4.05 Ageing Skin

Presented by:

Dr Iain Wilkinson (Consultant Geriatrician East Surrey Hospital)

Dr Jo Preston  (Consultant Geriatrician St George’s Hospital)

Faculty:

Dr Bernard Ho, Dermatology Clinical Fellow

Sip of MDTea

PDF version of infographic here

Broadcast Date: 10th October 2017

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Social media Spots this week

Exercise for Frail Older Adults https://t.co/6Ywx5OSExW

— Cambridge Geriatrics (@CamGeris) 9 September 2017

CEBD Nottingham

Canadian Geriatrics Society book and film list

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Show notes

PDF version here

Learning Outcomes

Knowledge:

• To understand normal physiology of the skin and how it changes in older adults
• To develop an understanding of how to manage dry skin in older adults
• To understand causes of itchy skin as a presenting complaint

Skills:

• To be able to recognise different emollients and how emollients they should be used

Attitudes:

• Recognise dermatological issues can be a manifestation of an underlying systemic medical problem
• To consider visual assessment in those falling, with delirium and as part of a CGA

 

Definitions:

• Xerosis – skin that is dry to touch, due to lack of moisture in the outer layer of the skin (stratum corneum), resulting in cracked skin
• Pruritus – itchy skin or unpleasant sensation that provokes the desire to scratch

Key Points from Discussion

Ageing skin physiology

See also Series 3 episode 3 for discussion of ageing skin physiology

• Protection:
  • Accumulation of UV damage as people age
  • Cell aging via loss of telomere ends
• Barrier:
  • Decreased sebum protection
  • Epidermal thinning; flattening of dermo-epidermal junction;
• Pain receptor:
  • Dermal thinning → reduction in nerve endings ➔ decreased sensation
  • Neuropathic pain increases
• Thermoregulation
  • Dermal thinning → reduced function to thermoregulate: hypothermia more common
  • Reduced moisture retention
  • Reduced ability to vasodilate in the capillary bed ➔ prone to heat retention
• Endocrine function (Vit D, melanin)
  • Decreased ability to synthesis vit D ➔ prone to vit D deficiency/reduced bone density
  • Decreased ability to synthesis melanin ➔ prone to skin cancers (in addition to photodamage done in previous years)
• Communication/Visual appearance
  • Wrinkling/Sagging of skin
  • Loss of demarcation between chin and neck in males

Dry skin

• Causes:
  • Genetic: Ichthyosis
  • Age related changes
  • Dry environment, low humidity
  • Drugs: retinoids, diuretics, EGFR inhibitors
  • Postmenopausal
  • Medical causes: hypothyroidism, CKD, malnutrition, dermatitis/eczema
• Complication:
  • Eczema, infection (through cracks in skin allowing infection in), contact allergy
• Management
  • Emollients, emollients, emollients
  • Things to consider:
    • Severity of the dryness
    • Tolerance
    • Personal preference
    • Cost and availability
  • Avoid aqueous cream as an emollient choice
• Further reading:
  • Dry Skin

Itchy skin 

• Causes:
  • Systemic:
    • Renal: Chronic renal failure – buildup of urea and waste materials
    • Liver: Cholestatic – buildup of bilirubin
    • Endocrine/metabolic: DM; hyperthyroidism; hypoparathyroidism
    • Hematological: IDA; polycythaemia; leukaemia; lymphoma
    • Neurological: neuropathic pruritus
    • Psychogenic: skin picking; depression; anxiety; delusional parasitosis
    • Oncological: can precede underlying malignancy such as lymphoma by many years
  • Skin diseases:
    • Psoriasis, Urticaria, Allergic contact dermatitis, Dry skin, Dermatitis herpetiformis, Scabies, Mycosis fungoides
  • Exposure-related:
    • Allergens/irritants – check contacts and exposures
    • Insects/infestations (i.e. bed bugs)
    • Medication (i.e opioids as side effect)
• Pruritus screen
  • Bloods can look for signs of the systemic diseases above
  • Consider:
    • Antimitochondrial antibody – autoimmune conditions
    • CXR
    • Immunoglobulins
    • Plasma electrophoresis
• Management: Treat underlying cause; Emollients, emollients, emollients

Elderly Hospitalised Patients – The Impact of Itch and Its Prevalence. Teoh et al, 2016. Annals of Academic Medicine Singapore

Prevalence of skin diseases in hospitalized geriatric patients: Association with gender, duration of hospitalization and geriatric assessment. Makrantonaki et al 2017

Cutaneous Vasculitis 

This is a complex collection of conditions with many different causes. Vasculitides are classified by the size of the vessels affected; small, medium or large.

• Older people are most likely to get small vessel vasculitis
  • Presents with raised palpable purple areas called purpura, or occasionally ulcers
• Diagnosis
  • Biopsy – histology shows inflamed blood vessels
• Reactive vasculitis
  • E.g. Secondary to acute infection
  • Tends to settle in 6-8 weeks
  • Supportive measures- emollients, topical steroids, light compression
• Vasculitis secondary to underlying inflammatory process
  • May be more severe and persistent
  • Need to manage underlying condition

Further reading:

https://www.dermnetnz.org/topics/cutaneous-vasculitis

Blistering conditions

Autoimmune basis

Usually require immunosuppression with steroids +/- steroid sparing agent

• Bullous Pemphigoid
• Pemphigus vulgaris

Resources:

Videos of how to apply emollients, and topical steroids.

http://www.bad.org.uk/for-the-public/patient-information-videos

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

Curriculum	Area
NHS Knowledge Skills Framework	Suitable to support staff at the following levels:   Personal and People Development: Levels 1-2 Service Improvement: Level 1
Foundation curriculum	Section   2 4 10	Title   Patient centred care Self directed learning Support for patients with long term conditions
Core Medical Training	Common competences:   The patient as central focus of care Managing long term conditions and promoting patient self-care System specific competences: Dermatology Geriatric medicine
GPVTS program	Section 3.05 – Managing older adults   Core Competence: Managing medical complexity Section 3.21 – Care of people with skin problems Core competence: clinical management Core competence: managing medical complexity
ANP (Draws from KSF)	Section 6 Clinical Examination   Section 7.31 Problems with Skin Section 20 Patient as central focus of care