Dr Emmy Babor GPSI Dermatology

Transcription

1 Dr Emmy Babor GPSI Dermatology

2

3 Wrinkles Sagging Thin skin (not all areas think about soles of feet) Loss of elasticity Pigmentary changes Dryness Loss of luminosity Baldness/ grey hair Increased nose and ear hair Finger nails thinner Nails grow slowly Toenails thicken Different pattern of disease Increased skin lesions

4 Causes of itchy skin Skin disease -look for signs, and inaccessible area such as small of back Skin disease with no signs - itch may precede rash e.g. in pemphigoid, so keep looking Medications e.g. opiates, statins, digoxin, chloroquine, clonidine, quinidine, gold, lithium, ACE inhibitors. Only way to establish if this is the cause is trial off the medication, needs to be for a month. Systemic disease Psychogenic e.g. delusional parasitosis, anxiety/depression. Willan s Itch/Senile Pruritus diagnosis of exclusion

5 Systemic dis causing itchy skin chronic renal failure, biliary obstruction (cholestasis), iron deficiency, thyroid dysfuncion, malignancy (hypercalcaemia, lymphoma, leucaemia, myeloma), diabetes, polycythymia.

6 FBC U&E Gluc Ca Fe, ferritin TSH LFT?HIV?CXR CPR Immunogloculins Plasma electrophoresis

7

8 Cause of Senile Pruritus?dryness skin of skin older skin is thinner/ has poorer barrier function, has altered water and lipid content, and reduced sebum and sweat production Pain/itch nerve fibres deteriorate with age which may lead to spontaneous activity

9 Management Treat underlying cause General measures Symptomatic treatment

10 General measures Advice not to scratch, keep finger nails short Keep cool avoid over clothing, hot bath. Shorten water (bath/shower) contact time, avoid soaps/alcohol cleansers/wet wipes

11 Symptomatic treatment - topical agents (NB physical compliance) Emollient, 1% menthol in aqueous (Dermacool), To consider but often impractical Calamine messy, BNF often ineffective Eurax 100ml/g, BNF uncertain value Doxepin 30g = > 10, risks sensitisation, burning. Capsaicin- 45g= >15 can burn, indic for neuralgia - oral meds - Anti-dep: amitriptyline, doxepin, mirtazapine, SSRIs anticonvulsants: gabapentin/pregabalin

12 Other options Phototherapy Behavioural therapy the Ezcema solution = breaking itch scratch cycle

13 Excoriations Lichenification Lichen simplex chronicus Purpura Disturbed sleep Depression

14 Nodular prurigo

15 Asteatotic/dyshidrotic eczema Eczema craquelé

16 Retinoids, beta blockers, tamoxifen, busulphan, clofibrate 1 1. Weisshaar E and Greaves MW in Evidence Based Dermatology 2 nd edition 2008 Blackwell Publishing, London

17

18 Seborrhoeic eczema

19 Discoid (nummular) eczema

20 Stasis dermatitis

21 Approximately 2% nursing home residents develop leg ulcer per year High recurrence rate Enormous drain on resources

22

23

24

25

26

27

28

29

30

31 The more drugs, the more likely Most suspected drug eruptions referred are not actually drug eruptions

32

33 Antibiotics: widespread, various patterns Thiazides: photosensitive Nicorandil: ulcers (perianal, oral) Allopurinol: widespread, EM-like Steroids: purpura, infections, acne-like

34

35

36

37

38 Skin thickens and hardens and is less flexible Tends to result in painful fissures Calluses form easily Special area for attention

39 (bullous pemphigoid) pemphigoid) Common Begins with urticated (itchy) red plaques Blisters often haemorrhagic Painful

40 Pemphigus vulgaris Less common More difficult to treat Usually affects mucosal surfaces

41 Viral: herpes zoster, papilloma virus, HIV Fungal: superficial and deep Bacteria: wounds and MRSA, cellulitis Infestations: scabies

42 Incidence increases with age Lifetime risk 50% in over 85s rate per 1000 person-years < >60 age group Schmader Clin J Pain 2002; 18: 350-4

43

44 Greatly increased risk with older age prevalence pain >1 month after healing (%) >80 age group

45

46 Onychomycosis is common in elderly Anti-fungal treatment may not result in normal nail

47

48 Tinea incognito

49 Pseudomonas

50 Intertrigo is common in elderly Contributed to by occlusion unwise applications Candida sp

51 Bathing Inaccessible sites/joint disease Carer availability and education Supply of large enough quantities Gadgets

52 Xerosis Itching (Willan s pruritus) Nodular prurigo Leg ulcers Skin cancers Seborrhoeic dermatitis Blistering disorders Polypharmacy drug eruptions Infections and infestations

53 Less oily Acne resolved Many naevi disappear Less pressure to look good? Baldness fewer hairdressing bills Cut nails less often Surgical scars easier to hide