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 — Dermatology 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 skin cancer services recommends that the treatment of Clinicians also need to be aware of Bowen’s disease presents mostly in Bowen’s disease and actinic keratosis suspicious lesions by ensuring that they sun-exposed areas, but in some cases, (pre-cancerous lesions) should be have an understanding of common is not caused by ultraviolet 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 (freckles, 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 Melanin reduces — hair turns grey, can also sandpaper texture; in most cases the increase causing hyperpigmentation 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). cryotherapy, 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.