Xerosis and Pruritus in the Elderly DISCLOSURE OF RELEVANT RELATIONSHIPS WITH Dr. Robert A. Norman INDUSTRY President and CEO Dermatology Healthcare, LLC Tampa, Florida Robert A Norman DO MPH Xerosis & Pruritus in the Elderly Clinical Associate Instructor Department of Internal Medicine Division of Dermatology Consultant – JSJ, Allergan. Nova Southeastern Medical Center Advisory Board – Coloplast, Connetics, Coria, Ft. Lauderdale, Fl www.drrobertnorman.com Abbott, Galderma Honoraria – Allergan, Amgen, Coloplast, Connectics, Coria, Abbott, Novartis.

Xerosis and Pruritus Xerosis (Dry Skin And Itching) • Dry, rough, scaly skin Abstract • May crack and fissure • Endogenous and exogenous causes Xerosis (dry skin) is a common • Incidence increases dermatological . Dry in elderly (age > 60) Skin, or Xerotic Eczema, can be labeled as Xerosis, Eczema craquele, Dyshidrotic Eczema, or Asteatotic Eczema.

Xerosis Xerosis

Incidence has increased in recent The condition is characterized by pruritic, dry, cracked and fissured years because of: skin with scaling. • more frequent bathing and Xerosis occurs most often on the legs showering of elderly patients. • fragranced baths These skin cracks or fissures are present from epidermal water loss.

1 Signs/Symptoms:

The skin splits and cracks deeply enough to disrupt dermal capillaries and bleeding fissures may occur. Itching or pruritis occurs leading to secondary lesions. Scratching and rubbing activities produce excoriations, an inflammatory response, lichen simplex chronicus and even edematous patches.

Differential diagnosis: stasis

Treatment—Moisturizers, alpha-hydroxy Avoidance of harsh skin cleansers

Xerosis

It is characterized as – pruritic (itchy) – dry – cracked – fissured

Xerosis

Xerosis has a spectrum of clinical findings

normal xerosis icthyosis

2 Ichthyosis Xerosis Classified as: • Ichthyosis is derived from the Greek word • Acquired ichthys which means “fish” • Congenital • Describes a group of diseases characterized by abnormal differentiation of the epidermis • Manifests clinically as scaling of the skin • Can be inherited or acquired

Causes of Xerosis Causes of Xerosis Environmental agents that lead to xerosis • Endogenous Causes include – Asteatotic eczema – hot water – Venous dermatitis – soap & detergents – – friction from clothing – Aging – frequent air travel – Hereditary conditions (ie. Ichthyosis) – pollution – Acquired conditions – other chemicals – air conditioning • Exogenous causes – low humidity – Excessive exposure to water, dry climate, detergents – seasonal changes

Stasis dermatitis

3 Stasis dermatitis Stasis Ulcers

Management: includes topical agents such as Alpha-Hydroxy acid moisturizers or steroid cream or ointment (triamcinolone for 10-14 days).

The stratum corneum of the skin is surrounded by a lipid bilayer composed primarily of ceramides, fatty acids, and cholesterol.

When these constituents are present in the proper proportion, they form the “skin barrier,” which functions like a brick wall (keratinocytes) covered by mortar (the lipid bilayer). This barrier protects the skin and keeps it watertight.

Ceramides (Cer) Defects in the stratum corneum or barrier can result in transepidermal Cer is an amide-linked fatty acid water loss, which dehydrates the containing a long-chain amino alcohol. skin and imparts a dry appearance. This amino alcohol is named as sphingoid base or sphingol. Cer is the backbone of all sphingolipids. An impaired barrier may also make skin more susceptible to damage Uchida Y, Hamanaka S Stratum from exogenous sources such as Corneum ceramides: Function, Origins, plants, chemicals, and even water. and Therapeutic Applications in Elias P, Feingold K Skin Barrier Taylor and Francis 2006

4 Frequent eruptions of erythema and Natural moisturizing factor (NMF), a pruritus typify dry, sensitive skin and substance that retains water inside indicate a likely defect in the stratum keratinocytes and renders them corneum. People with such skin are plump, also plays an important role at higher-than-average risk for in the pathophysiology of dry skin. eczema.

NMF is derived from the hydrolysis of the protein filaggrin, which confers structural support to the dermal layers and breaks down as NMF in the epidermal layers, exhibiting a strong capacity to bind water and hold it inside the cell.

Currently, there is no known method of artificially enhancing filaggrin The breakdown of filaggrin breakdown in order to elevate NMF acclimates to varying levels. In the 1970s, UV light was environmental conditions over a demonstrated to disrupt the course of several days. In a low- enzymatic hydrolysis of filaggrin to humidity environment, more NMF, suggesting that reduction of NMF is produced. sun exposure might improve skin dryness.

5 Causes of Xerosis The reduced production of sebum Xerosis is due in part to: also may play a role in dry skin. – Decrease in the natural moisturizing Sebum contains wax esters, factor in stratum corneum triglycerides, and squalene, all of – Defect in permeability barrier which protect the skin from the environment. (Clinics Dermatol. 1995;13:307–21).

Sebum-derived fats form lipid films on the The influence of sebum on dry skin is skin surface that help to prevent water not well understood loss. However, low sebaceous gland activity is not correlated with xerosis. A deficiency of NMF and low sebum Not all people with xerosis have decreased levels may cause dry skin and may sebum production, which is affected by increase skin sensitivity. diet, heredity, stress, and hormones (J. Invest. Dermatol. 1987;88:2s–6s). (Br. J. Dermatol. 1988;118:393–6).

Hyaluronic acid (HA), which can bind 1,000 times its weight in water, also helps retain Diet water in the skin. Aged skin is characterized by reduced HA levels, which Replenishing the three key components of causes dryness and makes the skin appear the stratum corneum--ceramides, fatty acids, and cholesterol--is the aim of some older and less plump. skin care formulations.

Glucosamine supplements may help increase Diet also plays an important role in HA production, although HA does not maintaining a healthy skin barrier; fatty penetrate the skin when applied topically acids and cholesterol are derived from the diet. Certain individuals receiving cholesterol-reducing drugs exhibit dry (Cosm. Toil. 1998;113:35–42). skin.

6 Hydration • Water helps maintain The addition of evening primrose oil, a healthy stratum borage oil, or omega fatty acids to corneum the diet may contribute to • Water increases the ameliorating dry, sensitive skin by permeability of the skin replenishing essential components of – Mechanism is not known the stratum corneum. – Relationship between permeability and overhydration is not known

Skin Assessment: Xerosis (Dry Skin) Therapy Coloplast Skin Health Division developed the following -Adequate hydration Xerosis Assessment Tool to be utilized when assessing -Avoid foaming detergents and soap and documenting patient skin conditions. It is derived found in laundry cleansers, body from documented clinical studies assessing xerosis cleansers, and face cleansers and review of clinical literature. -Avoid prolonged baths, particularly in hot or chlorinated water. The purpose of this tool is to provide clinicians with a tool to assess, document and establish interventions -Use humidifiers in low-humidity for xerotic (dry) skin before the patient develops environments scratching and/or develops skin complications. -Consider taking omega-3 fatty acid supplements -Moisturize two or three times daily.

Xerosis Assessment Tool Xerosis Scale for Measuring Dry, Scaly Skin What is Pruritus?

I 0: Absent I 1: Mild dry skin with minimal flaking • Pruritis or is a I 2: Moderate dry skin with flaking common complaint I 3: Severe dry skin with or without cracking/fissures • Can be due to many dermatological and Skin health interventions for xerosis includes medical illnesses appropriate bathing and moisturization strategies to • Can occur with or minimize the likelihood of a break in skin integrity. without skin lesions Developing an individualized plan of care for the patient with xerosis is essential in restoring skin health and greatly improving patient outcomes.

7 Pruritus

• Also known as “itch” • Dominant symptom of many skin diseases • May be the initial sign of many systemic diseases • Originates in the skin or in the central nervous system • Transmitted by unmyelinated C nerve fibers • Elicited by physical and chemical stimuli • The receptor for pruritic stimuli are located in the epidermis

Mediators of Pruritus

• Inflamed skin causes the release of a number of chemicals (histamine, prostaglandin, substance P, interleukins, tryptase, serotonin, and opioid peptides) which mediate pruritus • Pruritus in skin disease is multifactorial; neurogenic components may play a role in some skin diseases

Evaluation of Pruritus Evaluation of Pruritus Patients with severe pruritus that does not respond to conservative therapy should be evaluated for • Examination of the • metabolic or endocrine disorders – Diabetes mellitus skin – Renal failure – Thyroid disease • Assessment – Hepatic disease (obstructive) • malignant neoplasm – primary and secondary – Lymphomas lesions – Leukemia • hematologic disease – morphology and – Polycythemia vera distribution • human immunodeficiency virus infection – presence of • complication of lichenification pharmacologic therapy • neuropsychiatric diseases lymphoma

8 Evaluation of Pruritus Possible diagnostic tests to be performed – complete blood count with differential and platelets – thyroid-stimulating hormone – serum bilirubin, liver transaminases, alkaline phosphatase – fasting glucose – serum creatinine and blood urea nitrogen levels – chest radiography – HIV

9 The "itch-scratch" cycle is the dermatologic equivalent of chronic pain syndrome, and should be treated as such. Just as with chronic pain, there is a "reduced threshold" phenomenon that occurs in patients with chronic itch.

Chronicity not only lowers the threshold for the sensation of itch, it also increases the intensity of itch. Also, as with chronic pain, short bursts of spontaneous itch may occur, even when the skin is clear.

Pruritus Pruritus

Scratching may contribute to Chronic scratching may lead to

lichen simplex chronicus impetigo

Prevention and Treatment Treatment of Pruritus of Pruritus General measures include • DOs • Elimination of factors that aggravate dry – Wear cotton or silk clothing skin – Take short, lukewarm baths/showers • Patient education – Dry gently after bathing • Teaching of adequate methods of – Apply topical emollients immediately after interrupting the itch-scratch cycle bathing – Keep nails short – Stop the Itch-Scratch cycle

10 Prevention and Treatment Treatment of Pruritus of Pruritus • DON’Ts • Teaching of adequate methods of – Wear wool or synthetic clothing interrupting the itch-scratch cycle – Take long, hot showers/baths – Application of a cold washcloth – Live in cold, dry climates – Gentle pressure – Use soaps excessively – Scrub habitually – Have prolonged exposure to water scratchscratchscratch – Scratch

Treatment of Pruritus Treatment of Pruritus

• Topical agents Multiple topical and systemic treatments – emollients have been recommended for the – corticosteroids management of pruritus, as well other – anesthetics modalities – doxepin – capsaicin – menthol – topical immunomodulators

new t-shirt to prevent itching in children and Treatment of Pruritus adults. • Systemic agents --to be sold by Hill Pharmaceutical based on a fabric – hydroxyzine hydrochloride developed by Milliken. – diphenhydramine --It has an extremely low coefficient of friction and – doxepin (tricyclic antidepressant with wicks sweat better than cotton. antihistaminic properties) --close up pictures of cotton vs. this microfiber long – oral corticosteroids filament polyester.

--"We were able to show a statistically significant reduction in itching between cotton and this fabric in 60 subjects in a 4 week cross over study"

From Dr. Zoe Draelos

11 Figure 1 Figure 2

Dermatology Consultations in the Nursing Homes—A Ten Year Retrospective Dr. Robert A. Norman, Clinical Associate Instructor, Department of Internal Medicine, Division of Dermatology, Nova Southeastern Medical School, Ft. Lauderdale, Florida and Private Practice, Tampa, Florida, 8002 Gunn Hwy, Tampa, Fl 33626, [email protected], www.geriatricdermatology.com

Dermatologists Beware!! Research Findings List of recommendations. Top Ten Problems in Nursing Home Dermatology Pruritus and other You Are Becoming Even More Important!! 1200 related diseases The vast majority of people older than 70 years of age have at least one bothersome skin Long term care dermatology is a grow ing specialty, and w e all must w ork together to 4. Infections condition, and approximately ten percent have 3-4 dermatological problems. I completed a study of the nursing home patients I treat, and found the tw o most common improve the care of our patients. 1. Pruritu 3. Psychogenic Disorders •lDermatophyte problems are overw helmingly xerosis and pruritus (Table Four includes age and gender Treatment Recommendations s •lCandidiasis “This traditional neglect of the skin is w ell-nigh unforgivable and has cruel consequences for distribution). Given these results, attention needs to be paid to the recognition and treatment • lLichen Simplex •lCellulitis, Keep in mind the ten tips below . 2. Xerosi the w ell being of the elderly. The great majority of persons over 70 have at least one, often of these entities. Of ultimate importance is the comprehensive treatment of these problemsto Chronicus folliculitis, miliaria s tw o or three, skin conditions w hich would benefit from the attentions of a know ledgeable prevent stasis dermatitis and ulcer formation. • lPrurigo Nodularis 76 y/o female cellulitis of doctor. These diseases do not kill but they are persistent pestilences which spoil the quality of 1. Whenever possible, identify the reason for each prescribed medication and treatment. • lNeurotic the face. life…It is the skin more than any other organ w hich most clearly reveals the cumulative losses •Herpes Zoster 2. Begin treatment w ith the low est possible dose and prescribe short courses of treatment. Excoriations 1000 which time prints on the visage of the high and low alike.” Continually re-evaluate the clinical outcome. Check on the “prn” or routine medications • lDelusions of Diseases of the sebaceous Albert M. Kligman, MD in the forew ord to Barbara Gilchrest, MD’s book Skin and Aging no longer clinically indicated for a resident and eliminate unnecessary treatments. Parasitosis Processes CRC Press, Inc. Boca Raton, Florida 3. Assume the treatment w ill not be provided as often as prescribed. Workload, time restraints, and poor compliance are all issues which effect the treatment of skin conditions in the long-term care patient. If you prescribe Triamcinolone cream 0.1% for glands (Xerosis=772) tw o weeks for an eczematous dermatitis, I recommend w riting it TID w ith the hope that it will get applied at least once a day. 4. Work w ith the nursing staff and attending physician on neuropharmacological agents, 800 checking to make sure the prescribed drugs do not interfere with current treatments. Long-term Care Dermatology 5. Do not forget the simple preventions, such as antibacterial soaps, frequent handwashing, proper shoes, supports and devices for wound prevention, adequate hydration and humidity, proper lighting, and eliminating high-fall risks. Long-term care dermatology is truly its own art form. And it is a growing specialty, draw ing from Other dermatoses 2 the realm of both dermatology and geriatrics. 6. At least once a year, provide in-services to the nursing home staff on dermatology Those of us that work in long-term care serve a population composed of over 2.7 million patients, issues. The staff require CEU’s and are generally very appreciative of your time. You are a crucial part of the team in improving the residents’ treatment, and face-to-face the total estimated population in nursing homes and ALF’s. 5. 6. Autoimmune Disorders encounters are crucial in maintaining an ongoing quality of care. 81 y/o Male bullous Why the shortage of high quality skin care? Not enough attention is given to skin problems and Infestations 7. Inflammatory 600 pemphigoid. delay in care and treatment often occurs. Other problems include little access to specialists and 7. Consider doing a skin cancer screening for patients and employees. It’s a great service Disorders delayed disease recognition, especially for certain diseases seen more prominently in the elderly for them and can increase the number of people in your practice. population in nursing homes such as bullous pemphigoid. The w orld of today's hospital can be described as "high tech, low touch," in that the patient may 8. In addition to their clinical skills, long-term care medical directors and consultants have a be poked and probed, treated and then “streeted.” Nursing homes are certainly not hospitals, need to know what their ethical and legal obligations are. A comprehensive grasp of although many have sub-acute floors and hospital patients requiring significant post-op care are important issues, including end of life, restraints, and informed consent are important for sent to live in nursing homes until able to be sent home. Nursing homes are mostly “low tech medical directors and consultants decision-making in long-term care. All of these with high touch.” What the resident did for himself/herself in the past is now done with the principles and issues must be addressed in the spotlight of cost containment and Basal or squamous cell assistance of others. litigation. 400 Think about it. What happens if you were in a situation w here you are now put into a facility such The goals of care in an institutional setting may differ from those of the acute hospital. as a nursing home? The nurses and aides would help you get out of bed in the morning, toilet, The emphasis is placed on maximizing function, maintaining quality of life, and comfort bath, dress, eat and take your medications. The activities' staff would be around you attempting care rather than curing disease. Communicate w ith the resident’s family to address carcinoma of the skin to stimulate your interest and zest for life. The food service personnel w ould be cooking for your their fears and concerns and ensure their participation in the development of the care health and enjoy ment and therapists would be busy fighting an uphill battle against a possibly plan. deteriorating body and mind, and the social services staff would try to help solve problems ranging from financial difficulties to unpleasant roommates. Although many social service people 9. Follow -up care includes interventions to handle acute events, periodic reassessments of 10. Mechanical act as marketing operatives, w ith the primary function of recruiting residents, most social service the patient’s status and implementation of preventative programs to meet specific Disorders directors that I have encounter help educate families about themselves, their needs, and the 9. Neoplasia treatment and maintenance goals. Regular evaluations provide an opportunity to review 8. Vascular •Skin tears resources that are available in the community to serve these needs. the resident’s and staffs concerns, monitor vital signs including w eight, identify changes Disorders •Wounds 200 in the physical examination, re-examine the medication list and review the care plan. Scabies 10. Sometimes patients just have stories and just want to talk. Be patient w ith your patients and enjoy your time together. 0

Long-term Care Dermatology, Continued ICD 9 CM N1 % Male Mean Age References and

As a health care provider, we enter into the resident's home, a place that is often new and 1. Norman R Geriatric Dermatology 2001 Parthenon/CRC Publishing Code (SD)2 sometimes permanent. It is important to keep that in mind. In order to become part of the 2. Dharmarajan TS, Norman R Clinical Geriatrics January 2003 Parthenon/CRC Publishing other eczema resident's life and therapeutic family, you must keep a respect for the resident and his/her environment. Many move into nursing homes from their ow n residents or those of family and 3. Norman R Dermatologic Therapy November 2003 Guest editor(Issue on Geriatric friends and the rest are transferred directly from hospitals to nursing homes. The patient and Dermatology) family are under considerable pressure. Very often a long period of adjustment is needed, 4. Norman R Dermatologic Clinics January 2004 Guest editor (Issue on Geriatric Dermatology) coming to grips w ith the fact that many of these residents w ill never return to their previous homes or lifestyle. 5. Norman R. Causes and Management of Xerosis And Pruritis in the Elderly. Annals of Long Term Care 2001; 9(12): 35-40 6. MD Live http://www.mdlive.net (w eb) Norman, R (Geriatric Dermatology) 1 Total sample size = 1556 7. Marks, R Skin Disease in Old Age Martin Dunitz 1999 2 SD = standard deviation 3specified and unspecified hypertropic and atrophic conditions, keratoderma

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References

1. Norman, R ed Geriatric Dermatology (book) Parthenon International Publishing London/New York (2001) 2. Norman, R A Dermatologist’s Guide to Nursing Home Consultations Skin and Aging (The Journal of Geriatric Dermatology) January 1998 pp 62-72 3. Young EM, Newcomer VD, Kligman AM. Geriatric Dermatology, Lea Febiger, Philadelphia 1993 4. Marks R Skin Disease in Old Age Martin Dunitz London 1999 5. Norman R. Dermatological problems and treatment in long- term/nursing home care in Norman R. (ed) Geriatric Dermatology 2001 Parthenon/CRC Publishing pp.5-15. 6. Norman R. and Townsend R. Dermal manifestations of diabetes in Norman R. (ed) Geriatric Dermatology 2001 Parthenon/CRC Publishing 7. Dermatologic Therapy November 2003 Guest editor Geriatric Dermatology 8. Norman R. Causes and Management of Xerosis And Pruritus in the Elderly Annals of Long-Term Care Volume 9 Number 12 December 2001 pp 35-40 9. Clinical Geriatrics Norman, R (book; co-editor with T.S. Dharmarajan) January 2003 Parthenon/CRC Publishing 10. Pruritus, Itch Mechanisms, and Treatments Dermatologic Therapy July/August 2005 Volume 18 Number 4

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