Dr Emmy Babor GPSI Dermatology
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
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
Systemic dis causing itchy skin chronic renal failure, biliary obstruction (cholestasis), iron deficiency, thyroid dysfuncion, malignancy (hypercalcaemia, lymphoma, leucaemia, myeloma), diabetes, polycythymia.
FBC U&E Gluc Ca Fe, ferritin TSH LFT?HIV?CXR CPR Immunogloculins Plasma electrophoresis
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
Management Treat underlying cause General measures Symptomatic treatment
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
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
Other options Phototherapy Behavioural therapy the Ezcema solution = breaking itch scratch cycle
Excoriations Lichenification Lichen simplex chronicus Purpura Disturbed sleep Depression
Nodular prurigo
Asteatotic/dyshidrotic eczema Eczema craquelé
Retinoids, beta blockers, tamoxifen, busulphan, clofibrate 1 1. Weisshaar E and Greaves MW in Evidence Based Dermatology 2 nd edition 2008 Blackwell Publishing, London
Seborrhoeic eczema
Discoid (nummular) eczema
Stasis dermatitis
Approximately 2% nursing home residents develop leg ulcer per year High recurrence rate Enormous drain on resources
The more drugs, the more likely Most suspected drug eruptions referred are not actually drug eruptions
Antibiotics: widespread, various patterns Thiazides: photosensitive Nicorandil: ulcers (perianal, oral) Allopurinol: widespread, EM-like Steroids: purpura, infections, acne-like
Skin thickens and hardens and is less flexible Tends to result in painful fissures Calluses form easily Special area for attention
(bullous pemphigoid) pemphigoid) Common Begins with urticated (itchy) red plaques Blisters often haemorrhagic Painful
Pemphigus vulgaris Less common More difficult to treat Usually affects mucosal surfaces
Viral: herpes zoster, papilloma virus, HIV Fungal: superficial and deep Bacteria: wounds and MRSA, cellulitis Infestations: scabies
Incidence increases with age Lifetime risk 50% in over 85s rate per 1000 person-years 9 8 7 6 5 4 3 2 1 0 <10 20-50 >60 age group Schmader Clin J Pain 2002; 18: 350-4
Greatly increased risk with older age prevalence pain >1 month after healing (%) 40 35 30 25 20 15 10 5 0 0-29 30-49 60-69 70-79 >80 age group
Onychomycosis is common in elderly Anti-fungal treatment may not result in normal nail
Tinea incognito
Pseudomonas
Intertrigo is common in elderly Contributed to by occlusion unwise applications Candida sp
Bathing Inaccessible sites/joint disease Carer availability and education Supply of large enough quantities Gadgets
Xerosis Itching (Willan s pruritus) Nodular prurigo Leg ulcers Skin cancers Seborrhoeic dermatitis Blistering disorders Polypharmacy drug eruptions Infections and infestations
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