into tissue
    o This breaks down into hemosiderin depositions
  • Treatment
    o Compression dressings w/ or w/o Unna boot® to treat underlying skin condition
22
Q

Bacterial infection

A
  • Cause
    o Usually caused by Staph and Strep species (gram positive)
    o Due to alteration in skin architecture (loss of Langerhans’ cells) and loss of barrier function caused by physical factors (e.g., venous stasis)
  • Cellulitis
    o Infection of subcutaneous fat
    o Deeper than erysipelas and does not have a distinct border
  • Erysipelas
    o Infection of dermis and upper subcutaneous tissue
  • Treatment
    o Without open wound, topical treatment ineffective-need oral antibiotics
    o Usually PCN (but may have resistant staph infection), cephalosporin, clindamycin
23
Q

Herpes zoster

A
  • Cause
    o Due to impaired immune function
    o After recovery from chickenpox at young age, varicella zoster virus becomes latent in dorsal root ganglia, and reactivated with decline in immunity
  • Symptoms
    o Follows dermatome and very painful
    o Pain usually precedes onset of vesicular lesions and may last for months to years after disappearance of lesions (post-herpetic neuralgia)
  • Treatment
    o Oral acyclovir® and local wound therapy
    o Oral prednisone not recommended
    o Topical lidocaine
    o Zoster vaccine (Zostavax™) used for prevention only (effective 60% of the time)
24
Q

Herpes simplex

A
  • Types
    o Occurs as two types (1 and 2) with 1 being more common and usually occurs around the mouth (type 2 occurs in the genitalia)
  • Symptoms
    o After it infects skin it can remain latent in the nerve cell ganglia proximal to site of infection
    o In immune-compromised host, blisters form and then eventually ulcers with serpiginous borders
    o Abrupt onset, fever and malaise present before blisters-not as painful as zoster
  • Diagnosis via Tzanck smear
    o The vesicle should be unroofed aseptically.
    o Using a sterile instrument, the floor of the newly produced ulcer can then be scraped. The obtained material can be spread on a glass microscope slide and then dried and fixed for staining.
    o Staining can be performed with a Papanicolaou smear stain or, alternatively, whatever is available will suffice (eg, Gram, Giemsa, or Wright stain).
    o A positive result is the finding of multinucleate giant cells.
  • Treatment
    o Nucleoside analogs (Acyclovir®) and local wound therapy
25
Q

Molluscum contagiosum

A
  • Cause
    o Pox virus infection
  • Symptoms
    o Dome-shaped umbilicated papules transmitted by skin-to-skin contact
  • Treatment
    o Cryotherapy or electrodessication and curettage
    o When present, evaluate for immunocompromised states
26
Q

Tinea pedis

A 
-	Symptoms
o	Most common inter-digitally 
o	Asymptomatic 40% of time
o	Also common cause of plantar xerosis in elderly, especially if it is resistant to routine moisturizing 
-	Diagnosis
o	Diagnosis confirmed with KOH
-	Treatment 
o	Topical terbinafine, Ertaczo®
o	Use oral terbinafine if unresponsive to topical
27
Q

Onchychomycosis

A
  • Confusion as to offending fungus
    o Most experts claim 90% caused by dermatophytes, but another study claimed only 25% as causative agents
  • 4 different types
    o Distal subungual
    o Proximal subungual
    o Total subungual
    o Superficial white
  • Symptoms
    o Fungus produces keratinase which destroys nail and leads to the thickening, discoloration and loosening with accumulation of subungual debris
  • Diagnosis
    o KOH is NOT as reliable as other methods
    o Do a culture on Sabouraud’s medium or PAS staining instead
  • Treatment
    o Response to topical agents is limited
    o Oral terbinafine produces a complete cure (normal appearing nail and negative KOH or culture) 1/3 of time
28
Q

Scabies infestation

A
  • Cause
    o Common in nursing homes
    o Caused by mite and is contagious
  • Symptoms
    o Pruritic papules occur 2 weeks after infestation, with blisters more common in the elderly-may have serpentine channels as mite burrows
    o Primary manifestation is burrow found between fingers
    o Highly pruritic and will have overlapping signs of scratching which can hide diagnosis and be attributed to simply “itchy” skin in elderly
    o Severe form is Norwegian scabies where skin covered with thick, white scales and crusts-more widespread and on soles of feet; itching is not common
  • Diagnosis
    o Diagnosis by microscopic identification of mite or feces
  • Treatment
    o Treated with topical Elimite® (promethrin)
29
Q

Eczema (nummular)

A
  • Symptoms
    o Appearance similar to all forms of eczema which will have an inflammatory phase with vesicles and oozing, followed by a dry, crusty phase
    o Unique in that lesions are “coin-shaped” and frequently on extremities
    o Associated with cold temperatures and low humidity
  • Treatment
    o Treat with topical steroids and avoidance of harsh soaps or detergents
30
Q

Eczema (atopic)

A
  • Symptoms
    o Most often appears as dry, cracking skin on plantar surface of foot or toes
    o Patients will have some type of allergic history, usually “hay fever” or other environmental allergens
  • Treatment
    o Treat with topical steroids and avoid dry conditions
31
Q

Eczema (contact dermatosis)

A
  • Cause
    o In elderly, due to decreased ability to mount a delayed hypersensitivity reaction due to reduced number of Langerhans’ cells and T-cells and to diminished vascular reactivity
    o Irritants that cause this  Shoes, nickel, fragrances, balsam of Peru are common source
  • STUDY
    o One study showed significant occurrence in patients with concomitant leg ulcers treated with topical medications (silver sulfadiazine) due to inflamed skin which increases sensitization rates
  • Testing
    o If uncertain of cause, patient should be patch tested
  • Treatment
    o Topical steroids
32
Q

Lichen simplex chronicus (psycho-derm)

A
  • Used to be called neurodermatitis
  • Symptoms
    o Lichenified (exaggerated skin lines) hyperpigmented plaque
    o Patient habitually rubs and scratches area
  • Treatment
    o Treatment is topical steroids and anti-anxiety medications
33
Q

Bullous pemphigoid

A
  • Chronic autoimmune disease
    o Antibodies to desmosomal proteins causes separation of dermis and epidermis
  • Symptoms
    o Bullous eruption on normal and erythematous skin which is usually pruritic
    o Can develop in mouth and conjunctiva (refer immediately to prevent blindness)
  • Biopsy
    o Confirmation by biopsy and immunofluorescence
  • Causes “FIEF”
    o F = furosemide
    o I = ibuprofen
    o E = enalapril
    o F = flu vaccine
  • Treatment
    o Treatment is topical steroids and tacrolimus along with DMARDs
34
Q

Neoplasms

A
  • Seborrheic keratosis
  • Skin tags
  • Cherry angiomas
  • Actinic keratosis
35
Q

Seborrheic keratosis

A

o Stucco keratosis: hyperkeratosis that looks like it has been “stuck onto” the skin
o Sudden appearance of multiple lesions may signal internal malignancy known as Leser-Trelat syndrome

36
Q

Cherry angiomas

A

“Senile angioma”

37
Q

Actinic keratosis

A

o Scaly hyperpigmented or erythematous plaque due to UVB light
o Pre-malignant to squamous cell CA

38
Q

Malignancies common due to lower immunity and effects of UV light

A 
o	Malignant melanoma
o	Basal cell carcinoma
o	Squamous cell carcinoma
o	Keratoacanthoma
o	Sub-type of squamous cell CA
39
Q

Keratoacantoma

A
  • Erythematous, dome-shaped , 1-10 cm nodule with a keratin plug in the center
  • On sun-exposed areas
40
Q

A patient complains of intense itching and you are worried about a systemic cause. Select appropriate screening tests:
o CBC
o ALT and AST
o Creatinine
o HIV screening
o Check for interdigital papules or blisters

A

All of the above

41
Q 
A nursing home patient has dry, scaly skin that itches on the sole of the foot.  It has not responded to numerous OTC moisturizers or anti-fungals.  The patient relates an allergy to dust and no microscopic hyphae are seen.   The most likely diagnosis is:
o	Psoriasis
o	Eczema
o	Tinea
o	Xerosis
o	Scabies
A

Eczema

a;lskdjf (11 decks)

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