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Participants will be able to: • Describe the changes that occur with aging • Perform the appropriate work-up and Geriatric Dermatology initiate management of pruritus Objectives • Steve Daveluy MD Recognize and treat common inflammatory skin diseases Wayne State Department of Dermatology • [email protected] Recognize potential skin cancers and counsel on risk reduction

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• Skin changes with aging • Itch and • Tumors – benign and malignant • I have no relevant conflicts of interest for • Sun Protection Disclosure this session Outline • Elder Abuse

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Elderly Population Skin Changes with Aging

• Baby Boomers 1946-1964: 65.2 million in 2012 • Intrinsic • In 2029, youngest boomers reach 65: • Extrinsic: UV exposure, smoking • Census estimates: 71.4 million in US > 65 • Epidermal Barrier Defects • 20% of US population (14% in 2012) • Immunosenescence • Altered wound healing capacity • 65-74 years old: 40% skin problem requiring treatment by physician

US Census Bureau Chang. JAMDA 14 (2013) 724-730 Beauregard. Arch Dermatol 123:1638–1643, 1987 5 6

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Cutis Rhomboidalis Nuchae Skin Changes with Aging Skin Changes from UV Exposure Favre-Racouchot • Wrinkled, lax, increased fragility • Thinner Poikiloderma of Civatte • Decreased blood flow, sweat glands, subQ -> thermoregulation

Solar Purpura

Southern Medical Journal Nov 2012; 105 (11) Dermatology. 2018 Elsevier 7 8

Pruritus

• Incidence: 12% in 65+; 20% in 85+ • Associated sleep disturbance, depression • Berger et al proposed 2 visit algorithm • Visit 1: Initial assessment, treat xerosis Itch and Rash • Visit 2: Escalate if no improvement

Berger, et al. JAMA. 2013 Dec 11;310(22):2443-50 9 10

First visit Second Visit

• History: severity (0-10 scale), location (localized vs generalized), modifying factors • 2-3 weeks later • Review medications (topical and systemic) • Escalate if not improved after treating xerosis +/- • Exam: scabies (burrows, genital lesions), dry skin (fissured, patches on legs, flanks, and arms) • Review labs for metabolic pruritus • Labs: CBC, fasting glucose, TSH, AST, ALT, urea nitrogen/creatinine, calcium, • Thyroid, Parathyroid, Iron Def- responds to correction of imbalance phosphorus • Treat for xerosis • Renal Disease: gabapentin 300mg, Pregabalin 75mg post dialysis • Treat for scabies if found • Liver/cholestasis: Naltrexone, Butorphenol UVB • Rash: initiate topical therapy, KOH exam, refer to dermatology if initial therapy • Itch 7+/10, work-up(-): Consider malignancy (Lymphoma, fails Polycythemia) • No rash: metabolic workup (thyroid, parathyroid, iron def) and evaluate for malignancy or neuropathy. Consider scabies • Assess “B” symptoms, LN exam, CBC, LFTs, LDH, CXR

Berger, et al. JAMA. 2013 Dec 11;310(22):2443-50 Berger, et al. JAMA. 2013 Dec 11;310(22):2443-50 11 12

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Xerosis (Dry Skin) Chronic Eczematous Dermatitis of Elderly • Most common cause of chronic pruritus (itch) • • >50% of elderly Patients 60 years and older (mean 76) • Ammonium Lactate 12% lotion – restore pH, reduce • Eczematous Dermatitis associated with chronic CCB or HCTZ hyperkeratosis • Developed 3+ months into therapy Bathing: • 68-83% cleared upon discontinuation • Reduce frequency • Must discontinue for at least 1 year • Luke warm (not hot) water • Limit to 5 minutes • Moisturizing soap cleanser only to hair-bearing areas • Apply moisturizer ASAP afterward J Invest Dermatol. 2007 Dec;127(12):2766-71 Toncic. Clinics in Derm(2018) 36, 109-115 Chang. JAMDA 14 (2013) 724-730 JAMA Dermatol. 2013 Jul;149(7):814-8.

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Seborrheic Dermatitis

• Scalp, face, upper chest, intertriginous • Bilateral lower legs • , greasy scale • Can be complicated by allergic contact • Treatment: Ketoconazole cream or derm shampoo. 75-90% response • Often other signs of venous • 2nd line: topical steroids • Often mistaken for • Requires maintenance therapy • Can progress to ulcers or lipodermatosclerosis • Tx: compression, emollients, topical steroids

Buford. Clinics in Derm (2018) 36, 239-246 15 16

Rosacea

• 4 types: erythematotelangiectatic, papulopustular, phymatous, ocular • Most common autoimmune bullous disease • Incidence increases with age • Typically onset 60 years+ • More common in fair skinned individuals • Age 90: 300 fold risk increase compared to 60 years • Urticarial plaques and tense bullae

Proc Natl Acad Sci USA 1996; 93: pp. 8569-8571 Dermatology, 4th Ed. 2018. Elsevier Dermatology, 4th Ed. 2018. Elsevier 17 18

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Fungal Infections Herpes Zoster ()

• Barrier dysfunction, immunosenescence, decrease epidermal • Hutchinson Sign: nasal tip=ophthalmic branch of trigeminal nerve turnover • Incidence, severity, duration of pain and post-herpetic neuralgia • Each 1 year of advancing age -> 10% increase fungal infections increase with age • (tinea) and candida • Vaccine: approve for 50+, CDC recommends for 60+ • Shingrix (recombinant) preferred over Zostavax (live)

Tinea Candida Ketoconazole Terbinafine Clotrimazole Nystatin

Chang. JAMDA 14 (2013) 724-730 Chang. JAMDA 14 (2013) 724-730

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Benign Tumors Tumors – benign and malignant • • Cherry • • Acrochordons (Skin Tags) • Sebaceous Hyperplasia

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Seborrheic Keratosis • Appear 4th decade of life • Anywhere except mucous membranes, palms, • Bright red to purple, dome shaped soles • Often numerous • Tan to black, papular or verrucous, waxy, stuck- on appearance • Can simulate

Dermatology, 4th Ed. 2018. Elsevier Dermatology, 4th Ed. 2018. Elsevier 23 24

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Solar Lentigo Acrochordon ()

• Skin colored to hyperpigmented, pedunculated • Associated with obesity, diabetes

• Well-circumscribed • Round, oval or irregular • Tan to dark brown to black • Sun exposed areas: Dorsal hands, neck, face, upper trunk, shins • Independent risk factor for skin cancer

Dermatology, 4th Ed. 2018. Elsevier Dermatology, 4th Ed. 2018. Elsevier

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Sebaceous Hyperplasia Skin Cancer

• Benign enlargement of sebaceous glands • Basal Cell Carcinoma • Face and upper trunk • Squamous Cell Carcinoma • Yellowish papule, +/- , central follicular ostium • Melanoma • Skin Cancer Prevention

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Skin Cancer Skin Cancer Burden

• Most common cancer in US As of 2013: • Melanoma incidence increasing, mortality steady • 4.7 million Americans (1.51% of US pop) received care for skin cancer • Melanoma: 2% of skin cancers, 80% of skin cancer deaths • 3.7 million cases of Non-Melanoma Skin Cancer (BCC, SCC) • Melanoma 5 year survival: Local: 98.4% Distant: 17.9% • 1 million cases of Melanoma • UV radiation major environmental risk factor for all skin cancer • 13,770 deaths from skin cancer

Non-Melanoma Melanoma Skin Cancer

JAMA. 2018;319(11):1143-1157. J Am Acad Dermatol. 2017 May;76(5):958-972.e2 29 30

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Non-melanoma Skin Cancer Actinic Keratoses

• 75-80% Basal Cell Carcinoma • Precursor to SCC (0.075- • 25% Squamous Cell Carcinoma 0.096% per lesion per year) • More than all other cancers combined in US. 1 in 5 Americans • Sun-exposed skin: Head, neck, ears, dorsal hands/forearms, • BCC mortality only 0.12 per 100,000 upper trunk • SCC mortality 0.26 per 100,000 • Rough erythematous to tan • Skin Cancer cost: $8.1 billion: macule/papule with $4.8 billion NMSC, $3.3 billion melanoma. sandpaper-like scale

Med J Aust 2006; 184: pp. 6-10 J Am Acad Dermatol 1996; 35: pp. 1012-1013 Dermatology. 2018 Elsevier 31 32

Dermatology. 2018 Elsevier Squamous Cell Carcinoma Basal Cell Carcinoma

• Skin-colored to red papulonodule or plaque +/- scale, hyperkeratosis, • Pearly papule/nodule +/- ulceration ulceration • Superficial: rash-like, erythematous scaly patch/plaque • Sun-exposed skin: Head, neck, ears, dorsal hands/forearms, upper trunk • Morpheaform: scar-like patch • High risk: lips, ears, vulva, penis • Sun-exposed skin: Nose (mc), face, ears, dorsal hands/forearms, upper trunk

Dermatology. 2018 Elsevier

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Dermatology. 2018 Elsevier Melanoma Skin Cancer Risk Factors

• Superficial Spreading- most common, trunk in men, legs in women, UV Radiation is #1 • UV Radiation macule/patch with varied colors Modifiable Risk Factor • Ionizing Radiation • Nodular- trunk, head, neck, or any site. Blue, black, red nodule +/- ulceration • Genetic Syndrome (Xeroderma Pigmentosum, Albinism, Gorlin, etc) • Lentigo Maligna- sun-exposed skin, brown to black irregular macule • Exposure to chemicals, Arsenic • Acral Lentiginous- palms, soles, nails. Assymmetric brown/black macule • Immunosuppression (esp organ transplant) • Chronic skin injury/ • HPV (SCC) • Numerous nevi (melanoma)

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US Lifetime Risk of Invasive Melanoma US Melanoma Deaths

JAMA Dermatol. 2017;153(2):225-226. JAMA Dermatol. 2017;153(2):225-226. 37 38

Primary vs Secondary Prevention History of Sun Behavior • Pre-industrial revolution: pallor favored, tan in Primary = Prevention Secondary = Early Detection serfs toiling in fields • 1920s: Coco Chanel tanned on Mediterranean Affects Incidence Affects Mortality cruise • 1960s: color film and holidays widely available • 70s and 80s: Indoor tanning boom

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Circa 1890 Circa 1922 Protection from UV Exposure

• Sunscreen Circa 1946 • Protective Clothing • Behaviors • Vitamins Circa 1934

www.aad.org

Dermatology. 2018. Elsevier 41 42

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Slip on Clothing

• Slip on protective clothing • UPF instead of SPF • Slop on sunscreen • Rash guards, swim shirts • Slap on your hat • Sleeves • Seek shade • Laundry Additive • Slide on sunglasses

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Slap on your hat Seek Shade Slide on shades • 2 inch brim • Peak hours: 10am-4pm • UV protective sunglasses • Shadow rule • Bring your own

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Sunscreen

• Sun Protection Factor=SPF • Based on testing • Broad Spectrum=UVA coverage • Water resistant 40 min or Test conditions: 2mg/cm2 80 min Most adults: 25-50% • Not approved below 6 months of age

aad.org 47 48

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Sunscreen reduces melanoma risk Sunscreen FDA Safety • Sunscreen regulated by FDA OTC since Generally Regarded as Safe Australia and Effective (GRASE) 1,621 participants GRASE Insufficient Data Not GRASE Age 25-75 Zinc Oxide Avobenzone PABA Daily sunscreen vs Titanium Dioxide Cinoxate Trolamine Salicylate discretionary Dioxybenzone Treated 5 years Ensulizole Homosalate followed 10 years Meradimate MM: 11 vs 22 (p=0.05) Octinoxate Invasive melanoma: Oxybenzone 2 vs 11 Padimate O Sulisobenzone J Clin Oncol. 2011 Jan 20;29(3):257-63

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Sunscreen Absorption Sunscreen Absorption

• 24 participants • All active ingredients above 0.5ng/mL • 2 sprays, 1 lotion, 1 cream • “These results do not indicate that individuals should refrain from the • 2mg/cm2 to 75% of BSA 4 times daily for 4 days use of sunscreen.” • 30 blood samples over 7 days • Use for decades with no reported systemic side effects • Avobenzone, Oxybenzone, Octocrylene, Ecamsule • FDA Guideline: if <0.5ng/mL absorbed, can waive further study

JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586. [Epub ahead of print] JAMA. 2019 May 6. doi: 10.1001/jama.2019.5586. [Epub ahead of print] 51 52

Coral Reefs and Sunscreen • Hawaii banned Oxybenzone and Octinoxate • Coral reef bleaching determined to be due to climate change • Many sunscreens “coral reef safe” including zinc oxide and titanium dioxide Elder Abuse

Nature, 543 (7645) (2017), pp. 373-377 53 54

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Superficial abrasions Defensive injury on dorsal • Michigan reporting number: 855-444- and dermal hand hemorrhage: beaten 3911 with a narrow object. • Make an immediate report through phone or online. Within 72 hours, make written report Skin Signs of • Google: ”Report elder abuse Michigan” Elder Abuse • 3 knife stab wounds Can be difficult to distinguish from a knife • History and physical exam inconsistent • Self-neglect: BCC Pattern, distribution neglected for 3 years J Am Acad Dermatol. 2013 Apr;68(4):533.

J Am Acad Dermatol. 2013 Apr;68(4):533. 55 56

Unexplained of various stages on face (A) and trunk (B)

• A two-visit algorithm can aid in diagnosis and management of pruritus (itch) in the elderly Take Away • Skin exams are important to identify benign and malignant skin tumors Digitate purpura after Inguinal purpura, biopsy Points deep palpation by revealed leukocytoclastic • All patients should be counselled on sun physician in setting of hepatic coagulopathy protection

J Am Acad Dermatol. 2013 Apr;68(4):533. 57 58

Thank you Steve Daveluy [email protected]

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