Transcript File
By :Dr .Pawana Kayastha
SKIN CHANGES IN OLD AGE
•Typical changes: include atrophy, laxity,
wrinkling, dryness, irregular pigmentation and
sparse grey hair.
•changes are brought about by: age-related
alterations in structure and function of the skin
•cumulative effects of environmental insults,
especially ultraviolet radiation
•cutaneous consequences of disease in other
organ systems
•Immunity: alterations in immune surveillance
and antigen presentation, and reduced
cutaneous vascular supply which lead to
decreases in the inflammatory response,
absorption and cutaneous clearance of topical
medications.
•Consequences: these changes make the skin
less durable, slower to heal, and more
susceptible to damage and disease.
COMMON SKIN DISEASES IN OLD AGE
•Prevalence: about 40% of individuals over the
age of 60 years have significant dermatological
problems.
•Diseases: the most common in this age group
are:
• skin cancers
• leg ulcers, a major cause of morbidity in the
elderly
• blistering disorders
• herpes zoster (shingles) and post-herpetic
neuralgia
inflammatory skin diseases, e.g. asteatotic,
gravitational and seborrhoeic eczema,
.
psoriasis
lichen sclerosus et atrophicus
scabies
lymphoedema
pruritus of old age
drug-related rashes
Long
standing pigmented spot.
The
principal clinical concern is to distinguish
correctly between benign pigmented lesions and
melanoma.
The
situation is complicated by the fact that any
one of a number of changes in a pigmented lesion
is highly sensitive as a marker of melanoma,
specificity is low.
ABCDE FEATURES OF MALIGNANT MELANOMA
Asymmetry
Border irregular
Colour irregular
Diameter often greater than 0.5 cm
Elevation irregular
(+ Loss of skin markings)
Determine
the precise nature of the change.
Is it due to the development of itch,
inflammation, bleeding or ulceration, or does
it relate to the colour, size, shape or surface
of the lesion?
Subtle changes:plucking hair,shaving,irritants
Is the patient worried about change in one or
many moles?
Positive family history of melanoma. Fewer
than 10% of melanomas occur in individuals
with a strong family history but in some of
these families up to 50% of individuals may
develop melanoma.
Examine
the pigmented lesion carefully.
Look at the morphology of the melanocytic
naevi at other sites.
magnifying glass or dermatoscope
whether the lesion is a benign melanocytic
naevus or a malignant melanoma
Before trying to answer this, the clinician
needs to exclude the possibility that it is
another type of pigmented lesion:
Lentigo (a benign proliferation of melanocytes)
Freckle (ephelis, a focal overproduction of
melanin,)
Seborrhoeic wart (basal cell papilloma, a benign
keratinocyte tumour)
Dermatofibroma. This lightly pigmented firm
dermal nodule is common on extremities in
young adults. It feels larger than it looks. There
is dimpling when the skin is squeezed on both
sides (positive Fitzpatrick sign).
Pigmented basal cell carcinoma : This lesion is
usually found on the face of the elderly and is
slow-growing. It has a blue-brown hue with an
opalescent look. There may be a rolled edge
around an ulcer.
Subungual haematoma
Any
changing lesion which is suspected of being a
malignant melanoma should be excised without
delay, with a clear margin.
If
there is even a low index of suspicion of a
malignant melanoma ,then the lesion should be
reviewed 1 month and may be 3mths later.
Continuing change demands excision.
If
benign then reassurance but advised to report
back without delay if the change and concern
continue
If
in doubt cut out and then check the histology
An unpleasant localized or generalized
sensation on the skin, mucus membranes or
conjunctivae which the patient instinctively
attempts to relieve by scratching or rubbing
Many Causes, Many Treatments
Trivial to Life threatening
(mosquito bite)
(malignancy)
10-50% of cases with generalized itching
have systemic disease
Skin diseases associated with generalised
pruritus
Eczema
Scabies
Urticaria/dermographism
Pruritus of old age and xeroderma
Skin diseases associated with localised pruritus
Eczema
Lichen planus
Dermatitis herpetiformis
Pediculosis
CAUSES OF PRURITUS IN PREGNANCY
iin IN PREGNANCYGestation and
Condition
Obstetric
cholestasis
features
3rd trimester
Associated with
abnormal liver
function tests
Pemphigoid
3rd trimester
gestationis
Pruritus followed
by blistering
Starts around the
umbilicus
Polymorphic
3rd trimester,
eruption
after delivery
(urticarialpapules Polymorphic
) of pregnancy
lesions with
urticaria
Treatment
Emollients
Chlorphenamine
Colestyramine
Early delivery
Topical or oral
corticosteroids
Chlorphenamine
Prurigo
gestationis
2nd trimester
Emollients
Excoriated papules Topical
corticosteroids
Chlorphenamine
Pruritic folliculitis 3rd trimester
Aseptic pustules
on trunk
Topical
corticosteroids
Chronic
Renal Failure: 25-86% itching
(not in acute renal failure)
Attrib
to accumulation of pruritogens:
histamine (mast cells), serotonin
Ca, Phos, Mg, Al, vit A also implicated
1/3
uremic patients not on dialysis
Maintenance hemodialysis: 70-80%
20-25%
janudiced patients with hepatobiliary
disease associated with cholestasis
100% primary biliary cirrhosis
Viral hepatitis
Attrib
to bile salts in serum and tissues
Begins palms and soles & spreads inward
vera (50%)
iron def anemia,
lymphomas
Polycythemia
Hodgkins – 30%
T-cell: almost all
leukemias,
plasma cell dyscrasias,
mastocytosis
Central:
CNS abscess, spinal and cerebral
tumors (17%), CVAs
Attrib to effects on descending pathways which
itching
Neurogenic
Shingles (10-15% in US)
Notalgia paresthetica: sensory entrapment
syndrome causing neuropathy of T2-6 dorsal
spinal nerves
Diabetes
Thyrotoxicosis,Hypothyroidism
Generalised
due to dry skin
Localised may be due to Candida
Myxodema
Postmenopausal syndrome
Most common trigger: mucocutanious
candidiasis
HIV
Infection, infestation
Eosinophilic folliculitis
Unknown
infection
Malignancy
Unknown
Psychogenic
Unknown
opioids
commonly
Direct
action on medullary dorsal horn
and trigeminal nucleus of medulla – not
t/histamine release
Spinal
anesthesia with lidocaine: 30-100%
pruritis
Fentanyl:
Intrathecal 67-100%
Epidural 67%
Morphine
Intrathecal 62-82%
Epidural 65-70%
Penicillin:
immediate type I
hypersensitivity reaction
Vancomycin: massive nonimmunologic
release of histamine “Red Man
Syndrome”
(flushing CP, pruritis, muscle spasms,
hypotension)
Related to rate of infusion
Potentiated by muscle relaxants and opioids
Attenuated by H1 blockers
Rifampin
Fentanyl:
itching decreased when mixed with
bupivicane, increased when mixed with
procaine
Drug induced cholestasis
esp phenothiazenes, estrogens, tolbutamide,
anabolic steroids
LOOK
for skin changes
If no skin disease identified then search for
systemic diseases by systemic examination
Investigation –as per systemic illness
Pressure
Low-intensity
electrical
Histamine: acts directly on free nerve
endings in skin
Histamine
Substance
Prostaglandins
Proteases
Leukotrienes
Peptides
Serotonin
Enzymes
Acetylcholine
Cytokines
P
Cutaneous
(pruritoceptive)
Neurogenic
Neuropathic
Mixed Psychogenic
C-Fibers
originate @ dermal/epidermal jxn
Thin unmyelinated axons, lots of branching
Ipsilateral dorsal horn of spinal cord
Synapse with itch-specific secondary neurons
Cross to opposite anterolateral spinothalamic
tract to thalamus
Somatosensory cortex of postcentral gyrus
SLOW transmission and BROAD receptor field
Scratching
stimulates large fast-conducting
A-fibers adjacent to slow unmyelinated C
fibers
A-fibers synapse with inhibitory interneurons
and inhibit C-fibers
Scratching may either–stimulating ascending
sensory pathway-inhibit itch at the spinal
cord Or,may damage itch fibers directly
Painful
stimuli (thermal, mechanical,
chemical) can inhibit itching
Inhibition of pain (opioids) may enhance
itching
Inhibit mediators of itch: histamine,
prostaglandins, substance P, serotonin, cytokines
Block chemicals that induce pruritis: opioids,
antimicrobials
Treat effects of diseases which induce
itching: eczema, CRF, LF, heme, neuro, endo
cool compresses
emollients
topical steroids
antidepressants
anxiolytics
antibiotics
Tx
for uremic itching: renal transplant
Effective even when transplant is failing as
long as immunosuppresants are given
Antihistamines not effective
Also
effective: moisturizers, UV-B tx
(vit A in skin), oral activated charcoal,
cholstyramine, naltrexone, ondansterone,
topical capsaicin, azelastin, thalidomide,
IV lidocaine, erythropoetin, electric
needle stim
Tx:
reverse cholestatis, liver transplant
Also helpful: oral guar gum (dietary fiber)
binds bile acids; cholestyramine; rifampin!
(inhibits bile uptake), opioid antagonists,
codeine, propofol, ondansetron,Naltrexone
UVB
Not
helpful: scratching
Thyrotoxicosis
Lymphoma
Iron defn
HIV
Emollients
Cimetidine
Iron supplement
Treatment of opportunistic infection
Local corticosteroids, UVB
UVB
Pshychogenic
Psychotherapy
Anxiolytics
Antidepressives
opioid related pruritis :
Diphenhydramine – for systemic opioids
For Neuraxial Opioids:
Ondansteron
Naloxone (1-2mcg/kg/hr)
Nalbuphine (10-20 mcg/kg/hr)
Propofol (.5-1mg/kg/hr)
Lidocaine (2mg/kg/hr)
NSAIDs (diclofenac, tenoxicam)
Droperidol
Penicillin Reaction
Diphenhydramine