Dermatological Manifestations in the Elderly. Sanjay Siddha Staff Dermatologist UHN & MSH

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1 Dermatological Manifestations in the Elderly Sanjay Siddha Staff Dermatologist UHN & MSH

2 Disclosure No actual or potential conflicts of interest or commercial relationships to declare

3 Objectives Recognize and manage common dermatosis in the elderly Melanoma Non Melanoma skin cancer Benign lesions

6 Facts about melanoma mean age of diagnosis around 50 yrs one of the less common forms of cancer Canadian life time risk male 1:75 female: 1:90

7 Melanoma Melanoma localized to skin cured by surgical excision Patients with advanced disease poor prognosis Cost of treating (20%) stage III &IV : 90% total annual cost for treatment Early detection is the key

8 Early detection impractical to screen everyone identify & screen high risk patients biopsy of melanomas early observation/ monitoring of nevi

9 >100 normal moles Risk factors: higher risk (approx. 10-fold) >5 atypical moles 2 cases of melanoma in first degree relatives.

10 Risk factors: Lower (approx. 2 to 3 fold) freckles red hair or skin which burns in the sun any family history of malignant melanoma

11 Other risk factors past personal history of melanoma Relative risk 5-8% nevi 1.6% nevi 4.4% nevi 5.4% 1-5 atypical nevi 3.8%

12 Skin type Typical Features Tanning ability I Pale white skin, blue/hazel eyes, Always burns, does not tan blond/red hair II Fair skin, blue eyes Burns easily, tans poorly III Darker white skin Tans after initial burn IV Light brown skin Burns minimally, tans easily V Brown skin Rarely burns, tans darkly easily VI Dark brown or black skin Never burns, always tans darkly

14 Features to look for in the nevi A asymmetry B- border C- colour D- diameter/dark E- evolving

24 Clinical Diagnosis of Melanoma Patients detect 50% of melanomas (new or changing lesion) Detecting change is more useful

25 Ugly duckling sign Atypical nevus in a background of normal appearing nevi More normal appearing lesion in a patient with multiple clinically atypical nevi

29 Micro staging of cutaneous melanoma

30 Melanoma

33 Melanoma Early detection is essential and can be life saving! Surgical excision with 1 cm margins will cure 90% of patients with early melanoma (< 1 mm Breslow depth)

34 Location Women commonly develop on the lower limb (50% of women, 18% of men) Men : SSM or NM commonly develop on the trunk (35% of men, 14% of women), especially the back. chronic sun exposure - head and neck

35 Melanoma-Types Superficial spreading melanoma Nodular melanoma Lentigo maligna melanoma Acral lentiginous melanoma

36 Types of primary cutaneous melanoma Type frequency site SSM 60-70% Lower extremities women Trunk men & women NM 15-30% Trunk, head & neck LMM 5-15% Face nose & cheeks ALM 5-10% Palms, soles & nail unit

Superficial spreading (SMM) most common age 40-60 s risk

37 Superficial spreading (SMM) most common age s risk factors : nevi dysplastic nevi intermittent sun exposure sunburn

38 Nodular melanoma (NM) 15% of melanomas nodule: enlarging, bleeding/crusting elderly (M>F)

39 Lentigo maligna melanoma 10-15% of melanomas prolonged radial growth changing atypical pigmented macule chronic UV exposure (outdoor workers, elderly people)

43 Acral lentiginous melanoma (ALM) 1-3% of melanomas flat lesion like SSM Common in dark skin No relationship to UV exposure

47 Subungual melanoma arises in nail matrix hutchinson sign more common in dark skin

52 Melanoma Prevention UVR is primary cause of most melanomas More risk: Intermittent exposure Childhood exposure Tanning beds < age 35yr Childhood exposure nevi

53 Primary prevention Protection from the sun: avoidance and clothing primarily. Sun protection factor (SPF) 30 and above, Five star: ultraviolet A (UVA) protection as an adjunct

55 Secondary prevention People with higher risk (10-fold) categories: Refer for risk estimation and education Base-line photography: to monitor moles Dietary intake of vitamin D

56 Surgical management Thickness Excision margins In situ 0.5 cm < 1 mm 1 cm (AAD 1cm for <2mm) 1-4 mm 2 cm (AAD 2 cm for 2mm) > 4 mm 2-3 cm

57 When to refer new mole: growing quickly after puberty long-standing mole : changing progressively in shape or colour (any age) any mole 3 colours or lost its symmetry any new nodule: growing and is pigmented or vascular in appearance

58 When to refer (cont.) new pigmented line in a nail something growing under a nail mole which has changed in appearance and which is also itching or bleeding

59 Avoid Sun Even on a cloudy day, UV will get through to the earth s surface Sunlight is tricky - reflect off snow, water & sand

60 X-ray UVC UVB UVA Visible Light Stratosphere - Ozone Layer Dead Sea Level Sea Level

61 Sand SEA

63 How much sunscreen? One ounce(shot glass) 30 ml Cover the exposed areas of the body properly

64 Myths about sunscreen Retinyl palmitate: risk of skin cancer Oxybenzone: hormone disruptor Mostly in lab animals

65 Avoid mid day sun Sun Directly Overhead 4pm Midday Y X Surface Y EARTH Atmosphere

66 UV Protective Clothing The finer the weave, the greater the protection Silk is best Nylon stockings SPF of about 2

67 Sun protection: Save our skin Slip on a Shirt Seek out Shade Step out of the Sun Ouch! Slap on Sunscreens

69 Case 2

74 Case 2

75 Immediate Care Speak to a dermatologist Topical Dermovate ung b.d. Vaseline ung Treat any secondary bacterial infection

76 Severe Bullous Pemphigoid Widespread tense blisters of skin & mucosa Antigen: BPAg1 & 2 (hemidesmosome at the epidermaldermal junction) Elderly patients, 6-7 new/million Rarely drug induced

77 Management clobetasol propionate 0.05% cream (20 g) applied 2 times day, including clinically unaffected skin (total daily dose 40 g), oral prednisone 1 mg kg daily A significant benefit of the former - extensive disease (more than 10 new blisters a day) for disease control, adverse events and mortality.

78 Management Skin biopsy: Lesional for H&E Oral steroids Perilesional for DIF Steroid sparing agents Tetracycline +/- nicotinamide

80 Xerotic eczema (eczema craquelé)

81 Scurvy

83 Sebaceous gland hyperplasia

84 Dermatosis papulosa nigra

85 Stucco Keratosis

86 Seborrheic Keratosis

88 Skin Cancer Basal cell carcinoma (BCC): most common Squamous cell carcinoma (SCC) Melanoma: 4% skin cancers

89 Keratoacanthoma

90 Basal cell carcinoma - Pigmented

91 Basal cell carcinoma

92 Cystic BCC

93 Sclerosing BCC

94 Cutaneous Horn

95 Actinic Keratosis

96 Bowen s Disease

97 Bowen s disease

98 Management of AK Cryotherapy 5FU Zyclara (Imiquimod 3.75%) Curettage Low No. of AK S High No. of AK S Thin AK S Hypertrophic AK S Isolated Not responding Scalp, Nose, Ears, Cheeks, forehead Periorbital Below Knee Back of Hands

100 Dermatology MCQ Sanjay Siddha

101 1. What is your diagnosis?

102 What is your diagnosis? A. Seborrheic Keratosis B. Pigmented Basal cell carcinoma C. Melanoma D. Squamous cell carcinoma

103 2. What is your diagnosis?

104 2. What is your diagnosis? A. Contact dermatitis to Poison Ivy B. Bullous pemphigoid C. Herpes Zoster D. Irritant contact Dermatitis

105 3. Incidence of Melanoma Which one is true? A. In increasing across all age groups B. Is decreasing in the Elderly Population C. Is increasing in the Elderly population D. Is increasing in the younger age group 20-40yrs

106 4. Bullous Pemphigoid Which one is true? A. Is a Para neoplastic condition B. Is an autoimmune blistering condition C. Common in young adults D. Common in the Elderly E. All of the above

Clinical characteristics

Skin Cancer Fernando Vega, MD Seattle Healing Arts Clinical characteristics Precancerous lesions Common skin cancers ACTINIC KERATOSIS Precancerous skin lesions Actinic keratoses Dysplastic melanocytic