Lecture 12- Geriatric Derm Flashcards
The major dermatologic changes with aging are…
- epidermal and dermal changes
- Reduced lipids
- Slower wound healing
- Lower immune function
- Reduced collagen and elastin
- Hair changes
Epidermal Aging
- When young, the epidermis interdigitates with dermis
- With aging, the interdigitations flatten, resulting in
- reduced contact between epidermis and dermis
- Decreased nutrient transfer
- Increased skin fragility
- Easy bruising
Lipids and Aging
Aging is associated with decreased lipids in the top skin layer, which leads to…
- dryness and roughness
- decreased barrier function
Impaired healing and immune function with aging
- slower turnover of epidermal cells - accounts for slower rate of healing
- Lower number of immune antigen-presenting cells may cause reduced cutaneous immune surveillance
Aging Skin and Hair
- Changes in follicular melanocytes cause graying hair
- Shortened growth phase of hair follicles, and increased duration of telogen results in decreased hair density
Preventing Photodamage
- Use broad-spectrum sunscreens
- avoid direct sunlight
- Use protective clothing, including hats
- use sunglasses
Seborrheic Dermatitis
- Common chronic dermatitis
- erythema and greasy looking scales
- Usually along hairline, nasolabial fold, midline chest
- Dandruff a typical precuror
- more common in Parkinson patients
- cause unclear
Seborrheic Dermatitis Treatment
- suppressed by not cured
- mild topical corticosteroids
Rosacea
Diffuse erythema and erythematous papules and papulopustules on cheeks, forehead, and chin.
- Thickening of the skin on the nose and changes like those of early rhinophyma
- more common in fair-skinned people
- affects all ages
Rosacea treatment
- avoid skin irritants, strong soaps
- Reduce sun exposure
- use oral or topical antibiotics depending on severity
- for SEVERE rosacea, use oral isotretinoin as well as some surgical procedures for cosmetic fixes
Xerosis
- dry skin
- Exacerbated by environemental factors
- more often on legs, can result in pruritus
- severe cases manifest as Eczema
Xerosis Treatment
- avoid environmental triggers
- don’t take hot showers
- use moisturizers after bathing
- mild topical corticosteroids if bad
Neurodermatitis
- Chronic, pruritic conditions of unclear cause
- AKA lichen simplex chonicus
- show signs of chronic scratching
Intertrigo and Candidiasis
commonly found in the web space between the 4th and 5th toe
- intertrigo more common in older adults because of increased skin folds
- often associated with secondary candidal or mixed bacterial colonization
- common under breasts, around scrotum
Intertrigo treatment
Keep area dry, open to air
- use topical antifungal powder or cream
- Mild topical corticosteroid occasionally to reduce inflammation
Bullous Pemphigoid
- Tense, fluid-filled and hemorrhagic bullae on an erythematous base on trunk and extremeties
- autoimmune blistering disorder
- occurs mainly in adults in 60s and 70s.
- Blisters usually large and tense- may be filled with clear or hemorrhagic fluid
- Can last months to years, but often self-limited
- antigens develop in the hemidesmosomes
- antibodies bind them and activate complement cascade- lead to degraded mast cells causing separation of epidermis from basement membrane
Biggest difference between bullous pemphigoid and pemphigus vulgaris
- Bulous pemphigoid does NOT occur on mucus membranes while Pemphigus vulgaris DOES.
- also bullous pemphigoid seen in geriatrics while pemphigus vulgaris seen during middle age.
Bullous Pemphigoid treatment
- topical corticosteroids, calcineurin inhibitors, and nicotinamide with tetracycline
- if more extensive, use systemic corticosteroids or other immunosuppressants
Pruritis
- can be very sever in older adults
- just means itching- can be from tons of different things
Treatment of Pruritis
- treat underlying cause when possible!
- topical corticosteroids, emollients, menthal all good for symptom relief
Cutaneous Horns
- proliferation of keratinocytes
- Almost always benign- but Excision of them is key!
Stasis Dermatitis
- Early sign of chronic venous insufficiency of legs- triggered by chronic venous hypertension and incompetent valves
- usually seen around medial ankle area
Stasis Dermatits Treatment
- Compression bandages or stockings
- Leg elevation at rest
Venous and Arterial Ulcers
- of the lower extremity- often caused by vascular disease or neuropathy
- majority are from venous disease
- mixed arterial cause the next most common
Onychomycosis
- nails infected by fungi
- about 1/3 of older adults have this
- more common in adults with obesity, DM, PAD, immunodeficiency, chronic tinea pedis, or psoriasis
- caused by dermatophytes mostly, but also yeasts and saprophytes
Onychomycosis
- no topical antifungals are effective
- Oral terbinafine, fluconazole, and itraconazole
- long treatment period typically, with high relapse rates
Herpes Zoster
- clusters of vesicles and pustules on an erythematous base involving a thoracic dermatome
- most common in older than 50 population
- the most important reason for varicella zoster virus (VZV)
- Reactivation also associated with HIV, malignancy, and use of immunosuppressive drugs
Herpes Zoster Complications
- Involvement of the ophthalmic branch of trigeminal nerve- which can lead to Hutchinson’s sign- vesicles on the tip of the nose
- Ramsay-Hunt Syndrome- 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- can be very painful!
Diagnosis of Herpes Zoster
- characteristic physical exam
- Tzanck smear from base of vesicle shows multinucleated giant cells
- definitive diagnosis by viral culture
Treatment of Herpes Zoster
- start within 72 hours of rash with acyclovir, valacyclovir, or famciclovir
- early treatment halts the progression of disease, and increases rates of clearance of the virus from vesicles
Treatment of post-herpetic neuralgia
- No definitive therapy!
- zoster vaccine recommended for adults over 50
Candidiasis
- rash resembles intertrigo but also have peripheral satellite pustules
- oral thrush can develop
- diagnose with KOH prep revealing spores and pseudohyphae
Treatment of candidiasis
- Keep skin dry
- improve hygiene
- topical or oral anticandidal agents like azoles
Seborrheic Keratoses
- benign growths- common in adults over 40
- tan, gray, black, waxy, or warty papules and plaques
- “stuck on appearance!”
- can be confused with melanoma
- WELL DEMARCATED border
Cherry Angiomas
- most common acquired cutaneous vascular proliferations
- round to oval, bright red, dome-shaped papules
- remove with excision, eletrodissecication, or laser
- benign!
Actinic Keratoses
- Rough, scaly, red-brown macules on sun-exposed skin
- Also known solar keratoses- from chronic UV exposure
- Poorly circumscribed, occasionally scaly, erythematous macules and papules in sun-exposed areas
- considered “pre-malignant”- but can resolve without treatment
- 20% progress to squamous cell cancer
Squamous Cell Carcinoma
- occurs most in sun-exposed areas
- chronic, erythematous papules, plaques, or nodules with scaling, crusting, or ulceration
Treatment of squamous cell carcinoma
- surgical excision
- cryotherapy or local radiation another option
Basal Cell carcinoma
- A pearly papule that is ulcerated in the center and has a characteristic rolled border
- most common cancer in the U.S.
- treat with surgical excision
Melanoma
- incidence increasing
- worst kind of skin cancer because it metastasizes early and quickly
- see more geographic nodules without a well demarcated border
- does not look “stuck on”
Melanoma ABCDE
A- asymmetrical shape B- Border- smooth even C- Color- more than one D- Diameteres- more than 6 mm E- Evolution
