9 - Geriatric Skin Disorders Flashcards
1
Q
Normal skin aging
A
o Chronological = physiologic alteration in skin function
o Photoaging = secondary to UV exposure
2
Q
Decrease in skin lipids with againg leads to
A
dryness
3
Q
Decreased cell replacement with againg leads to
A
roughness, delayed healing
4
Q
Decreased DNA repair with againg leads to
A
increased malignancies
5
Q
Fragmentation of collagen and elastin with againg leads to
A
Wrinkles, increase in ulcers
6
Q
Reduced connective tissue support of blood vessels with againg leads to
A
increased purpura
7
Q
Decreased sensation with againg leads to
A
Increased injury
8
Q
Impaired thermoregulation with againg leads to
A
vulnerability to heat and cold
9
Q
Reduced function of subcutaneous glands with againg leads to
A
decreased lipids
10
Q
Reduced function of sweat glands with againg leads to
A
risk of overheating
11
Q
Decrease in Langerhans cells with againg leads to
A
Delayed healing and increase in infection
12
Q
Reduced subcutaneous fat with againg leads to
A
increased risk of injury
13
Q
Flatteneing of DE junction with againg leads to
A
increase risk of skin tears and listers
14
Q
Reduced linear nail growth with againg leads to
A
Onychogryphosis, longitudinal striations, brittle nails
15
Q
Decreased melanocytes with aging leads to
A
Increase in malignancies
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
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
Molluscum contagiosum
- 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
Tinea pedis
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- 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
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27
Onchychomycosis
- 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
Scabies infestation
- 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
Eczema (nummular)
- 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
Eczema (atopic)
- 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
Eczema (contact dermatosis)
- 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
Lichen simplex chronicus (psycho-derm)
- 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
Bullous pemphigoid
- 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
Neoplasms
- Seborrheic keratosis
- Skin tags
- Cherry angiomas
- Actinic keratosis
35
Seborrheic keratosis
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
Cherry angiomas
"Senile angioma”
37
Actinic keratosis
o Scaly hyperpigmented or erythematous plaque due to UVB light
o Pre-malignant to squamous cell CA
38
Malignancies common due to lower immunity and effects of UV light
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o Malignant melanoma
o Basal cell carcinoma
o Squamous cell carcinoma
o Keratoacanthoma
o Sub-type of squamous cell CA
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39
Keratoacantoma
- Erythematous, dome-shaped , 1-10 cm nodule with a keratin plug in the center
- On sun-exposed areas
40
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
All of the above
41
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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
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Eczema
