Geriatric DermatologyThe Pharmacist’s Role

ObjectivesAt the end of this session the participant will be able to:• Describe the dermatological changes that occur as

we age• List some of the common disorders that are prevalent

in an older population• Describe the risk factors and consequences of

decubitus ulcers• Describe treatment options for Xerosis

Skin ChangesIn the Elderly

EtiologyIntrinsic: occurs in everyone and is related to genetic changes in cell processesExtrinsic: produced by external causes (e.g. UV exposure, smoking, environmental pollutants)

Age related skin disorders are related to:• Decreased mobility• Innate cutaneous age-related changes• Drug induced disorders• Chronic Diseases (e.g. CAD, Diabetes, CHF, HIV)• Cellular changes in the epidermis & underlying structures

Cellular changes in aging skin:

• Altered lipid metabolism impaired ability to recover from injury• Sluggish keratinocytes impaired ability to recover from injury• Decreased melanocyte density decreased protection from UV rays• Decreased Langerhans cells density decreased immune function• Loss of collagen and elastic tissues wrinkles and skin fragility• Decreased function of cutaneous nerves, microcirculation and sweat

glands poor thermoregulation and increased risk of burning• Decreased subcutaneous fat in distal extremities less “padding” to

protect from trauma

All these factors lead to increased risk of:• Fragile skin (skin tears, abrasions, cuts)• Traumatic purpura (bruises)• Ischemia (cell death, decubiti)• Xerosis (dry skin)• Infections • Skin cancers

Decubitus Ulcers• Stage III

Decubitus Ulcer with necrosis on sacrum

Decubitus Ulcers• Usually occur over bony prominences• Caused by ischemia, which leads to cell death and tissue

damage• Related to the forces of:

• Pressure• Shear• Friction

• Frequently complicated by secondary infection, leading to:

• Cellulitis• Osteomyelitis• Sepsis

High Risk Patients• Elderly patients, especially those in LTC facilities &

hospitals• Critical care patients• Oncology patients• Diabetics• End stage renal, heart or liver disease patients• Patients with femoral fractures• Incontinent patients• Patients with impaired mental status• Patients with impaired nutritional status

Stages of Decubitus UlcersStages of Decubitus Ulcers

Stage I Nonblanching erythema of intact skin

Stage II Superficial to partial thickness involvement of the epidermis or dermis

Stage III Deep necrosis with full-thickness skin loss that may extend down to, but not through, underlying fascia

Stage IV Extensive necrosis to underlying fascia, possibly extending into muscle, bone, and supporting structures

Treatment of Decubitus Ulcers• Stage-dependent• Ranges from cleansing and application of protective ointments and

specialized dressings to surgical debridement of necrotic tissue.• The pharmacist should be aware of any topical agents and specialized

dressings being used and encourage compliance to any ordered regimen.

• The pharmacist may recommend nutritional, vitamin, and mineral supplements, after consultation with a nutritionist, when wound healing is delayed

• The pharmacist may recommend appropriate pain management for pain related to dressing changes and chronic pain which may be decreasing mobility

• Secondary infection should be treated with systemic antibiotics, NOT topical formulations

Treatment of Decubitus Ulcers• Appropriate treatment should be determined by a

wound care specialist, as use of inappropriate dressings may cause harm (e.g. occlusive dressings over an infected wound may lead to sepsis and debriding dressings used on granulating wound beds may delay healing)

• Wound dressings may be combined in different ways by different practitioners dependent on the individual case and prior experience

Treatment of Decubitus Ulcers• Appropriate wound dressings should:

• Maintain a moist wound bed• Control moisture levels on healthy wound margins (to avoid

maceration)• Permit gas exchange (oxygen required for healing)• Provide thermal insulation• Prevent secondary infection and decrease colonization of

wound bed• Adhere to body to maintain good wound-dressing contact

without damaging healthy skin when removed• Avoid over-adherence to wound bed to prevent trauma on

removal (unless debridement is needed)• Fill wound cavities to promote healing by primary intention

Treatment of Decubitus Ulcers• Dressings which may be used for outpatient treatment may

include• Gauze (wet to dry dressings)

• mechanical debridement• must be done at least TID (to avoid over-drying)• stop once wound bed is mostly clean or granulation tissue will be removed

• Simple occlusive dressings (e.g. Opsite)• Useful to prevent skin breakdown in vulnerable areas, or prevent further

breakdown in Stage I areas• Semipermeable – allows gas exchange and keeps out microbials• Allows visual inspection of wound area through dressing• Change PRN • Gentle on healthy skin when removed correctly• Never use on an infected wound

Treatment of Decubitus Ulcers

• Hydrocolloid dressings (e.g. Duoderm)• Keep wound bed moist• Offer some absorption for wounds with minimal exudate• Offer some thermal protection• May be changed infrequently depending on wound (q2days

– q7days)• Semipermeable – allow gas exchange and keep microbials

out• Different shapes available for different body parts (i.e.

Sacrum)• Adhesive is gentle to healthy skin when removed• Do not use on infected wounds

Treatment of Decubitus Ulcers

• Impregnated dressings (e.g. Mesalt,)• Exert osmotic pressure and dissolve necrotic tissue

using the body’s own fluids• Provide an environment which discourages bacterial

growth in the wound bed (high salt content)• Pack the wound to heal by primary intention• Should only be used in wounds with large amounts of

exudate (in order to avoid drying the wound bed)• Change at least BID• May be used on infected wounds

Treatment of Decubitus Ulcers

• Absorbent dressings (e.g. foam, calcium alginate)• Highly absorbent materials to control wound

exudate• Come in various forms and can be used to pack

wounds and/or as an outer layer• Provide thermal protection to the wound• Allow dressings on clean wounds to be changed

less frequently • Frequently used in conjunction with impregnated

dressings to control moisture

Treatment of Decubitus Ulcers• Topical treatments may include:

• Saline • Used to cleanse the wound and debride necrotic material

(wet-to-dry, syringe irrigation)• Commercial wound cleansers (instead of saline)• Hydrogels/Xerogels

• Keep dry wound beds moist to promote healing• Allow longer periods between dressing changes• Act as gentle packing to encourage healing by intention

Treatment of Decubitus Ulcers• Topical treatments may include:

• Silver sulfadiazine creams/gels/solutions• Some antibacterial properties to wound colonization (biofilm theory)• May reduce odour in infected wounds• May alleviate some pain in wound bed• Help to keep the wound bed moist

• Sulfa based antibiotic creams• Antibacterial properties to wound colonization (not used for true

wound infections)• Help to keep the wound bed moist

• Other antiseptics (e.g. Dakin’s Solution, Chlorhexadine) may be ordered but do not offer any advantage over saline, do not promote wound healing and should be avoided

Prevention is key…The pharmacist should support the efforts of the healthcare team to prevent decubitus ulcers and encourage caregiver compliance with preventative strategies• Encourage mobility as appropriate (manage pain)• Turning schedules for bedbound patients (q2h)• Pressure reducing mattresses and wheelchair cushions (egg

crates and sheepskin are comfort measures only; they do not reduce pressure)

• Keep skin dry and clean(control wound drainage, incontinence and other sources of moisture)

• Minimize physical restraint use• Assess skin daily and keep intact skin in good condition using

barrier creams, moisturizers and emollients

Xerosis

XerosisXerosis (dry skin) is characterized by:• Pruritus (itchiness)• Dryness• Cracks• Fissures (like cracked porcelain)• Occurs mostly on the legs (but sometimes hands and

trunk)• Excoriation (from scratching) leading to infection or

dermatitis

Causes of xerosis• Dry air e.g. low winter humidity • Exposure to the wind • Over-washing • Reduction in production of natural moisturisers (sebum) in

old age • Diuretic medications • Underactive thyroid gland • Inherited factors • A skin condition such as atopic dermatitis (eczema),

psoriasis or ichthyosis • Any combination of these

Treatment of Xerosis• Occlusive moisturizers and emollients

• Oils, lotions, creams and ointments

• Humectants, keratolytics and keratoplastics• Urea, ammonium lactate, and alpha hydroxy products

• Non-pharmacologic management

Occlusive moisturizers & emollients

• Oils of non-human origin, either in pure form or mixed with varying amounts of water through the action of an emulsifier ,to form a lotion or cream.

• Provide a layer of oil on the surface of the skin to slow water loss and thus increase the moisture content of the stratum corneum.

• Should be used liberally and frequently• Unscented, nonallergenic is preferable• Preferably applied when skin is damp• No EBM comparing different moisturizers.• There is no '‘right’ moisturiser for all patients: the most

suitable one often having to be found by trial and error.

Formulations• Bath oil deposits a thin layer of oil on the skin upon

rising from the water. • Lotions are more occlusive than oils. These are best

applied immediately after bathing, to retain the water in the skin, and at other times as necessary.

• Creams are more occlusive again. Thicker barrier creams containing dimeticone are particularly useful for those with hand dermatitis.

• Ointments are the most occlusive, and include pure oil preparations such as equal parts of white soft and liquid paraffin or petroleum jelly.

Which formulation?The choice of occlusive emollient depends upon the area of the body and the degree of dryness and scaling of the skin:• Lotions are used for the scalp and other hairy areas

and for mild dryness on the face, trunk and limbs. • Creams are used when more emollience is required

on these latter areas. • Ointments are prescribed for drier, thicker, more

scaly areas, but many patients find them too greasy.

Humectants, keratolytics & keratoplastics• Humectant: a substance that promotes retention of

moisture • Keratolytic: a substance that softens keratin and

improves the skin's moisture binding capacity• Keratoplastic: substances which normalize

keratinization• Many products have more than one of these properties• All or some of these may not be tolerated by patients

due to stinging and irritation

Urea• Hydrating effects – urea is strongly hygroscopic (water-loving) and

draws and retains water within skin cells

• Keratolytic effects – urea softens the horny layer so it can be easily released from the surface of the skin

• Regenerative skin protection – urea has a direct protective effect against drying influences and if used regularly improves the capacity of the epidermal barriers for regeneration

• Irritation-soothing effects – urea has anti-pruritic activity based on local anaesthetic effects

• Penetration-assisting effects – urea can increase the penetration of other substances, e.g. corticosteroids as it increases skin hydration

Ammonium Lactate & Alpha Hydroxy Acid Products• Symptomatic relief of dry skin by increasing

moisture capacity of stratum corneum. • Have also been shown to reduce excessive

epidermal keratinization in patients with hyperkeratotic conditions.

• Loosen the glue-like substances that hold the surface skin cells to each other, therefore allowing the dead skin to peel off.

• The mechanism of action of topically applied neutralized lactic acid is not yet known.

Adverse ReactionsPossible adverse reactions of both occlusives and humectants/keratolytics include:• Irritation (burning sensation, stinging) – usually

caused by an ingredient in the cream or lotion base• Allergy - true allergies are rare• Folliculitis - Over-occlusive emollients can result in

blocked hair follicles and painful pustules (folliculitis) or boils

Nonpharmacologic Management• Reduce washing to every second day, or less often,

although the body folds may be sponged daily if desired. • Baths or showers should be kept as brief as possible. • Water should be lukewarm. • Minimise the use of soap and avoid harsh cleansers. Use

a mild soap or better still, a detergent-based cleanser. Cleansers that have the same pH as the skin (5.5) may be advantageous.

• Reduce the need for bathing by keeping as clean as possible

• Humidify air in dry environments

Skin InfectionsSkin infections are common in elderly patients due to frequent skin trauma, dermatitis, and impaired immunity, and may be:• Bacterial (e.g. impetigo)• Viral (e.g. varicella, herpes simplex)• Fungal (e.g. seborrheic dermatitis, candida, tinea)

Impetigo

Impetigo• Usually found near the mouth or nares, but may be

anywhere on the body• May be bullous (staphylococal) or nonbullous

(streptococcal)• Treated with oral and topical prescription antibiotics • OTC preparations are not effective• Encourage good hygiene to avoid contact spread• Confused elderly should be kept isolated until 48

hours of treatment has elapsed

Varicella (Herpes) Zoster

Varicella (Herpes) Zoster• Varicella or herpes zoster, also known as shingles, results from

reactivation of the dormant varicella zoster virus in adults, the same virus that causes chickenpox in children.

• Vesicles• usually appear along one dermatome (nerve path)• rarely cross the midline• may crust over after several days• usually dry out over 2-3 weeks

• Post herpetic neuralgia may last from months to years after the rash is gone

• OTC therapy will not treat the virus but may assist with symptom management

OTC use in Shingles• NSAIDs may be helpful in pain management in milder cases• Antihistamines may be helpful to alleviate itching of the rash• Hydrocortisone cream may be helpful to alleviate itching of the

rash• Antipruritic lotions (e.g. calamine) may also help to alleviate itch• Capsaicin cream (e.g. Zostrix) may help with pain once the

vesicles have crusted over and also with post herpetic neuralgia• Ensure that the patient has sought medical treatment for the

virus itself and that OTC treatments are not contraindicated by other medications or pre-existing disease

Fungal Infections Dermatological fungal infections are highly prevalent in the elderly and include:• Seborrheic dermatitis• Candida• Tinea Pedis (Athlete’s Foot)• Tinea Cruris (Jock Itch)• Onychomycosis (Tinea Unguium nail infections)

Seborrheic dermatitis

Seborrheic dermatitis• Caused by a combination of an over production of skin oil

and irritation from a yeast called malassezia.• Usually found in sebaceous areas

• Scalp (called cradle cap in infants)• Eyebrows• Nasolabial folds• Ears• Chest

• Presents a reddened patches or plaque with greasy scales

• May be pruritic (itchy)• May be related to nutritional deficiencies or disease

states (eg. Parkinsons, HIV)

Seborrheic dermatitis• Generally managed with OTC products

• Selenium sulfide• Zinc pyrithione• Coal tar• Ketoconazole 2%

• Low potency topical steroids may be used in more severe cases

Candida

Candida• Found mostly in skin folds where there is

warmth, moisture and skin to skin contact:• Inguinal• Between the fingers• Perianal• Under the breasts

• Appears as a demarcated “beefy-red” eruption with satellite pustules

Candida• Often related to:

• Obesity• Diabetes• Immunosuppression• Chronic debilitation• Occlusion under incontinence products• Systemic antibiotic therapy

Candida• OTC Treatments may include

• Exposure to air• Use of desiccants (Burrow’s solution, Castellani’s

paint)• Zinc oxide (topically)• Topical azole antifungal agents BID

MiconazoleEconazoleKetoconazoleCiclopirox

• Antifungal powders may be used to dry the skin and prevent maceration

• Terbinafine cream is NOT effective against Candida.

Tinea pedis (Athlete’s Foot)

Tinea pedis (Athlete’s Foot)• Caused by dermatophytes • Presents with erythema, scaling and maceration• 3 types:

• Interdigital – dry scaling between toes• Moccasin-type – involves entire sole and sides

of foot• Vesiculobullous – plantar surface; usually the

arch

Tinea pedis (Athlete’s Foot)• Usually treated with topical azole antifungals:

• Clotrimazole• Ketoconazole• Econazole• Terbinafine• Ciclopirox

• Systemic treatment reserved for extensive/persistent infections

• Oral treatment may be used for elderly patients who would have difficulty seeing or reaching their feet to apply cream

Tinea pedis (Athlete’s Foot)• Prevention is key:

• Dry feet thoroughly after washing (especially between toes)• Avoid walking barefoot in public places• Wear cotton socks

•Intermittent application of antifungal creams, powders or sprays may help prevent recurrences

Tinea Cruris (Jock Itch)

Tinea Cruris (Jock Itch)• Presents as an itchy, red rash in the groin area• Men are more likely to acquire this infection• Treatments include:

• Reduce and control moisture• Topical antifungals

• Severe or resistant cases may benefit from oral treatment

Onychomycosis

Onychomycosis• Fungal nail infections usually caused by dermatophytes

• Trichophytons rubrum• Trichophytons mentagrophyte

• Very few cases caused by Candida or molds• Prevalence increases with age (nearly 20% of patients

over 60 are infected)• Predisposing factors:

• Trauma• Peripheral vascular disease• Immunosuppression• Diabetes• Contiguous spread of tinea pedis

•Cannot be treated with OTC products

Blistering Diseases

Blistering Diseases• Blistering diseases in the elderly are rare and may be

immune-mediated, drug-induced, or secondary to systemic illness.

• It can be fatal, even when treated• Cannot be treated with OTC therapies• Pharmacists should be aware that blistering diseases

may be drug-induced.• Medication classes associated with blistering diseases

include • Antibiotics• Diuretics• beta-blockers• medications containing a thiol group (captopril, penicillamine,

piroxicam)

Nutritional DeficienciesDeficiencies in certain vitamins and minerals may present with skin findings, and the elderly are at greater risk of poor nutrition due to:•Chronic disease•Physical limitations which hamper food preparation•Poor food choices due to economic restrictions•Delayed gastric emptying•Slowed intestinal motility•Dry mouth•Changes in taste perception•Altered dentition

Vitamin C Deficiency• Skin manifestations of vitamin C deficiency may be

related to defective collagen production. • Common dermatologic concerns include:

• perifollicular hemorrhage • gingival hypertrophy • altered wound healing

• Systemic findings may include fatigue, anemia, and joint swelling.

• Symptoms related to vitamin C deficiency may present after 3 months without vitamin C intake.

Zinc Deficiency• In the elderly, malabsorption or malnutrition may

lead to zinc deficiency• Highest risk is found in those with

• Long term parenteral nutrition• Alcoholics• Patients with cirrhosis

• Zinc deficient patients will present with• perioral or perianal erythematous, scaling plaques• Nonhealing leg ulcers• Hair loss

Vitamin B DeficienciesSkin findings may present when a patient is deficient in• Riboflavin (B2)• Niacin (B3)• Pyridoxine (B6)

Riboflavin (B2) DeficiencyPatients with Riboflavin deficiency may present with• Angular cheilitis (Inflammation, burning, redness,

and ulceration or cracks at the corner of the mouth)

• Stomatitis (inflammation of the mouth lining)• Seborrheic dermatitis

Niacin (B3) Deficiency• Patients with Niacin deficiency may present with

dermatitis• Those at risk for niacin deficiency include:

• Alcoholics• Patients taking chronic antibiotic therapy• Patients with cirrhosis• Patients with carcinoid syndrome (Carcinoid syndrome is

a group of symptoms associated with carcinoid tumors -- tumors of the small intestine, colon, appendix, and bronchial tubes in the lungs.)

Pyridoxine (B6) Deficiency• Patients with Niacin deficiency may present with

seborrheic dermatitis and photosensitivity• Risk factors include:

• Alcoholism• Cirrhosis• Drug therapy: isoniazid, penicillamine & L-dopa

Skin CancersMore than 50% of skin cancer-related deaths occur in persons over 65 years of age.• Photocarcinogenesis due to sun exposure is a

continuous and cumulative process• Decreased melanocyte density decreased

protection from UV rays• Decreased Langerhans cells density decreased

immune function

Skin CancersCan be divided into two main types

• Non-melanomas• Rarely fatal but cause tissue damage and may

become invasive• Usually caused by UV radiation, sunlight, and HPV

• Melanomas• Most lethal skin cancer• Rates increasing dramatically

Non-MelanomasMost common types are• BCC (basal cell carcinoma)

• Most common type of skin cancer• Do not metastasize• Usually treated with surgery

• SCC (squamous cell carcinoma)• Untreated may progress and become invasive• Can metastasize to lymph nodes• Usually treated surgically

Melanoma• Most lethal skin cancer• Rates increasing dramatically• Four main types:

• Superficial spreading (most common)• Nodular• Lentigo (occurs only in the elderly)• Acral lentiginous

• Early excision is the only curative management

MelanomaAll members of the health-care team, including pharmacists should be aware of the ABCDE’s of melanoma recognition.

How to recognize a melanoma (ABCDE)

A Asymmetrical in shape

B Border is irregular

C Colour is not uniform; may have different shades of black, brown, gray, red or white

D Diameter >6 mm (pencil eraser)

E Evolution of colour, shape, elevation, or size in recent months

Skin Cancer Prevention• Inconclusive evidence that sunscreen protects against

skin cancer – use it, but don’t rely on it• this may be partly related to poor application or the fact

that people feel protected, so they stay out in the sun longer

• Intermittent exposure to sun seems to be the biggest risk factor (ie. Weekend exposure after working inside all week)

• The most effective preventative measures are to minimize sun exposure (avoid sunburn and tanning) -- especially during peak UV-B hours; seek out shade and cover up with hats, long sleeves, and long pants

The Pharmacist’s RoleThe pharmacist has an important role in Geriatric Dermatology• Stress the importance of non-pharmacological management for

prevention of decubitus ulcers, xerosis, and fungal infections• Include all OTC and topical medications in medication

assessments• Evaluate and recommend appropriate drug therapy (both

prescription and OTC)• Monitor for drug-drug/drug-disease interactions• Monitor for known dermatological side effects of drug therapy• Consider additive effects of combined topical and oral

corticosteroid therapy

ReferencesSep 4, 2009By: Cristina E. Bello-Quintero, MD, PharmDDrug Topics

Overview of geriatric dermatology:

Impetigo Treatment & ManagementAuthor: Lisa S Lewis, MD; Chief Editor: Russell W Steele, MD Medscape Reference: Drugs, Diseases and Procedures

DermNet NZFacts about skin from the New Zealand Dermatological Society Incorporated. http://www.dermnetnz.org

The Good, the Bad, and the Ugly of SunscreensM BerwickClinical Pharmacology & Therapeutics 89, 31-33 (January 2011)Skin Cancer in the ElderlyKONSTANTINOS N. SYRIGOS1, IFIGENIA TZANNOU1,NIKOLAOS KATIRTZOGLOU1 and EVANGELLOS GEORGIOU2in vivo 19: 643-652 (2005)

National Center for Biotechnology InformationPubMed HealthA.D.A.M. Medical Encyclopedia.http://www.ncbi.nlm.nih.gov/pubmedhealth/

National Quality Measures ClearinghouseManagement of Pressure Ulcers: Guideline Synthesis

Registered Nurses' Association of Ontario (RNAO). Assessment and management of stage I to IV pressure ulcers. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2007 Mar. 112 p. [118 references]Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence Nurses Society (WOCN); 2010 Jun 1. 96 p. (WOCN clinical practice guideline; no. 2). [341 references] Decubitus Ulcers Treatment & Management

Author: Don R Revis Jr, MD; Chief Editor: John Geibel, MD, DSc, MA Medscape Reference: Drugs, Diseases and Procedures