Instructor: Independent Study
Module developed by: Tisha D. Anyanike, M.D. (2007)
Module revised by: Sharee A. Wiggins, NP, Post-MS(N), BC-GNP, BC-ANP (2007)
Reviewed by: Doug Woolley, MD, MPH
Specific Learning Objectives
A. Introduction
Before reviewing the learning objectives and content, please take the Pre-Test.
Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.
B. Knowledge - students should be able to:
C. Skills – students should be able to:
D. Attitudes
E. Readings
Required Reading
Mash, M. J., Fedor, M., & Bonnington, L. (Chapter 52), 612-622. In, Ham, R. J., Sloane, P. D., Warshaw, G. A. Bernard, M. A., & Flaherty, E. (Eds.). Primary Care Geriatrics (5th Ed.) (2007). Mosby: St. Louis.
Recommended Reading
If you would like to see more dermatology slides with brief descriptions of each condition, click here. Other dermatology photos can be found at: www.dermatlas.org from Johns Hopkins University.
As the largest organ in the body, the skin also displays some of the most common changes associated with aging. However, most of these signs are strongly influenced by photo-aging (ultraviolet light exposure) and disease. Numerous normal aged-related changes in the skin occur throughout various skin structures. The effects of many of these microscopic changes can be observed on gross exam by simple inspection. Others cannot be seen, but impact the aging body nonetheless.
Table 1 - Normal Changes in Aging Skin at Microscopic & Macroscopic Levels
MICROSCOPIC Changes
IMPACT
- Flattened epidermal interdigitations
- Dermal thinning (about 20% with aging)
- Thinning appearance of skin
- Great risk of skin tears
- Reduced Vitamin D synthesis from 7- dehydrocholesterol (since the highest concentrations are in epidermis)
- Capillary fragility
- Reduced non-collagen extracellular matrix such as proteoglycans, matrix proteins, and water
- Subcutaneous fat atrophy
- Wrinkling (though much is due to photoaging) and atrophied appearance
- Appearance of wasting
- Slower epidermal cell turnover
- Contributes to slower wound healing
- Decreased lipids/sebaceous lands
- Contributes to drier, rougher appearance
- Reduced amount of immune antigen- presenting cells
- Reduced immune response
- Decreased collagen and elastin
- Fragmented fiber orientation
- Reduced resiliency
- Wrinkling
- Fewer apocrine glands
- Decreased sweating in response to excessive heat
- Follicular melanocyte changes
- Graying hair
- Shortened anagen (growth phase) and increased telagen (resting phase)
- Decreased density / thinning hair
Normal Aging
Photoaging
Photo Credit: www.dermatology.about.com
Ultraviolet light exposures in the form of UVB and UVA both have effects on aging and damage to the skin. These shorter wavelengths are more biologically active and cause damage through various mechanisms including DNA injury, decreased DNA repair, oxidative and lysosomal damage, and altered collagen structure. The actual effects of UV radiation on the skin are photoaging. The most effect modalities for prevention of ultraviolet (UV) radiation are broad spectrum sunscreen that covers both biologically active forms of ultraviolet light (UVA and UVB), and avoidance of direct sunlight through the use of protective clothing and sunglasses.
Photodamage to the skin often manifests as several benign and malignant conditions including seborrheic keratoses, actinic keratoses, squamous cell carcinoma, basal cell carcinoma, and melanoma. (Table 2) These conditions become more apparent as the skin ages and have more exposure to ultraviolet radiation. They can have many different appearances in some cases which can make it difficult to differentiate between benign and malignant conditions during physical examination. It is therefore, often recommended that if a lesion is suspicious, as determined by the ABCD mnemonic (Figure 1), it should be biopsied or at least referred to a dermatologist for further evaluation. In some cases, the biopsy itself is curative. Clinical wisdom considers any lesion suspicious if it shows no signs of healing after 14 days.
Table 2 - Photodamage Skin Conditions
CONDITION
APPEARANCE
BENIGN OR MALIGNANT
TREATMENT
Solar Lentigines
(aka: senile or actinic lentigines; sun spots; liver spots – having nothing to do with the liver)
Well-demarcated brownish macules < 5mm in sun exposed areas (hands, arms, face common); older lesions may be darker.
Present in >90% fair skinned adults > 60
Benign
None
Seborrheic keratoses
Tan, gray, or black;
waxy/warty;
papules or plaques; classically describe as having a “stuck on” appearance
Benign
None necessary; if bothersome cryosurgery or shave excision
Actinic keratoses
(aka: solar keratoses)
Poorly circumscribed; varies – rough, scaly, flesh colored or erythematous, macules or papules on sun-exposed areas
Benign but can be premalignant for squamous cell
Cryotherapy; topicals (5-FU, immunomodulators); excision
Squamous cell carcinoma
Varies - chronic erythematous papules, plaques, or nodules with scaling, crusting, or ulceration in sun-exposed areas
Malignant (2nd most common skin cancer in U.S.); mets rates: trunk/limbs 4.9%; ear 11%; lips 13.7%; arising from chronically injured tissue 40%
Surgical excision
Basal cell carcinoma
Varies - superficial ulcer with rolled borders; nodular
(pearly); morpheaform (scar-like)
Malignant (most common cancer in the U.S.); extremely low risk of mets
Surgical excision
Melanoma: 4 types
- Superficial
- Lentigo
- Acral
- Nodular
Varies - high level of suspicion with any new pigmented lesion or change in an existing lesion (see ABCD mnemonic)
Malignant with high risk of mets; Acral type (nailbeds & soles of feet) the most common in African Americans
Surgical excision; also adjuvant therapy based on depth and spread
Seborrheic Keratosis
Photo Credit: www.medicine.ucsd.edu
Actinic Keratoses Photo Credit: www.skincancerguide.ca
Squamous Cell Carcinoma (SCC)
Basal Cell Carcinoma (BCC)
Malignant Melanoma (MM) Figure 1 - ABCD Mnemonic for examining a new skin lesion
A – Asymmetry
B – Borders
C – Color
D – Diameter
E – Evolving (any changes at all)
F – Family history (1:10 have + FHx)(E and F are assessed but not always included in the mnemonic)
These benign lesions, also known as cherry hemangiomas, are smooth, small (1-5 mm in diameter) dome-shaped papules that appear on the trunk. They are composed of clusters of dilated capillaries and can bleed with trauma. The lesions can appear as early as age 20, but increase with age and are commonly found in older adults. No treatment needed.
Cherry Angiomas
This condition is simply a flat ecchymosis due to capillary rupture with minimal trauma. As age-related dermal thinning occurs, the capillaries become fragile. Prophylactic care aimed at prevention from trauma is prudent – particularly of the hands, forearms, and lower legs.
Senile Purpura Photo Credit: http://www.nsc.gov.sg/
Seborrheic dermatitis is a chronic skin condition that is typically found at the hairline, forehead, nasolabial folds, in or behind the ears, or on the chest in older adults. Its appearance is typically described as erythematous, greasy, and flaky. Its cause is unclear, but it seems to have a higher prevalence in men. It is also commonly found in persons with Parkinsons Disease and stroke or other spinal cord injury. Treatment consists of suppression as there is no cure. Mild topical steroids work well for acute cases while medicated shampoos that act against yeast (e.g., selenium sulfide or ketoconazole) are best for maintenance therapy.
Seborrheic Dermatitis
Rosacea is a condition that can affect all ages, but is more common in fair-skinned persons. It is a chronic condition characterized by recurrent facial flushing due to various stimuli (e.g. alcohol, sunlight, certain foods, vasodilating drugs). The etiology is unknown. Treatment consists of avoidance of irritants and reduction in sun exposure. Oral antibiotics in the tetracycline class seem to control moderate to severe flares while topical antibiotics, such as erythromycin, clindamycin, or metronidazole, work well for mild cases or maintenance therapy. Severe or refractory cases may require use of isotretinoin. A rare outcome of rosacea is rhinophyma – the nose and central facials features which has the appearance of erythema and hypertrophied glands in the area of the nose.
Rhinophyma http://www.ghorayeb.com/Rhinophyma.html
Xerosis, also called xeroderma, is dry skin that is caused by the decreased water content and barrier function of the skin as it ages. It is typically described as rough, itchy, and scaly. In severe cases it may have a cracked appearance called eczema craquele. Avoidance of environmental triggers and frequent use of emollients is most helpful in relieving this condition. In severe cases where irritation and inflammation are present mild topical steroids may be used intermittently.
Xerosis of foot with onychomycosis (nail fungus) and a corn from
shoe pressure on digit #5)
Photo credit: www.joshuakaye.com/images/xerosis.jpg
Erythema craquele
Older patients may also experience a condition known as neurodermatitis, or lichen simplex chronicus, which is a chronic, pruritic condition of unknown etiology. Its appearance is typically of chronic scratching and treatment is with potent topical corticosteroids, emollients, and behavioral modification.
Neurodermatitis
Herpes Zoster (“shingle”) is a reactivation of the Varicella Zoster Virus that occurs in older adults who are immunosuppressed. It typically presents as vesicular lesions on an erythematous base with intense pain along a dermatome. The prodrome of burning pain usually precedes appearance of the classic rash by several days. If immunity is intact then it is usually a self-limiting condition. If not, then complications may develop, of which the most common is post-herpetic neuralgia (PHN) which can cause debilitating pain for months. When given within 72 hours of onset, antiviral agents can limit the course of the disease and severity of complications should they occur.
Complication
Description
Intervention
Involvement of the ophthalmic branch of the Trigeminal nerve – Hutchinson’s sign
May present as vesicles on the tip of the nose
Ophthalmic exam and monitoring; antivirals within 72 hrs of onset
Ramsey-Hunt syndrome
Involvement of facial or auditory nerve; lesions of external ear or tympanic membrane; facial palsy w/o tinnitus, vertigo, deafness
antivirals within 72 hrs of onset
Post-herpetic neuralgia
Persistent pain after rash has healed or 30 days after rash onset
Difficult to tx; NSAIDs, local anesthetic patches, opioids, local anesthetic injections, AEDs (antiepileptic drugs) antidepressants, capsaicin, acupuncture, corticosteroids
Herpes Zoster Photo credit: www.aafp.org
This chronic autoimmune disease is commonly in the elderly, and particularly among long-term care patients. It primarily affects the skin with tense blisters (bullae) located exclusively on the upper and lower extremities, groin, axillae, and abdomen. Blistering in other areas strongly suggests pemphigus, a much more serious condition. As the bullae rupture, secondary infection is possible. Depending on severity and extent of dermal involvement, either topical or systemic corticosteroids are used.
Bullous Pemphigoid Photo Credit: www.nlm.nih.gov
Cellulitis is a condition of localized, spreading infection within solid tissues which is characterized by hyperemia, local heat, and edema. At times the infiltrated skin may take on the appearance and texture of an orange peel. The infection can range from mild to severe, and be treated with oral antibiotics on an outpatient basis or with IV antibiotics in the hospital setting. In severe cases that are potentially life-threatening, corticosteroids may also be needed. The most common pathogen causing a superficial cellulitis is streptococcus pyogenes. But, staphylococcus aureus can also produce a less involved superficial cellulitis that occurs in association with an existing break in skin integrity.
Local cellulitis Photo Credit: www.nepalinternationalclinic.com
Scabies is an infestation with the mite Sarcoptes scabiei that is spread by person- to-person contact. It commonly occurs in institutionalized older adults and can be difficult to eradicate. It usually presents as intense pruritis, erythematous papules, and with linear burrows present on the skin surface, particularly the interdigital webs of the hands, axillae, genitalia, and periumbilical region. It is most commonly treated with topical permethrin and may require retreatment in one week if the pruritis or lesions persist. All bedding and clothing must be laundered in hot water to prevent spread or reinfestation. The pruritis associated with this condition may persist for weeks to months. On exam, care should be taken to differentiate between burrows and secondary lesions due to scratching.
Scabies
These superficial wounds with irregular margins and a beefy red appearance are most commonly located on the medial lower leg or superior medial malleolus. They may have minimal to heavy exudate. Any condition causing valvular incompetence of the veins (varicose veins, history of DVT, idiopathic incompetence, CHF, obesity and advanced age), can lead to venous stasis and pooling of capillary blood. As capillary volume increases, capillary hypertension develops and ultimately dermal ulceration appears. When the condition is chronic, it is known as CVI – chronic venous insufficiency. This results in class trophic skin changes: 1) brown or brownish/purple skin discolorations from hemosiderin deposits due to iron staining of tissues from ruptured RBCs; 2) brawny (non-pitting) edema; 3) stasis dermatitis – erythema, eczematous changes, scaling and a weeping dermatitis. Treatment of venous ulcers involves getting control of the lower extremity venous hypertension. This can be achieved with special layered compression dressings or graduated pressure stockings, whereby the highest pressure is at the ankles and gradually decreases toward the knees. Adjunctive treatments for infection and exudate control may also be needed. Efforts to manage the edema (weight loss, leg elevation above the level of the heart, and use of elastic antiembolism stockings [these are not pressure graded]) are necessary for life.
Venous Stasis Ulcer
These ulcers are easily contrasted with venous stasis ulcers in appearance. The wounds may be deeper with minimal drainage, may be pale, more round, and the margins are typically well demarcated, yielding a “punched out” appearance. Common locations are: between toes, over the lateral malleolus, and over phalangeal heads/areas susceptible to trauma. The etiology is peripheral arterial disease (PAD) and risk factors which contribute to it, such as diabetes, tobaccoism, long-standing and poorly controlled hypertension, advanced age. Chronic local trauma (for example: poor footwear) may precipitate an arterial ulcer with significant underlying PAD. Management includes maintaining a clean moist wound bed with special dressings. Often surgical revascularization must be done in order for oxygen and nutrients to be delivered to the tissues. Arterial ulcers are due to ischemia and gangrene is a real risk. Patient education about smoking cessation strategies to avoid local trauma may also be needed.
Arterial ulcer Photo credit: www.myfootshop.com
Arterial ulcer with gangrene Photo credit: www.myfootshop.com
Diabetic ulcers typically have smooth even margins and a deep wound bed. They commonly occur on the plantar surface of the foot, but can also occur over metatarsal heads or on the heels. The dual pathology is poorly controlled diabetes – often with diabetic peripheral neuropathy – and pressure or trauma in the asensate area the patient cannot perceive. Treatment may include surgical debridement or even amputation in severe cases, particularly where gangrene has developed. Gangrenous toes may even “auto amputate.” Special dressings to maintain a clean, moist wound environment essential for healing, control of blood sugars, us of special footwear for pressure reduction, treatment of infections and patient education (foot inspection and control of blood sugars) are all part of diabetic foot ulcer management. The best treatment is prevention. At times adjunctive treatment with recombinant human platelet-derived growth factor (becaplermin), an FDA approved product for use in diabetic ulcers. The purpose is to stimulate angiogenesis and accelerate healing time.
Diabetic foot ulcer Photo credit: www.aafp.org
Fitzpatrick, T. B., Johnson, R. A., Wolff, K., & Suurmond, D. (2002). Color Atlas and Synopsis of Clinical Dermatology (4th ed.). New York: McGraw-Hill.
AMDA. The Geriatric Top 10. Series of 10 articles in Caring for the Ages; 2003.
Brill LR, Cavanagh PR, et al. Prevention of lower extremity amputation in patients with diabetes. Treatment of Chronic Wounds: Number 7 in a series.
Luggen, A. S. (2003). Wrinkles and beyond: Skin problems in older adults. Advance for Nurse Practitioners; 11(9); 55-62,102.
Sussman C, Bates-Jensen BM. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. 1st edition. 1998.
Swartz, M. H. Textbook of Physical Diagnosis (4th ed.). (Chapters 7 & 24). Philadelphia: Saunders.
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The University of Kansas Medical Center
