Dr Emmy Babor GPSI Dermatology

Transcription

1 Dr Emmy Babor GPSI Dermatology

2 Time Light exposure (Skin type x time x light intensity) Smoking

3 Sun exposure plays a major part but even sun-protected skin ages

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9 Flatter Might be reason blisters at this site are more common

10 Collagen/dermal structural proteins including elastic fibres Blood vessels Nerves Immune function

11 Hair Sweat glands Sebaceous glands Nails Thinner, sparser, greyer Reduced size and function Enlarge but decrease secretion Grow slowly and develop ridges

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15 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

16 what are the causes how should we investigate and manage generalised pruritus in the elderly?

17 Sensation in skin provoking a desire to scratch This is often an extremely unpleasant sensation that disturbs sleep and can cause low mood.

18 May have developed in evolutionary terms from need to rid skin of parasites Scabies is a common cause of itching in elderly in UK in care homes Most people who itch do not have parasitic diseases

19 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

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

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

22 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

23 Management Treat underlying cause General measures Symptomatic treatment

24 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

25 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

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

27 Excoriations Lichenification Lichen simplex chronicus Purpura Disturbed sleep Depression

28 Nodular prurigo

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30 Skin of 13 elderly patients with itching and no rash was compared to age and sex-matched controls Itchy people perceived their skin to be drier (VAS) Degree of dryness correlated with severity of itch Itchy cases had decreased skin surface conductance and increased intracorneal adhesion Long et al J Am Acad Dermatol 1992; 27: 560-4

31 Altered water and lipid content Stratum corneum forms poor barrier Reduced sebum and sweat production External influences eg excessive washing, detergents and soaps, ph, low humidity,

32 Asteatotic/dyshidrotic eczema Eczema craquelé

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

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35 Seborrhoeic eczema

36 Discoid (nummular) eczema

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38 Stasis dermatitis

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

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

52 In the UK, where older people make up a fifth of the population but consume almost half of prescription items Adults aged >65 years take a mean of two daily prescribed drugs. In the >75 years age group living in the UK, this mean daily drug usage increases to 2.5.

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

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

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

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

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63 Diagnosis by biopsy (with perilesional immunofluorescence) Treatment with systemic steroids Alternatives are high dose tetracyclines ± nictotinamide, potent topical steroids Pain relief/ dressings Aspirate blisters

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

65 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

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

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

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71 Tinea incognito

72 Pseudomonas

73 Transient acantholytic dermatosis First described 1970 Mostly men Trunk Worse in summer Some response to topical steroids, retinoids

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

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

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

78 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

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