Geriatric Dermatology

1. Geriatric Dermatology The Pharmacist’s Role

2. Objectives At 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

3. Skin Changes In the Elderly

4. Etiology Intrinsic: occurs in everyone and is related to genetic changes in cell processes Extrinsic: produced by external causes (e.g. UV exposure, smoking, environmental pollutants)

5. 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

6. 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

7. 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

8. Decubitus Ulcers Stage III Decubitus Ulcer with necrosis on sacrum

9. 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

10. 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

11. Stages of Decubitus Ulcers

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Xerosis

23. Xerosis Xerosis (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

24. 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

25. 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

26. 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.

27. 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.

28. 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.

29. 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

30. Urea Hydrating effects – urea is strongly hygroscopic (water-loving) and draws and retains water within skin cells Keratolyticeffects – 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

31. 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.

32. Adverse Reactions Possible adverse reactions of both occlusives and humectants/keratolyticsinclude: 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

33. 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

34. Skin Infections Skin 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)

35. Impetigo

36. 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

37. Varicella (Herpes) Zoster

38. 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

39. 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

40. Fungal Infections Dermatological fungal infections are highly prevalent in the elderly and include: Seborrheic dermatitis Candida TineaPedis (Athlete’s Foot) TineaCruris (Jock Itch) Onychomycosis (TineaUnguium nail infections)

41. Seborrheic dermatitis

42. 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 Nasolabialfolds 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)

43. 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

44. Candida

45. 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

46. Candida Often related to: Obesity Diabetes Immunosuppression Chronic debilitation Occlusion under incontinence products Systemic antibiotic therapy

47. 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 Miconazole Econazole Ketoconazole Ciclopirox Antifungal powders may be used to dry the skin and prevent maceration Terbinafinecream is NOT effective against Candida.

48. Tineapedis(Athlete’s Foot)

49. Tineapedis(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

50. Tineapedis(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