Episode 4.05 Ageing Skin

October 10, 2017

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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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

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

 

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

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