Common skin disorders in the elderly.

Slide 1:Skin associated systemic disease in elderly

Monsawan miniphan M.D. 3/02/2005

Slide 2:Scope of diseases

Skin associated common systemic disease Diabetes Hyperlipidemia Endocrine disease Others

Slide 3:Malignancy of skin Bacal cell carcinoma Squamous cell carcinoma Malignant melanoma

Slide 4:Skin and aging

Two basic theories of aging Programmatic theory Inherent genetic program Stochastic theory Cumulative environmental damage

Slide 5:Skin aging

Intrinsic aging Universal Inevitable change Attribute to the passage of time alone Photoaging Superimpose on intrinsic aging Attribute to the chronic sun exposure

Slide 6:Histologic features of aging skin

Epidermis Flatted dermo-epidermal junction Variable thickness Variable cell size and shape Occasional nuclear atypia Fewer melanocyte Fewer Langerhans cell

Slide 7:Dermis Atrophy Fewer fibroblast Fewer mast cells Fewer blood vessels Abnormal nerve ending

Slide 8:Appendage Depigmented hair Loss of hair Fewer glands Abnormal nail plates

Slide 11:Functions of skin decline with age

Cell replacement Thermoregulation Barrier function Sweatproduction Chemical clearance Sebumproduction Sensory perception Vit production Mechanical protection DNA repair Wound healing Immune responsesive

Slide 12:Common skin disease in elderly

Benign neoplasia Seborrheic keratosis : focal epidermal homeostasis loss leading to increase endothelin1

Slide 13:Variants of seborrhoeic keratoses include Solar lentigos: flat brown marks in sun exposed areas Stucco keratoses: numerous small dry grey stuck-on lesions usually found on lower legs and feet Dermatosis papulosa nigra: numerous brown warty papules on face and neck of dark-skinned individuals

Slide 16:Treatment Removed : wish, uncertainty of the correct diagnosis. Methods used to remove seborrhoeic keratoses include: Cryotherapy. (liquid nitrogen) Curettage & cautery. Laser surgery Shave biopsy (shaving off with a scalpel)

Slide 17:Malignant neoplasia Squamous cell carcinoma Basal cell carcinoma Malignant melanoma UV induce DNA damage Decrease DNA damage repair capacity

Slide 18:Basal cell carcinoma

the most common type of cancer in humans Affect adults, more common in elderly Sun exposure Grow slowly over months or years

Slide 19:Types of basal cell carcinoma Nodular BCC Superficial BCC Morpgoeic BCC

Slide 20:Nodular BCC Small translucent growth, rolled edges May be pigmented Ofte smaall blood vessels on surface, bleeding spontaneous

Slide 22:Superficial BCC Multiple lesions Upper trunks or shoulders Slow growing patches, shiny pink, slightly scaly, bleeding easy

Slide 24:Morphoeic BCC Skin-color, waxy, thicken scar Most difficult to diagnosis Prone to recurrent

Slide 26:Treatment depends on its type, size and location, the number to be treated Excision. The lesion is cut out and the skin stitched up. This is the most appropriate treatment for nodular, infiltrative and morphoeic BCCs. Very large lesions may require a flap or graft to repair the defect after excision

Slide 27:Squamous cell carcinoma

Common type of skin cancer Type of squamous cell carcinoma In situ SCC Invasive SCC

Slide 28:In situ SCC One or more flat red scaly patches up to several centimetres wide, often found in large numbers on the lower legs. These patches are also known as �Bowen's disease Malignant cell confine in epidermis

Slide 29:Causes of in situ SCC Sun exposure Immunosuppression HPV Arsenic ingestion Ionizing radiation

Slide 31:Invasive SCC Develop in solar keratosis Solar or actinic keratoses are common small scaly lesions arising on the face, ears and hands of white skinned people who have spent many years outdoors Thickened or tender keratosis may be developing into invasive SCC. SCCs are often crusty and may bleed easily On the lips, SCC is more common in smokers

Slide 32:Develop in thermal burn scars and longstanding leg ulcers In genital areas, SCC are usually related to infection with papillomavirus (genital warts) or skin disease such as lichen sclerosus or lichen planus vulvar cancer Not usually a threat to life as secondary spread (metastasis) is uncommon SCC on the lip or ear appear to be the sites most likely to metastasise, so ulcers or lumps in these areas should be taken particularly seriously

Slide 35:Treatment Excision : the most common treatment of invasive SCC Cryotherapy Radiation

Slide 36:Malignant melanoma

serious skin cancer which is curable if detected early Growth from melanocyte in epidermis or mucous membrane Common in 50-70 yr

Slide 37:Causes of melanoma Sun exposure particularly during childhood Serious sunburn, especially when young - however, melanoma sometimes occurs on areas of the body not normally exposed to the sun Family history of melanoma Fair skin that burns easily - melanoma is common in people with Northern European ancestry, and is not common among dark-skinned people A large number of abnormal moles (called atypical naevi). These moles are usually larger than 6mm, with an irregular shape and multicolours

Slide 38:The ABCDs of melanoma A : asymmetry B : border irregularity C : colour variation D : diameter > 6 mm

Slide 41:Treatment Surgical removal Sentinel node biopsy

Slide 42:Papulosquamous disorders

Psoriasis : change in patient environment leading to koebnerization systemic medication Atypical presentation : flexural psoriasis Drugs aggravated : b-blocker, NSAIDs, ACEi Trigger factors : urinary incontinence, hearing aids, braces

Slide 44:Xerosis

Disturbance of epidermal maturation Decrease water content in outer layers of stratum corneum Dry , rough, skin

Slide 46:Pruritus

Penetration of irritants through the damage stratum corneum Alter sensory threshold Metabolic disorder Endocrine disorder Adversr drug reaction Parasitic infestation : scabies

Slide 47:Infection

Compromised local cutaneous health predispose to growth of infective organism Age-associated decreased immune response Underlying systemic disorder associated with decreased immune response

Slide 50:Metabolic and endocrine disorder DM Renal failure Thyroid disease Hepatic disease Lymphoma, leukemia, PV

Slide 51:Skin problems associated with diabetes mellitus

Necrobiosis lipoidica Rare, insulin dependent DM One or more tender yellowish brown patches develop slowly on the lower legs over several months Round, oval or an irregular shape The centre of the patch becomes shiny, pale, thinned Prominent blood vessels (telangiectasia) Often painless

Slide 54:Treatment

Tropical steroid, usually under a plastic occlusive dressing Intralesional steroid injections or steroid tablet Aspirin and dipyridamol combination Pentoxifylline tablets Oral cyclosporin Photochemotherapy (PUVA)

Slide 55:Diabetic dermopathy Their cause is unknown Round brown or purple slightly thinned patches seen on the shins of diabetic patients Similar lesions are sometimes seen in non-diabetics Treatment is not necessary or useful

Slide 57:Hyperlipidemia

Xanthomata 4 forms : tendinous subcutaneous nodule found in fascia, ligament and extensor tendon of hand, knee and elbow Planar : yellow, soft, macule or plaque found on the upper eyelids Tuberous : yellow to reddish nodule at extensor surface of elbows, knees and knuckles Eruptive : sudden, multiple reddish yellow papule extensor of extremities, buttock

Slide 61:Acantosis nigricans

Hyperpigmentation, hyperkeratosis,velvety distribuion at intertriginous area Most common area : axilla, genitaria, groin, popliteal fossa, anticubital and neck

Slide 62:Associated condition Insulin resistant related Obesity Pseudoacromegaly DM Polycystic ovarian disease

Slide 63:Malignancy related : Adenocarcinoma : gastric Melanoma Sarcroma Lung carcinoma : small cell, squamous, bronchoalveolar Lymphoma Endocrine malignancy : carcinoid, pheochromocytoma, thyroid,testicular Wilm tumor

Slide 64:Drug induce Somatotrophin Testosterone Nicotinic acid OC Corticosteroid Idiopathic

Slide 65:Syndromes Acromegaly Addison Cushing Dermatomyositis Down Cirrhosis Hypothyroid SLE scleroderma

Slide 67:Vitiligo

Autoimmune disease, pigment cell are destroyed Irregular white patches on the skin Any part of the body may be affect

Slide 68:Who is prone to vitiligo At least 1% of all population In general : good health Greater risk : DM, thyroid, B-12 def., Addison, alopecia areata

Slide 69:Cause of vitiligo Unknown Autoimmune against the pigment cell Treatment Topical steroid PUVA

Slide 71:Associated with cancers of the esophagus, lung, breast, bladder, stomach, and cutaneous T-cell lymphoma

Slide 72:Erythroderma

Slide 73:Diffuse erythema of the skin usually associated with induration and scaling Associated with the leukemic phase of cutaneous T-cell lymphoma (Sezary syndrome) Other malignancy associations: lung, liver, prostate, thyroid, colon, pancreas, stomach

Slide 74:Collagen Vascular Disease:Dermatomyositis

Slide 75:Heliotrope erythema

Slide 76:Gottron�s papules

Slide 77:Dermatomyositis

Malignancy risk may be as high as 15% in women No increase in malignancy risk with polymyositis or childhood dermatomyositis Females over age 40 have a 32-fold increase risk of ovarian cancer

Slide 78:Other disorders associated with malignant disease

Pruritus Sister Mary Joseph nodule Erythema gyratum repens Subcutaneous fat necrosis Sweet�s syndrome

Slide 79:Hypertrichosis lanuginosa acquisita Necrolytic migratory erythema Leukoderma Sign of Leser-Trelat

Slide 80:Sister Mary Joseph Nodule

Slide 81:Sister Mary Joseph nodule

Collective term for a metastatic deposit at the umbilicus originating from any primary malignancy Appearance of this lesion usually heralds advanced disease and has a poor prognosis. Attributed to Sister Mary Joseph Dempsey who was the first surgical assistant to William Mayo Associated malignancies: stomach, colon, ovary, pancreas

Slide 82:Sweet�s Syndrome (Acute Febrile Neutrophilic Dermatosis)

Slide 84:Sweet�s SyndromeSubtypes

Classic (71%) Neoplasia (11%) � hematologic malignancies, usually AML Inflammatory Disease (16%) Pregnancy (2%)

Slide 85:Sweet�s Syndrome

Major Criteria (both required) Abrupt onset of tender or painful erythematous plaques or nodules occasionally with vesicles, pustules or bullae Predominantly neutrophilic infiltration in the dermis without leukocytoclastic vasculitis Minor criteria (2 of 4) Preceded by an nonspecific respiratory or gastrointestinary tract infection or vaccination or associated with: Inflammatory diseases as chronic autoimmune disorders, infections etc. Hemoproliferative disorders or solid malignant tumors Pregnancy Accompanied by periods of general malaise and fever (>38�C) Laboratory values during onset (three out of four necessary): ESR > 20mm n.W., C-reactive Protein positive, segmented-nuclear neutrophils and stabs > 70% in peripheral blood smear, leukocytosis > 8.000 Excellent response to treatment with systemic corticosteroids or potassium iodide

Slide 86:Necrolytic Migratory Erythema(Glucagonoma Syndrome )

Slide 87:Necrolytic Migratory Erythema

Rare syndrome associated with a glucagon producing alpha cell tumour of the pancreas Associated findings: glossitis, stomatitis, weight loss, hyperglycemia, anemia, alopecia, diabetes Diagnosis: angiography, octreotide scan Resection of the tumor clears the eruption Similar eruption may be seen with cirrhosis, pancreatitis, celiac sprue, and zinc deficiency

Slide 90:Hypertrichosis Lanuginosa Acquisita

Acquired excessive growth of lanugo (velus) hairs Initially covers face and ears; may involve all hair-bearing skin Malignancy associations include colon, rectum, bladder, lung, pancreas, breast.

Slide 92:Sign of Leser-Trelat

Sudden appearance of multiple seborrheic keratoses Association with internal malignancy is unproven