10/18/2020 Participants will be able to: • Describe the skin 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 1 2 • Skin changes with aging • Itch and Rash • Tumors – benign and malignant • I have no relevant conflicts of interest for • Sun Protection Disclosure this session Outline • Elder Abuse 3 4 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 1 10/18/2020 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 fat -> 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 +/- scabies • Exam: scabies (burrows, genital lesions), dry skin (fissured, red 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 2 10/18/2020 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. 13 14 Seborrheic Dermatitis Stasis Dermatitis • Scalp, face, upper chest, intertriginous • Bilateral lower legs • Erythema, greasy scale • Can be complicated by allergic contact • Treatment: Ketoconazole cream or derm shampoo. 75-90% response • Often other signs of venous hypertension • 2nd line: topical steroids • Often mistaken for cellulitis • 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 Bullous Pemphigoid • 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 3 10/18/2020 Fungal Infections Herpes Zoster (Shingles) • 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 • Dermatophytes (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 19 20 Benign Tumors Tumors – benign and malignant • Seborrheic Keratosis • Cherry Angioma • Lentigo • Acrochordons (Skin Tags) • Sebaceous Hyperplasia 21 22 Seborrheic Keratosis Cherry Angioma • Appear 4th decade of life • Anywhere except mucous membranes, palms, • Bright red to purple, dome shaped papule soles • Often numerous • Tan to black, papular or verrucous, waxy, stuck- on appearance • Can simulate melanoma Dermatology, 4th Ed. 2018. Elsevier Dermatology, 4th Ed. 2018. Elsevier 23 24 4 10/18/2020 Solar Lentigo Acrochordon (Skin Tag) • Skin colored to hyperpigmented, pedunculated papules • 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 25 26 Sebaceous Hyperplasia Skin Cancer • Benign enlargement of sebaceous glands • Basal Cell Carcinoma • Face and upper trunk • Squamous Cell Carcinoma • Yellowish papule, +/- telangiectasias, central follicular ostium • Melanoma • Skin Cancer Prevention 27 28 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 5 10/18/2020 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 33 34 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/Ulcer • HPV (SCC) • Numerous nevi (melanoma) 35 36 6 10/18/2020 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 39 40 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 7 10/18/2020 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