Clinical REVIEW Changes that occur in older people’s skin

With the UK population living longer, and with people over the age of 70 presenting with at least one skin condition, there is an increasing need to improve knowledge and management of skin conditions affecting the older person. Assessment of the older person’s skin should be included in any nurse/patient consultation. Clinicians are arguably best-placed to assess and plan appropriate skin care for older patients and should consider the skin in assessment or treatment, regardless of the referred condition (Associate Parliamentary Group on Skin [APPGS], 2000; Norman, 2003; Courtenay and Carey, 2006; Wounds UK, 2007).

omeostasis refers to the 8 Poor dietary intake/poor hygiene as a body’s ability to maintain consequence of other impairments. ‘Lifestyle, ‘normal’ functioning, adjusting comorbidities and Hto external and internal changes to Assessment of the older maintain ‘normal life’ (Clancy and Smith, person’s skin family history play 2010). The skin is integral to homeostatic In acknowledgement of the reduced a substantial role functioning, however, the aging process capacity of the skin’s homeostatic ability, in how the skin takes its toll and reduces homeostatic clinicians must look to their assessment behaves in the ability, putting the skin under threat of the skin as being fundamentally (Madhulika et al, 2005) (Table 1). An important. They must also consider older person’ understanding of the changes that occur prevention and preservation when in aging skin and the importance of this conducting any skin assessment, organ in maintaining homeostasis of the old or young, while approaching the body is crucial when nursing the older examination sensitively with the aim of person. preserving patient dignity at all times.

Lifestyle, comorbidities and family Clinicians must look for potential failure history play a substantial role in how the of the skin barrier where symptoms may skin behaves in the older person, such as: include: 8 Chronic skin disease (eczema, 8 Scaling CARRIE WINGFIELD varicose eczema) 8 Red sore skin (factors — Nurse Consultant; President 8 Incontinence incontinence, reduced mobility, British Dermatological Nursing Group; 8 Associate University Lecturer, University of Decreased mobility obesity) East Anglia 8 Immunosuppression 8 Dryness 8 Diabetes 8 Maceration 8 Renal disease 8 Itching, scratch marks (excoriation) 8 Thyroid disease 8 Infection 8 Iron deficiency 8 Pressure areas, skin breaks and 8 Changes in mental health ulceration

52 Wounds Essentials 2012, Vol 2 Clinical REVIEW

8 Skin folds — redness, weeping 1996). There is a low rate of conversion et al, 2007). The National Institute for 8 Low mood to SCC, with less than one in 1,000 per Health and Clinical Excellence (NICE) 8 Poor sleep patterns. annum. 2010 guidance on services recommends that the treatment of Clinicians also need to be aware of Bowen’s disease presents mostly in Bowen’s disease and suspicious lesions by ensuring that they -exposed areas, but in some cases, (pre-cancerous lesions) should be have an understanding of common is not caused by radiation carried out by the patient’s GP, unless benign skin lesions that appear on the hence it can appear on the genitals, there is diagnostic doubt. older person’s skin. The rationale is that under nails, palms, and in subungal and the clinician is then better placed to perianal areas. Causes of Bowen’s disease Bearing in mind that patients will recognise suspicious lesions that are not include sun damage, arsenic tonic, be passing through the hands of skin tags or seborrhoeic keratoses. immunosuppression, viral infection primary care nurses, as well as GPs, it (human papillomavirus [HPV]), chronic is important that surgeries establish Check sun-exposed sites, such as: skin injury and dermatoses. The majority a pathway of management for the 8 Scalp of studies report a risk of progression to assessment of these conditions to ensure 8 Ears invasive SCC at 3–5%. timely treatment. Immunosuppressed 8 Dorsum of hands and transplant patients may warrant 8 Nose Pre-cancerous skin lesions are often regular attendance in a dermatology 8 Temples numerous, as well as common, with department for their management. 8 Back. approximately 23% of the population aged 60 and older presenting with AKs. Immunosuppressed and transplant One of the major accelerating factors in The incidence of Bowen’s disease is 15 patients may warrant regular attendance aging skin is where lifestyle has caused per 100,000 people, although the data in a dermatology department for their excessive photo damage/sun damage, are limited and unsubstantiated (Cox management. so in their assessment, clinicians must ask: ‘What lifestyle has this person had?’ Occupations such as builders, farmers, Table 1 postmen and women, and the military, Homeostatic function of the skin (adapted from Clancy and Smith, 2010; as well as those living abroad, are all Wounds UK, 2007) common groups where lifelong exposure to the sun may have a consequence. This Homeostatic function of Alteration of function in older skin can present with skin changes, such as the skin xerosis (dry skin — Figure 1); thickened Protect against: leathery skin, increased wrinkles (solar Trauma — internal tissue dam- Reduction in elastin/collagen increases the elastosis — Figure 2); and irregular age, ultraviolet light, risk of tears and trauma and increased pigmentation (, temperature, bacteria and toxins lentigines). Also, a wide variation of pre-cancerous skin lesions can appear Maintenance of body Thinning of the dermis; decrease in sensation; including; actinic keratosis and Bowen’s temperature — to warm and temperature control; decrease moisture reten- disease (Figures 3, 4, 5) (Bhawan and cool the body by vasoconstric- tion; dryness. Loss of subcutaneous fat, feeling Anderson, 1995). Cancerous lesions are tion and vasodilation of coldness also more prevalent, presenting as basal Barrier to infection — Reduction of sweat glands in the dermis re- and squamous cell carcinomas (BCC production of sebum, sweat ducing sebum production. Increased washing, and SCC) (Figures 6, 7, 8). creating antibacterial PH for example, incontinence adds to the effect level of skin of increasing PH alkaline, which, in turn, Actinic keratoses (AK) are lesions that increases dryness, itching and impairs skin appear on chronic sun-exposed adult barrier, leading to risk of infections skin sites. The most common sites Production of vitamin D — regu- Lower vitamin D production, more time spent are the face, scalp, ears and dorsum of lating calcium and indoors, more clothing covering up hands (Figure 9). Early presentation can phosphate supplies in body fluids be felt on the skin as an area of rough, Production of Melanin reduces — hair turns grey, can also sandpaper texture; in most cases the increase causing to skin lesions are asymptomatic. Between 15–25% of AKs spontaneously regress Psychological function Loss of confidence, appearance change, can over a one-year period (Harvey et al, cause social anxiety

54 Wounds Essentials 2012, Vol 2 The Primary Care Dermatology Society 1999) (Figure 10). This type of SCC is leaving a cosmetic result acceptable (PCDS) guidelines recommend that aggressive and spreads locally (Chong to the patient. Treatments such as patients should be offered the choice and Klein, 2005). , curetting or photodynamic as to whether they treat their pre- therapy (PDT), and topical treatments, cancerous lesions or not (PCDS, 2010). Treatment and management of such as 5-floruracil, diclofenac sodium If the clinical and patient decision is BCC and SCC 5% and imiquimod are frequently to actively treat, there are a variety of BCCs are excluded from the national used for pre-cancerous lesions, such as modalities to choose from (Table 2). cancer waiting time targets (two weeks). actinic keratosis, Bowen’s disease and Low-risk BCCs can be referred to GPs superficial BCCs. The disadvantage of BCC is described as the most common with suitable skin cancer training. Where these treatments is that they do not give cancer in Europe, Australia and the USA this resource is not available, referral is the benefit of final histopathology results (Gilbody et al, 1994; Miller et al, 1994). It to secondary care. Surgical excision or to confirm diagnosis or if the lesion has is sometimes referred to as a rodent ulcer radiotherapy is advised for the majority been completely cleared. or basalioma. They rarely metastasise of BCCs (Bath-Hextall et al, 2007). However, some patients may undergo and morbidity is low and mostly The principle aim is to cure the lesion, a small biopsy prior to these treatment associated with neglected long-term lesions (Ting et al, 2005). BCCs present as slow growing lesions predominantly on the head and neck but are also seen on limbs and trunk. Aetiology is mostly connected to sun exposure and in some cases genetic predisposition.

Clinical presentation varies and includes the following: 8 Nodular 8 Figure 1. Xerosis – dry skin Figure 2. Solar elastosis. Cystic (asteatotic eczema). 8 Superficial 8 Morphoeic (scelrosing) 8 Pigmented.

SCC In suspected SCC, referral to secondary care is appropriate using the two-week wait cancer route. This refers to national guidelines issued in April 2000 by the Department of Health (DH). The aim was to encourage urgent referral by a GP of suspected cancer cases, across a wide range of specialities. Figure 3. Actinic keratosis ear. Figure 4. Actinic keratosis scalp.

Considerations for suspecting SCC are: 8 Rapid recent growth 8 Elevated lesion, on removal of scale 8 Bleeding/ulceration 8 Unresolving lesions on the lips.

SCCs have the potential to metastasise and are locally invasive — again, most incidence is related to chronic sun exposure. Immunosuppressive and transplant patients are more at risk. Figure 5. Bowen’s disease. Figure 6. Basal cell carcinoma. Previous chronic wounds, burns and leg ulcers can also develop into SCCs, termed as Marjolin’s ulcers (Esther et al,

Wounds Essentials 2012, Vol 2 55 Clinical REVIEW options to confirm diagnosis. These Pigmented lesions Malignant melanoma (MM) is the types of treatments may be advocated Pigmented lesions should not be most life-threatening of all skin cancers where comorbidities may place the overlooked as their presence on (Figures 14, 15). Ultraviolet exposure is patient at risk of surgical excision or older skin often causes confusion considered to be responsible in 65–95% there is extensive presentation. and differential diagnosis. The two of cases. Suspected melanomas in most common pigment lesions are an existing or new pigmented lesion Potential anatomical sites, such as the seborrhoeic keratoses (Figure 11) and are referred via the two-week cancer lower leg, may increase the risk of solar and both are benign (Figure pathway. Clinical diagnosis is preferably delayed healing due to poor circulation 12). Seborrhoeic keratoses are the most made with an elliptical excisional biopsy and this risk may be minimised with common benign tumor in older people and sent for histology. a treatment such as PDT. These and develop from the proliferation treatments would not be advocated for of epidermal cells. Solar lentigo is Obtaining a basic overview of the infiltrated or nodular BCCs, SCCs or sometimes referred to as an age spot or skin lesions mentioned here will assist melanoma spot and is caused by sun damage. clinicians in their general assessment of the older person’s skin but the SCC diagnosis is usually made by Other pigmented lesions include lentigo more simple observations are just as histology either with full excision or with maligna (melanoma in situ), lentigo important. biopsy. Surgical margins are using taken maligna melanoma and melanoma. wider than BCCs. If SCC is suspected (Figure 13) is a pre- Assessment of older skin — in primary care, the two-week wait cancerous lesion and not the same as where to start? cancer target should be adhered to, and lentigo malignant melanoma and the Start simple — this is the key. The treatment should not be carried out in two should not be confused. It typically clinician should focus primarily on the primary care (NICE, 2010). progresses very slowly and can remain in skin barrier function. Dry skin is a factor a non-invasive form for years. in homeostasis balance and a common For patients where surgery is not factor in the aging skin, contributing advocated, radiotherapy is a primary The transition to true melanoma is to other secondary-associated treatment option and is an adjuvant noted as a 3–10% risk and because of conditions, such as eczema, nodular therapy for those with metastatic or this risk, if identified, surgical excision prurigo, infection, cellulitis, pruritus high-risk cutaneous SCC, following is often proposed. It is normally found (itching) and ulceration. The decreased surgery. When examining a patient with in the elderly (peak incidence in the thickness and changing anatomy of BCC, SCC or the potential for either, ninth decade), on skin areas with high the epidermis and dermis results in examination should include the whole levels of sun exposure, such as the reduced sweat glands increasing dryness body, looking for other lesions and face and forearms. It is also known as and breakdown of the skin barrier palpable lymph nodes. ‘Hutchinson’s melanotic ’. function. This potentially leads to cracks and fissuring, leaving opportunistic portals for bacterial colonisation, skin Table 2 breakdown and further damage. One Treatment options for actinic keratoses/Bowen’s disease (adapted from technique for managing this decrease in de Berker et al, 2007) essential function is the use of emollient therapy. NICE (2004; 2007) supports 8 If no therapy opted, simple emollients are acceptable for superficial AKs the evidence that emollients should be 8 The use of a sun block should be advocated for seven months to reduce the considered as the first-line treatment development of AKs for dry skin conditions, regardless of age 8 5-Fluororacil cream bd for 4–6 weeks to affected areas. Proven to be effective group. in the clearance of AKs and Bowen’s. Side effects of inflammatory response need to be discussed with patient 8 Emollients as a therapeutic Diclofenac gel (less aggressive than 5-Fluororacil) suitable for mild AKs, poor intervention follow up data for efficacy Emollients can have a dual role in either 8 0.5% 5-fluororacil (5FU) cream and salicylic acid. Once-daily 90 days for AKs direct application to the skin or as a 8 for AKs and Bowen’s, used on its own or in combination with soap substitute, replacing detergent- topical treatment. Beware thin elderly skin, especially on the lower leg, in based products (soap/shower gels). terms of slow healing and potential of ulceration They are a useful therapeutic method 8 Photodynamic therapy (PDT) used with photosensitising cream in the preservation of the skin barrier (5-aminolaevulinc acid, 5-methhylaminolaevulinate). Appropriate for function, although there is little evidence extensive AKs and Bowenoid lesions via hospital dermatology department to suggest one brand is better than any

56 Wounds Essentials 2012, Vol 2 other, in terms of efficacy (Rawlings et al, can increase itching, scratching and the therapeutic change. 2004). Discussing with the patient/carer formation of inflammatory dermatoses, emollient types and choice to find the such as eczema. How to make the right most acceptable product can encourage emollient choice regular and repeated use (Loden, 2003). Pathogens will also increase, together Emollient therapy can be listed as having with an alteration of the skin’s normal the following benefits: Clinicians may encounter resistance bacterial flora, making the skin more 8 Occlusive — trapping water in the when changing an older person’s daily susceptible to infection and delayed stratum corneum skin care regimen, especially when they healing. The objective of implementing 8 Active — moving water from the are asked to consider moisturising daily, a change from soap to emollient dermis to the epidermis together with changes in their bathing substitutes is to reduce the negative 8 Exfoliative and washing practice. This resistance effect of soap on skin barrier function 8 Anti-inflammatory may come from the actual person or (Cooper and Gray, 2001). 8 Antimitotic from their carers in terms of enacting 8 Antipruritic change. The rationale behind changing Emollients are not an attractive 8 Accelerates regeneration of skin a washing regimen to include emollient option for patient, carer or nurse. barrier. soap substitutes is that soap increases the The decision to use them will require pH levels in the skin, causing irritation careful explanation, education and There is a wide variety of emollient and depletion of lipids from the skin consideration of the person’s personal therapy available and prescribing surface, thereby increasing dryness. This hygiene regimen, in order to bring about practice varies from one person

Figure 7. Basal cell carcinoma. Figure 8. Squamous cell Figure 9. Actinic keratoses carcinoma. dorsum, hand.

Figure 10. Marjolin’s ulcer, leg. Figure 11. Seborrhoeic keratoses. Figure 12.. Solar lentigo (Plural lentigines).

Figure 13. Lentigo maligna Figure 14. Melanoma Figure 15. Amelanotic (melanoma in situ). (malignant). melanoma (malignant).

Wounds Essentials 2012, Vol 2 57 Clinical REVIEW to another and can lead to patient conditions such as eczema. and is often seen to coexist with confusion and poor concordance varicose veins. Clinical signs include (Holden et al, 2002). It is worth knowing Emollients should always be considered inflamed, red, eczematous skin; itching; the components and functions of the as a first-line therapy in the treatment of scaling; pigmentation (haemosiderin different types to aid clinician and inflammatory dermatoses — the two deposit); hardened, tight, red/brown patient choice. most commonly presenting are eczema skin/tissues (lipodermatosclerosis, and varicose eczema. Often, these which is vulnerable to ulceration); and Types of emollient conditions are accompanied by itching atrophy blanching. Treatment usually Aqueous cream is a popular choice and this symptom alone can influence consists of topical corticosteroids and as a cost-effective emollient therapy. treatment and differential diagnosis of emollient therapy. The efficacy of topical In the past, it has been advocated as the skin condition. corticosteroids is helped by correct both a soap substitute and direct skin diagnosis, and an understanding of mode application product. Being water-based, Common dry skin conditions of action and potential side-effects. It can it requires a number of preservatives to and itching in the older person sometimes be more effective to use a prevent bacteria contamination – these Common skin diseases in the older potent steroid for a short amount of time, preservatives can lead to skin sensitivity person that are accompanied by itching rather than a milder potency for a longer and stinging in some patients (Cork et include: period of time (Davis, 2001). al, 2003). Recent research into the use of 8 Eczema aqueous cream by Tsang and Guy (2010) 8 Scabies Treatment requires a common-sense identified skin thinning and irritation 8 approach, as a poor response will be over a period of four weeks connected to 8 Drug reactions achieved if topical corticosteroids are the sodium lauryl sulphate content — a 8 /sclerosus not applied frequently enough or if they detergent agent. This is acknowledged 8 Immune-bullous disorders are not potent enough. Effective use of to be a small study and requires further (pemphigoid). emollients and the use of paste bandages research to support. However, clinicians to aid occlusion and encourage skin have long discontinued the practice of Where there is no presenting rash, barrier repair are also relevant therapies using this product as a direct emollient. systemic disorders need to be This was not the purpose of its original investigated, the most common being: Conclusion design, but it can still recommended as a 8 Iron deficiency The older person’s skin is susceptible soap substitute. 8 Renal failure to homeostatic imbalance and 8 Biliary obstruction requires timely diagnosis and access The petroleum-based emollients can 8 Malignancy to therapeutic agents to reduce the reduce loss of water from the skin 8 Lymphoma (Ersser, 2000). risk of uncomfortable symptoms, by 98% when compared with other disease and infection. Both community emollient products, with only 20–30% Biochemistry investigations are essential and secondary care nurses can play retention (Rawlings et al, 2004). The to eliminate conditions such as anaemia, a major role in ensuring adequate downside is the greasy component kidney and liver function impairment, assessment of the older person’s skin that can encourage poor patient hypothyroidism, and diabetes. If no through recommendations for dry concordance. They can be very useful underlying cause can be found and dry skin management and identification of under bandages for treatment of varicose skin or rashes are evident, diagnosis changes leading to treatment, shorter eczema and some benefit the patient by of the rash and topical treatments care pathways and improved quality of being both soap substitute and direct will take priority. Conditions such as life. application. eczema and tinea (fungal) infections, particularly on the lower limbs, should The use of emollient therapy can Lotions, creams and gels are more be adequately treated with the correct accelerate the regeneration of the skin fluid in nature and are lighter products, topical preparations, mainly topical barrier function (Held et al, 2001) and lending themselves to pump dispensers corticosteroids and emollients. Fungal should not be underestimated as a and reducing the risk of cross-bacterial conditions require anti-fungal topicals, first-line treatment. Improving clinician’s contamination. They can double as such as terbinafine. Both conditions in knowledge of skin lesion recognition soap substitutes and direct application this anatomical area can predispose the will ultimately benefit the patient in hair-bearing areas can reduce the patient to bacterial infection, which can through correct diagnosis and referral for risk of folliculitis (infected hair follicles). lead to cellulitis and chronic oedema treatment of suspected skin cancers. They can also contain antimicrobials, (Wingfield, 2009; Wingfield, 2011). useful in reducing bacterial colonisation, Venous stasis eczema (varicose eczema) This article has provided a basic such as Staphylococcus aureus in skin is a common inflammatory condition overview of some of the issues seen in

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