Common Skin Problems : Cosmetics for Seniors : 50plusskincare.com

Pruritus is a sensation of intense itching that triggers an attempt to rub or scratch. The classical characteristics of pruritis include scratching and inflammation. Pruritis is known to be a feature of inflammation which is the result of activation of the body’s immune response. While xerosis (see below) is the most common reason for pruritus, systemic disorders can be implicated part of the time. Underlying metabolic conditions that can cause pruritis include renal failure, HIV, diabetes mellitus, thyroid disease, parathyroid disease, hypervitaminosis A, iron-deficiency anemia, neuropathy, liver disease, malignancy, and the use of certain medications. Dermatologic conditions, other than xerosis, can include infestations, infection (fungal, bacterial, or viral), dermatitis, and eczema.” In addition, low humidity and cold temperatures can also exacerbate pruritus. Scratching can cause excoriations, which then may progress to secondary eczema or become infected.

Treatment
The initial treatment focuses on the relief of the itching. Once temporary relief is acquired, efforts should focus on finding the underlying cause. Topical symptomatic treatments include emollients, moisturizers, topical corticosteroids, and pramoxine hydrochloride preparations (alone or combined with menthol or petrolatum). For pruritis associated with atopic dermatitis, pimecrolimus is very effective. Doxepin cream has been shown to be very effective in treating pruritis associated with eczematous dermatitis. It can be used alone for acute pruritis or with corticosteroids in chronic conditions. Other medications that have been employed to treat generalized pruritis include oral doxepin, cyproheptadine, or cetirizine depending on the patient and severity of symptoms. "Nonpharmacologic measures may be tried for mild pruritis, such as avoiding hot water and irritants such as fragrant or deodorant soaps, maintaining proper humidity, using cool water compresses, and trimming the nails. Cooling lotions, such as camphor and menthol, may also be used.

Xerosis

Xerosis is the most common underlying problem associated with pruritis. Xerosis, also known as dryness, is a common characteristic of older skin as aging reduces the capacity of the skin to moisturize itself, causing the skin to become dry. Since water is the main "softener" of the skin, dry skin may become rough, scaly, and eventually red, inflamed, and itchy. In addition, there are a number of situations that deplete the skin’s moisture. For example, xerosis tends to be worse in the winter when the humidity is lower and forced hot air from home heating systems dries out the skin. Also, the daily use of cleansers and/or bathing without replacing the natural emollients of the skin may also trigger the onset of xerosis.

Although xerosis may be triggered by drugs or physical health problems it is usually not associated with a systemic disease. Nonetheless, a history of preexisting diseases, conditions, therapies, and medications may contribute to making the elderly more susceptible to xerosis. Such a history may include radiation, end-stage renal disease, nutritional deficiency (especially zinc and essential fatty acids), thyroid disease, and neurologic disorders with decreased sweating, antiandrogen medications, diuretic therapy, human immunodeficiency virus and malignancies.

Xerosis normally presents on the legs of elderly patients as normal dryness normally occurs most often over the lower legs. However, it may be seen on the hands and trunk. Xerotic skin appears as cracked skin. These cracks originate from the moisture loss in the skin. Then, the skin splits and forms fissures. Itching (or pruritis) follows, leading to secondary lesions because of scratching. The scratching produces excoriations followed by an inflammatory response. Consequently, bacteria can easily penetrate the excoriated skin, and cause secondary infection. (Secondary infection is always a risk with any break in the skin barrier.) This contact dermatitis may cause persistent and, possibly, more extensive dermatitis despite therapy. Once the xerotic cycle begins, itching, fissures, inflammation, and even infection develop. Therefore, the cycle of itch-scratch needs to be broken to prevent complications. Ending this cycle is the goal of xerosis treatment.

Treatment
Dr. Norman gives the following treatment advice. Treatment of xerosis includes ammonium lactate 12% lotion, moisturizers, and topical corticosteroids, are the primary components of xerosis treatment as well as certain behavioral management tactics. The keratolytic (topical agents that remove the dead, flaky portions of skin) effect of ammonium lactate 12% lotion is effective in reducing the severity of xerosis. Creams that contain keratolytic agents such as urea, are not as hydrolyzing, but can rid the skin of the abnormally thickened layer of skin. In individuals with sensitive skin, sensitive-skin variant formulation should be substituted for alpha hydroxy acids, as they can cause stinging and irritation. Liberal use of moisturizers reduces scaling and enhances the desquamation process. In moderate to severe cases, treatment by applications of topical steroids (Class III-VI) is recommended. Oral antipruritics may be added if moderate to severe pruritis is present.

Secondary treatment consists of increasing hydration and moisturizing the skin. It may be helpful to apply non-scented emollients, such as white petrolatum, liberally and frequently on the skin immediately after bathing and frequently throughout the day. Emollients are creams that can be applied to the affected area to prevent water from evaporating from the skin's surface. They also smooth over the scaly edges that can flake off and cause intense itching. Discontinue the use of products that may further dry the skin, such as alcohol, strongly scented soaps. It is also helpful to limit bathing to every other day, up to a maximum of once a day (because too much water can actually cause the skin to dry out), using tepid or cool water. Therefore, habitually showering or bathing more than once a day should be avoided to prevent dry skin. Control of the environment is also important. Dry skin is often a problem in cooler climates, especially during winter months home heating systems are used regularly. This dry heat draws moisture from the skin. Outdoors, cold winter air causes the body to protect itself by drawing blood away from the skin. When this occurs, the skin is not well nourished and xerosis can result. Consequently, the indoor environment should be cool vapor humidified, and the individual's exposure to cold temperatures and wind should be limited.

Vascular Disorders

These disorders include, but are not limited to, varicose veins, varicose ulcers, and bruising. Venous insufficiency is the most common cause of leg ulcers, followed by mixed venous and arterial disease and arterial disease alone. Diabetic neuropathic ulcers comprise almost 10% of lower extremity ulcers. The costs associated with leg ulcers—financial, social, and psychological—are enormous.

Varicose veins are enlarged leg veins that appear blue and bulging and are common in the elderly. When blood returns to the heart and flows back into the veins through a faulty valve, the veins become twisted and swollen. This condition is seldom dangerous, but can cause the legs to ache. The aching associated with varicose veins can be eased by keeping feet elevated when sitting or lying down, by wearing support hose or elastic bandages-such as TED stockings, and by not standing for long periods of time.

In most cases, varicose veins cause few symptoms, however, occasionally, they may cause complications associated with the condition. Bleeding is one complication of varicose veins. Bumping or scratching a large varicose vein may lead to serious bleeding. Varicose veins bleed more than healthy veins because of the abnormally high pressure within the damaged veins. Phlebitis, another complication of varicose veins is an inflammation of the vein. A form of phlebitis that sometimes affects varicose veins is called superficial thrombophlebitis, which is an inflammation of a vein just below the surface of the skin, which results from a small blood clot. When clots form in veins near the surface of the body, swelling and redness appear along the affected area of the vein. This condition is not considered life threatening, as opposed to deep vein thrombosis. Treatment for most cases of thrombophlebitis consists of simply relieving the discomfort. It does not require any specific therapy. Warm compresses over the involved vein and anti-inflammatory medication is usually all that is required. The most serious consequence of phlebitis is the development of postphlebitic leg, also known as stasis syndrome. It is usually the result of long term phlebitis involving deeper veins. The involved area in a postphlebitic leg may become discolored, scaly, and swollen, with hardened areas beneath the skin and the development of painful ulcers. A third complication of varicose veins is varicose ulcers that is discussed in detail below.

With age, the veins of the leg can become dilated causing a problem with the valves. “The valves may cease to function or they may try to close but cannot form a complete barrier due to the larger diameter of the vessel. In either of these cases, there is a backflow of blood that pools in the lower leg”, states Dr. Norman. Venous stasis ulcers occur when the veins of the leg become dilated by a backflow of blood and may lead to sustained high pressure and can cause varicose ulcers. Venous stasis ulceration of the lower extremity is a common problem among diabetic patients,” he adds.

Varicose ulcers often develop on the outer area of the lower leg around the ankle area. The ulcers may last for months or even years. They may be accompanied by swelling and red, itchy, scaly skin around the ulcer. Other characteristics of venous insufficiency ulcers include a reddish-brown color of the ulcer, shallow depth, irregular margins, and minimal pain.

Another cause of ulcers on the legs is poor blood flow in the arteries. This condition is usually associated with medical disorders such as arteriosclerosis, hypertension, diabetes, mellitus, and smoking. Arterial ulcer lesions occur more frequently over bony prominences and they gradually increase in size. “Leg ulcers caused by arterial insufficiencies are much more painful than those caused by venous insufficiency and elevation of the ulcerated leg tends to make the symptoms worse,” instructs Dr. Norman. General prevention measures aim at keeping the feet clean and dry, controlling glucose levels, and maintaining optimal venous return by not standing for long periods of time,” advises Dr. Norman. As far as medication management, diuretics should be used with caution and for a limited period of time only, as they can cause volume depletion and metabolic disorders in elderly. Antibiotics should be reserved only for patients with an obviously infected ulcer or cellulitis. NSAIDs or acetaminophen can been used to relieve discomfort but as with any case, should be used with caution,” states Dr. Norman.

While bruising is not quite a vascular disorder, it is caused by an injury to a blood vessel, and is so common in the elderly that it is worth mentioning. By age 90, 70% of elderly people show senile purpura commonly on the backs of the hands, forearms, neck and face, that may take up to several months to completely heal. Many elderly people complain of "black and blue" marks or bruises, particularly on the arms and legs. These are usually a result of the skin becoming thinner with age, long term exposure to the sun causing damage, loss of fat and connective tissue, which weakens the support around blood vessels, making them more susceptible to injury. “Bruising may be distressing and may leave dyspigmentation or scarring, but are not associated with any serious complications,” states Dr. Norman. Both sexes are equally affected and the incidence increases with age.

Bruising sometimes is caused by medications that interfere with blood clotting such as ibuprofen, naproxen, asprin, and coumadin, other medications such as antidepressants, asthma medications, and cortisone medications which can damage the blood vessels. Bruises also develop easily in the elderly, because the skin and blood vessels have a tendency to become thinner and more fragile with aging, and there is an increased use of medications that interfere with the blood clotting system.

The skin is the largest and most accessible organ of the body; neoplasms of the skin are easier to detect then tumors of other organs. Neoplasms (the process of tumor formation with a new growth of tissue serving no physiological function), can be malignant or nonmalignant. While benign neoplasms remain localized at the site of origin, a malignant neoplasm tends to invade the local site and/or spread to other sites (metastasize). Benign neoplasms have a structural and functional resemblance that is close to normal tissues and cells (well differentiated). Conversely, malignant neoplasms are abnormally structured and show less similarity to normal tissue (undifferentiated). As a general rule, benign neoplasms do not give rise to malignant neoplasms. The primary tasks should be to achieve a definitive diagnosis, determine the extent of the primary tumor(s), examine for the presence of metastases, while considering any concurrent disease. A dermatologist should evaluate skin lesions, especially those that are growing, not healing, bleeding, or changing appearance.

Basal Cell Carcinoma and Squamous Cell Carcinoma

According to the American Academy of Dermatologists basal cell carcinoma (BCC), is the most common form of skin cancer, while squamous cell carcinoma (SCC) is the second most common cancer of the skin. Both are thought to be caused by exposure to the harmful ultraviolet rays of the sun. Some hypothesize that the increase in incidence is related to the decrease in the ozone layer, allowing more ultraviolet radiation from the sun to enter the earth's atmosphere. Those most affected with SCC are middle-aged and elderly persons, especially those with fair complexions and repeated sun exposure. BCC is more common in older, fair-skinned people with blond or red hair and blue or green eyes.

Basal cell cancer spreads slowly and does not normally metastasize but instead, destroys tissue by infiltrating the surrounding area. While SCCs can spread to internal organs, when treated in a timely manner, squamous cell carcinoma rarely metastasizes. SCCs often arise from actinic keratoses (see below). If left untreated, SCCs can be aggressive.

Basal cell cancer usually appears as shiny or small bleeding bumps on sun-exposed areas of the skin, such as the face, scalp, ears, chest, back, and legs. The tumors can have several different forms. The most common appearance is a small dome-shaped bump that has a pearly white color. Blood vessels may also be seen on the surface. BCC can also appear as a pimple-like growth that heals, only to come back again and again. A sign of BCC is a sore that bleeds, heals and then reoccurs. A less common form, “morpheaform”, looks like a smooth white or yellow scar.

SCC appears as a crusted or scaly area of the skin, with an inflamed red base. SCC can present as a growing tumor, a non-healing ulcer, or just as a crust. SCC usually develops in common sun-exposed areas such as the face, the rim of the ear, the lips or the back of hands. A skin biopsy is usually needed to confirm diagnosis.

Depending on the location of the tumor, size of the tumor, characteristics of the tumor, health of the patient, etc., there are a variety of treatment options. Most treatment options are relatively minor that require only local anesthesia and can be performed in a physician’s office or even at the nursing home. Surgical removal of the entire tumor is the most common treatment option. A type of micrographic surgery, called "Mohs", is a very involved method performed by specially trained dermatologic surgeons. It is used to remove the whole tumor, sparing much of the “normal” skin. Other dermatologic surgery treatments include laser surgery, cryosurgery, radiation therapy, and electrodesiccation and curettage (which involves alternately scraping or burning the tumor in combination with low levels of electricity). When treated early, squamous cell and basal cell skin cancers have a 95 percent cure rate.

Melanoma

Malignant Melanoma is less common than BCC or SCC but is the deadliest form of skin cancer. Six out of every seven deaths from skin cancer in the

United States

are due to melanoma. Men over the age of 50 are at the highest risk. Melanoma is more likely to occur in those who had severe sunburns as children. Melanoma can metastasize to other organs and can be fatal. Therefore, the appearance of a new mole or any change in an existing mole could be a sign of melanoma and should be examined immediately by a dermatologist since early diagnosis and treatment of melanoma is essential.

Melanoma usually appears as a dark brown or black mole-like growth with irregular borders and variable colors. The most frequent sites for both men and women are the upper back, the chest and abdomen in men, and the lower legs of women. There is also a tendency for people to develop melanoma who have a family history of it. I recommend asking if there is a family history of melanoma as part of an admission assessment.

Standard treatment for melanoma is surgical removal of the lesion or mole, along with a border of normal skin and underlying tissue. The size of the border depends on the stage of the melanoma, (e.g., stage I requires a 1 cm border while stage II requires a 3 cm border.) If the melanoma is at a stage III, the lymph nodes and lymphatic tissue involved are removed as well. The stage of the tumor relates to survival rate as well. After treatment, the five year survival rate for stage I is 98% and for stage II is 85%, while survival rate for stage III ranges from 66% to 83%.

Actinic Keratosis

Actinic keratoses (AKs) are treatable skin lesions resulting from damage to the skin by too much exposure to the ultraviolet rays of the sun. While AKs are not malignant tumors, they have the potential to progress to squamous cell carcinoma. Therefore, successful treatment and prevention of progression to SCC relies on early recognition and diagnosis.

AKs most often appear on older people with blond or red hair, fair skin and blue or green eyes. Keratinocytes (the tough-walled cells that give the skin its texture and make up more than 90 percent of the epidermis) are the cells most affected with AK. AKs may also extend into the dermis, the layer of skin under the epidermis. The alteration in growth and differentiation of the keratinocytes presents as the clinical features of AKs, which show as rough, scaly skin, "bumps" on the skin, mottled skin, and cutaneous horn AKs are often described as scaly red or brown spots. It’s this alteration in cell growth and differentiation that may lead to the transformation of AKs into SCC.

The most common treatments for AKs are cryosurgery (freezing with liquid nitrogen), surgical removal and topical 5-fluorouracil (5-FU-an anti-tumor agent that destroys the AK cells.) However, topical 5-FU may not be the best choice for the elderly patient, especially those with cognitive deficits, because it can be uncomfortable and sometimes painful and would have to be tolerated over the course of the treatment.

Pigmented Nevi

The most common of all neoplasms, pigmented nevi may arise at any age, but most often form at two to three years of age and at puberty. They consist of collections of normal melanocytes (an epidermal cell that produces pigment).

There are several types of pigmented nevi. Junctional nevi occur as smooth, hairless, brown (light or dark) macules that can be slightly elevated, are usually multiple and can appear anywhere on the body. Intradermal nevi are the dome-shaped, skin-colored moles that are commonly found on the scalp, hand, and neck of adults. They can also become pedunculated (attached by a stalk). Halo nevi are pigmented nevi that develop a ring of peripheral depigmentation, usually formed in a perfect circle. Over time, they will clear up (involute). Blue nevi are benign, congenital or spontaneous appearing, and present as blue-gray or blue nodules. They are commonly located on the head, neck, forearm, and the hand. Giant hairy nevi are present at birth and appear as large continuous areas of multiple patches of pigment often “warty” looking and very hairy and are often cosmetically deforming.

Normally pigmented nevi require no treatment. However, any pigmented nevi which exhibits one or more of the following warning signs should be investigated; an irregular border, an irregular distribution of pigment, onset after age 40, change in size or color, pain, irritation, pruritus, infection, bleeding or crusting. A biopsy followed by a pathology exam is the recommended procedure if any of these warning signs are present. When the diagnosis of benign pigmented nevus is in doubt, surgical excision is usually appropriate.

Hemangiomas

Hemangiomas are usually a benign tumor made up of blood vessels. They typically occur as a slightly elevated area of skin, purplish or reddish in color.

Up to 80% of hemangiomas are found on the head or neck but can occur anywhere on the skin or even on internal organs. There can be a single lesion or there can be a dominant primary lesion with smaller associated hemangiomas. They can be superficial-appearing flat and reddish in color, deep-beneath the surface of the skin and bluish in color or compound-a combination of both.

Treatment for hemangiomas is normally done when they occur, which is likely in the patient’s youth. Treatment is rarely performed on nursing home patients. However, treatment options include surgical excision, laser treatments, steroid and or alpha interferon therapy.

Factors that increase the risk of skin cancer

· Sun exposure habits such as golf, gardening, farming, fishing, hiking, sunbathing, and outdoor swimming

The most common cause of superficial cellulitisis streptococcus pyogenes. However, staphylococcus aureus can produce a superficial cellulitis that is less extensive than that of the streptococcal origin and usually only in association with an existing open wound or cutaneous abscess. Infection is most common in the lower extremities. Skin abnormalities, such as trauma, ulceration, tinea pedis, or dermatitis, often precede the infection. Areas of lymphedema or other edema are also susceptible. While cellulitis is most commonly seen in the lower extremities, it can occur anywhere on the body.

Diagnosing cellulitis usually depends on the clinical findings. According to Dr. Norman, the major findings are local erythema and tenderness, frequently with inflammation of the lymphatic vessels and regional lymphadenopathy (abnormal enlargement of the lymph nodes). Large areas of ecchymosis are rare. “The skin will be hot, red, and edematous, often with an infiltrated surface resembling the skin of an orange”, explains Dr. Norman. The borders are usually indistinct and petechiae are common. Blisters may develop and rupture and necrosis of the involved skin can occasionally occur. Leukocytosis is common, but doesn’t necessarily have to occur. Systemic manifestations such as fever, chills, tachycardia, headache, hypotension, and delirium may precede the cutaneous findings by several hours, but many patients do not appear ill.

Treatment for cellulitis consists of reducing edema and administering systemic antibiotics. “For patients who do not have serious systemic illness, oral treatment is satisfactory”, states Dr. Norman. “Penicillin is usually the drug of choice for streptococcal infections. Nevertheless, in patients who cannot or won’t take an oral medication, an intramuscular injection provides a complete course of treatment”, he adds.

Herpes zoster is often referred to as shingles and occurs most often in the elderly. It is an infection that produces painful skin eruptions of fluid-filled blisters. Shingles is a condition caused by the same virus that causes chicken pox. It is believed that the varicella-zoster virus causes chicken pox in childhood, then lies dormant in nerve tissue for years or decades until it is reactivated to cause shingles.

While shingles can affect people at any age, it is more common and often more painful in older adults, with peak incidence between 50 and 70 years of age. Shingles usually affects otherwise healthy people, but immunosuppressed persons are at a higher risk. The higher incidence among elderly persons may be due to a decrease in cellular immunity. Other factors that predispose to a recurrence of the virus include the use of immunosuppressants or corticosteroids, malignancy, trauma, local irradiation and surgery. Shingles recurs in about 6% of patients, usually at the same site as the initial episode. The virus, once acquired, cannot be eliminated.

The active virus produces intense itching, pain and grouped vesicles along a unilateral, area of skin innervated by a certain nerve root, also known as a dermatome. “It usually involves a single dermatome”, states Dr. Norman, “but can include other dermatomes.”

Shingles lesions are infectious until a dry crust appears. A person who has never had varicella may develop chicken Pox after direct contact with the lesions or with contaminated dressings. Usually, only young children are susceptible, although pregnant women and immunocompromised persons are vulnerable also.

Preceeding the appearance of the lesions, you usually will see symptoms you such as chills, fever, malaise, GI disturbance, and paresthesia or neuralgia along the affected dermatome. Red and fluid filled lesions, resemble those of chicken pox, usually appear along the affected area within 3 days. These eruptions develop rather rapidly into grouped vesicles, varying in size, which may be hemorrhagic and may be very painful. As the condition progresses, new lesions continue to form and pain continues to be severe. “If, however, severe widespread distribution occurs, suspect an underlying lymphoma or other causes of immunodeficiency”, warns Dr. Norman.

The active phase may continue for a week or longer, but healing may require several weeks, especially in older adults, but normally after about 5 days, the vesicles begin to dry and crust.

A dermatologist should be consulted immediately if shingles is suspected, as there are quite a few complications that can arise from shingles. Sometimes, a blistery rash may spread over a large portion of the body, known as disseminated zoster. If the shingles virus affects the nerves originating in the brain, serious complications involving the face, eyes, nose, and brain can develop. Areas of skin may have less sensitivity or a loss of feeling after shingles has healed. Particularly in the elderly, hyperpigmentation or scarring may result. Also, bacterial infection of the blisters may develop.

Treatment for shingles includes a combination of antiviral drugs, steroids, antidepressants, anticonvulsants, and topical agents. Treatment with anti-viral drugs such as acyclovir, valacyclovir or famciclovir (see box) is most effective in the early phase of shingles. “Oral antivirals are appropriate if the elderly patient is seen within 3 days of the onset of the eruption. The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with these drugs.

Miscellaneous Infections of the Skin

Impetigo is an acute bacterial infection on the surface of the skin caused by streptococcus and or staphylococcus. It can present as blisters (bullous) or a non-bullous form. Bullous impetigo is characterized by thin-wall blister filled with a cloudy fluid. These tend to burst and leave a red rim around the lesion with crusty honey-colored exudate. Non-bullous impetigo develops as vesicles or pustules which rupture, leaving an inflamed base with a yellowish crust.

The infection can be transmitted between humans. The infection can also be transmitted from one site to another on the same person. Poor hygiene, tropical climates, and improper sanitation can contribute to infections. Topical treatment may resolve mild infections, but most cases require oral antibiotics to resolve.

Folliculitis is a bacterial infection of hair follicles, usually caused by Staphylococcus. The basic lesion surrounds the hair follicle and presents as a red spot or bump. Poor hygiene can contribute to folliculitis. Treatment with topical mupirocin and oral antibiotics may be required to prevent the infection from spreading.

Miliaria is another name for prickly heat. This rash, presenting as minute red papules, causes an unbearable pricking sensation rather than an itch. Miliaria arises from the obstruction of the sweat ducts, caused by an increase in normal Staphylococcus epidermidis and Staphylococcus aureus bacteria, producing a sticky substance which blocks the sweat ducts. The patient continues to produce sweat, but is unable to secrete it because of the obstructed ducts, resulting in a leakage of sweat under the skin surface, leading to the rash. The rash typically develops in skin folds and in areas of friction either caused by clothing or skin to skin contact.

A case of miliaria commonly lasts 5-6 weeks despite treatment. Treatment is both symptomatic (cooling and drying the involved areas) and prophylactic (avoiding conditions that may induce/increase sweating). You can treat the symptoms with lotions containing calamine, boric acid, or menthol, cool compresses, frequent showering with mild soap, topical corticosteroids and topical antibiotics.

Following are excerpts from professional publications where Dr. Robert Norman describes problems typical of aging skin

Pruritus