Caring for Ageing Skin
| Drug Eruption
| Leg Ulcers
| Skin Infections
| Bullous Pemphigoid
| Outbreaks of Scabies
| Skin Cancer
Skin changes as we age, due to a number of reasons:
1. Intrinsic ageing: The inevitable changes caused by the passed of time as we age.
2. Photoageing: Caused by the effects of the sun over time, 90% of visible signs of ageing in Australians is caused by chronic sun exposure.
3. Influences: The nature of our lifestyle, smoking and genetic characteristics also play a part in these changes.
Skin changes caused
- Dryness and roughness
- Discolouration of the skin such as freckling and lentigines
- Wrinkling from fine surface lines and deep furrows
- Dilated blood vessels (telangiectasia )
- Fragile skin from loss of elasticity.
- Sun spots (actinic keratoses)
Prevention of skin ageing
Primary means and routine skin care for prevention of photoageing should include sunscreen and physical protection such as hat and clothing.
Minimise your time in the sun between 10 and 2 (or 11 and 3 in daylight savings). Ultraviolet light is strongest during these times.
Sunscreen should be broad spectrum providing both UVB and UVA protection, as shown on the packaging label.
Broad-spectrum sunscreens are better at protecting against damage to the skin, and in delaying skin cancer development compared with non-broad-spectrum sunscreens.
Not smoking or quitting now will help you age more gracefully.
Seek shade when outdoors in strong sunlight.
FACTS & STATS
- Is the largest organ of the body
- Protects us from the ‘outside world’
- Requires an intact barrier to work properly
Smoking and skin ageing
- Cigarette smoking makes photoageing worse, particularly in women
- There is a direct relationship between the number of packyears smoked and the severity of wrinkling, greyish discoloration, acne-like changes (comedones), and drooping of the face.
- Smokers display poor wound healing capacity and have an increased risk of skin cancers
Functions of the skin that decline with age
- Skin barrier function that protects the skin
- Repair and replacement of damaged skin cells
- Clearance of chemicals from the skin
- Hydration of moisture levels in the skin
- Responsiveness of the immune system in the skin
- Sweat production
- Temperature control
- Vitamin D production
- Would healing
- Sensory perception
In addition to ageing of the skin, various skin disorders can develop over time. People aged over 70 have a least one troublesome skin condition, and approximately 10% have three or four significant skin conditions.
How to apply sunscreen:
- Use a SPF30+ broad spectrum sunscreen on all exposed areas of skin.
- Apply sunscreen 15 minutes before going outdoors.
- Apply generous amounts and be careful not to miss any areas such as the ears & knees.
- When outdoors, reapply at least every 2 hours and after swimming, as sunscreen can be wiped off by clothing, rubbing, water and sand.
- By 2050, the number of people between 65 and 48 years of age will more than double.
- The population of people aged above 85 years is expected to more than quadruple from 0.4 million to 1.8 million.
- People aged 65 years or over are projected to increase from 13% in 2010 to 23% by June 2050.
In many cases, especially in the elderly, itch is caused by dry skin (xerosis). It is made worse by low humidity, frequent bathing or application of irritants to the skin.
Itch is temperature dependent i.e. it is generally worse when the person is warm or hot. So wear light clothes, keep the bedroom cool and use light bedclothes.
Causes of itch:
- Dry skin (xerosis)
- Kidney (renal) disease
- Liver disease
- Thyroid disease
- Some nutritional deficiencies e.g. iron deficiency
- Some cancers e.g. lymphomas, solid tumours
- Blood (haematological) diseases e.g. polycythaemia vera
- HIV infection
- Adverse drug reactions e.g. itch due to morphine and related drugs
Signs and symptoms
- Dry skin
- Scratch marks on the skin
- If you have dry skin, minimise shower time and have warm showers (not hot).
- Soap tends to dry out the skin further. Instead use an emulsifiable bath oil, bodywashes with 'neutral' pH or 'soap'
- Apply a greasy ointment or moisturiser to the body and limbs. Examples of some useful moisturising creams include: Ego QV cream, Dermaveen cream, Hamiltons cream, Cetaphil cream, Dermeze, Aqueous cream.
- If unable to use an ointment, less greasy cream is next best.
- Lotions are also available, although they are usually less moisturising than creams or ointments
Other treatments for itch
- Calamine & menthol cream: can give short-term (symptomatic) relief.
- Corticosteroid ointments and creams: ineffective in itching of clinically normal skin (i.e no rash to see)
- Ultraviolet phototherapy (treatments supervised by a dermatologist)
- This type of very itchy eczema is more common in winter and in elderly people. It particularly affects the legs, arms and hands.
- In some patients, the surface texture of the skin assumes a cracked appearance resembling crazy paving.
- Contributing factors: frequent washing, central heating (because of decreased humidity)
- The condition often worsens in winter and improves in the summer, but eventually can become permanent if untreated.
- Irritation in this form of eczema is often intense, and worse with changes of temperature, particularly on undressing at night.
- Erytherma, scaling and dryness.
- The Skin can have a cracked, ‘crazy paving’ appearance.
- Cracked skin
Treatment of asteatotic eczema
- Central heating should be humidified where possible, and abrupt temperature changes should be avoided.
- Wool is usually poorly tolerated and possibly damaging by irritation.
- Baths are best restricted and should not be hot. It is better to take a short warm shower (not hot).
- Moisturising creams or ointments should be used after bathing or daily.
- This is one of the forms of eczema in which soaps and detergent cleansers can worsen the problem by drying out the skin even more. A soap substitute should be used instead.
- A topical steroid ointment may b e needed if the above measures are not sufficient.
- Reactions to drugs (medications) are common and may vary from a mild rash to life-threatening reactions
- Once a patient has developed a drug reaction, they will always remain allergic to that drug, and should avoid it in the future
Signs and symptoms
- Blistering of the skin, painful skin, involvement/ulceration of the mucous membranes (mouth, eyes, genitals), fever. If any of these symptoms are present, then the patient’s GP should be notified immediately.
- Wide spread red rash
- Painful skin
- Ulceration of the muscous membranes (mouth, eyes, genitals)
Picture courtesy of: Copyright © 2012 Infectious Diseases Society of America
Exanthematic (maculopapular) drug eruptions
- This is the most common type of all cutaneous reactions to drugs, and presents as a red, raised rash on the skin.
- It can occur after almost any drug at any time up to 2-3 weeks after administration
- It may be accompanied by fever.
- The clinical features are variable. The rash may be itchy but is not always.
- The distribution is also variable but is generally symmetrical. The trunk and extremities are usually involved.
Antibiotics (especially ampicillin, penicillin, sulphonamides, gentamicin), anticonvulsant medication (phenytoin, carbamazepine), NSAIDs e.g. ibuprofen.
- These reactions occur within 24–36 hours of taking the medication
- These reactions can cause swelling of the mouth, eyes plus red, raised, itchy welts (“hives”) on any area of the body.
- On rechallenge, lesions may develop within minutes.
Penicillins, sulphonamides and NSAIDs.
Causes of leg ulcers
- Venous hypertension: varicose veins, deep venous thrombosis (DVT)
- Arterial disease: Atherosclerosis, diabetes, hypertension
- Skin cancers
- Connective tissue diseases
- Pyoderma gangrenosum
- Blistering disorders
Signs and symptoms
- Brown or red discolouration of the skin
- Breaks in the skin or open, non-healing wounds
- Swelling of the lower legs
- Caused by malfunction of the veins in the lower limbs
- The ulcer may be preceded by patchy redness or discoloration of an intense bluish red colour.
- The ulcer is characteristically situated on the medial lower aspect of the leg.
- Venous ulcers do not usually develop initially below the level of the ankle bones (malleoli) or on the foot.
Management of venous ulcers
- Compression bandages or stockings
- Exercise and movement
- When resting, legs should be elevated, ideally with the ulcer just above the level of the heart to ensure the maximum reduction in venous pressure.
- Patients should always be instructed to sleep in a bed rather than in a chair
- Weight control and adequate intake of essential vitamins and minerals in a balanced diet is essential for wound healing
- The contribution of other medical conditions, particularly heart and chest problems, needs to be considered
- Smoking should be stopped and excessive alcohol intake should be avoided
- Cleansing of the ulcer should be kept simple. Irrigation of the ulcer with warmed tap water or sterile saline is usually sufficient
- Dressings should keep the ulcers moist but not wet.
- Dressings should be left undisturbed for as long as possible.
Two of the most common skin infections that affect the elderly are cellulitis and thrush.
- Cause: bacterial infection of the skin that typically occurs after bacteria penetrate the skin after entering through a cut, break or ulcer in the skin. The most common bacteria involved are Staphylococcus or Streptococcus types.
- Site: any part of the body may be affected, but the lower leg is a typical site. If both lower legs are affected (i.e. red, swollen) then the patient may have venous eczema rather than cellulitis, which requires different treatment.
Cellulitis of the lower leg
Skin will be red, warm to touch, swollen and typically painful.
- Oral antibiotics. If the infection is spreading, sometimes the patient may need intravenous antibiotics.
- Prevention: monitor for any breaks or cuts in the skin. If there are, keep the area clean and cover with a dressing until healed.
- Cause: yeast infection.
- Site: moist, occluded areas of the skin (groin creases, under the breasts) or mucosal surfaces (inthe mouth, genital area).
- Predisposing factors: diabetes, treatment with antibiotics, obesity.
Red, moist areas of skin, sometimes with small red lumps at the outermost edges of the rash (“satellite lesions”). In the mouth it usually presents as a white coating on a red base.
- An imidazole cream e.g. clotrimazole or nystatin cream. In resistant cases, sometimes oral treatment (tablets) may be necessary.
- Prevention: dry the problem areas thoroughly after showering, cease oral antibiotics unless necessary, consider testing for diabetes.
- This is an uncommon but important blistering disease of elderly people
- Onset usually after 60 years of age, with an average age of 80 years
- Disease duration is usually 3–6 years, with most patients achieving complete remission off treatment.
- Bullous pemphigoid can be fatal, particularly in the active blistering phase in elderly people, and if untreated, about one-third of patients can die
- Often starts with intense itch and raised, red lesions
- Later: large, tense blisters develop
- The aim of treatment is to suppress disease activity with the minimum dose of drugs necessary. During prolonged treatment, it is advisable to aim for the presence of a blister once every few weeks so as to be certain that the patient is not being over treated.
- Treatment usually consists of a combination of tablets (oral medication) and ointments or creams that would need to be prescribed by the patients’ GP or dermatologist.
- If there are large, tense blisters, these can be aspirated (to let the fluid out) and covered with an appropriate non-stick dressing
OUTBREAKS OF SCABIES
- Scabies is an infectious disease that can be caught by close contact with someone with scabies.
- Close contact includes sharing the same bed, clothing, or even just living in the same house as a person with scabies. Other close physical contact such as nursing or caring for an individual can also spread the scabies mite.
- Away from the host (person or animal), scabies mites survive for 24–36 hours at room conditions (21°C and 40–80% relative humidity)
Outbreaks of scabies in nursing homes and other health care facilities
- Advice must be sought from the residents doctor if scabies is suspected
- All the patients or residents should be examined to detect any cases of severe or crusted scabies, and isolated until cured.
- Personnel coming into contact with such a patient should wear longsleeved gowns and gloves.
- All individuals on an affected ward or in a residential home, including all medical and nursing staff and their families, should receive prophylaxis with a topical scabicide cream (such as permethrin – see above)
- Bedding and clothing should be laundered (see treatment of scabies)
- Increasing itching, especially at night
- Other family members or close contacts also itching
- Rash, especially on the wrists, hands, nipples or genitals
Look for rash around the wrists and fingers
- Itching is usually very intense, often worst at night and when the patient is warm.
- The onset of itch occurs 3–4 weeks after the infection is acquired, and coincides with a widespread rash.
- Reinfection provokes immediate symptoms.
- The typical lesions of scabies on the skin are burrows or small itchy lumps.
- Commonly affected areas are wrists, borders of the hands, sides of the fingers and the finger web spaces, the feet and, in males, on the genitalia.
- All members of the family and close physical contacts should be treated, whether symptomatic or not.
- The treatment of all household members is often repeated at 7-10 days to maximise chance of eradication of the infestation.
- Permethrin cream (Quellada or Lyclea) is the treatment of choice in Australia because it is effective and low toxicity. It is available at the pharmacy without prescription.
- Before going to bed apply 5% permethrin cream to the whole body except the head and neck. It takes around 30mL’s to cover the average adult.
- Make sure the cream is particular attention to the elbows, breasts, groin/genitals, hands and feet (including under the nails). If one burrow is spared then the infestation will persist.
- Leave cream on for at least 8 hours before washing. Reapply cream after washing hands during this time.
- All bed linen and clothes should then be changed and washed (wash with hot water to kill the mite and its eggs).
- Any clothing or bedding that can’t be washed should be put aside for 7 days before using (e.g. placed in a plastic bag).
- These are very common benign lesions (i.e. not cancerous) that occur with increasing age and may be confused with skin cancers
- They are usually asymptomatic but may be itchy.
- They are most frequent on the face and the upper trunk.
- The most common appearance is that of a warty plaque which appears to be stuck on the surface of the skin, varying from dirty yellow to black in colour.
- Treatment: No treatment is usually necessary. If required, removal may be possible with a small sharp curette, cautery or diathermy, freezing.
- Australia has one of the highest incidences of skin cancer in the world.
- In Australia, skin cancers account for 80% of all newly diagnosed cancers.
- Two in three Australians will be diagnosed with skin cancer by the time they are 70.
Common types of skin cancers
- Non-melanoma skin cancers
- Basal Cell Carcinoma
- Squamous Cell Carcinoma
- The clinical diagnosis of melanoma is based upon recognition of a progressively changing pigmented lesion, which is growing and becoming irregular in shape and colour.
- The American ABCD rule:
- A = asymmetry
- B = irregular border
- C = irregular colour
- D = diameter over 1 cm
Melanoma – an irregular, pigmented lesion
Basal Cell Carcinoma (BCC)
- BCC is the most common type of skin cancer
- Outdoor occupations (particularly farming), freckling, and Scottish or Irish descent are particular risk factors
- The early tumours are commonly small, translucent or pearly, raised and rounded areas covered by a thin layer of skin through which a few dilated blood vessels may show.
- Tend to be slow growing and commonly occur on areas of skin most exposed to the sun e.g. face, arms, upper back and chest.
Excision (surgical removal), curettage and cautery. Cryotherapy, Radiotherapy, Photodynamic therapy, Topical immune response creams.
Squamous Cell Carcinoma (SCC)
- SCCs usually present as red, scaly lumps on the skin that may be tender to touch.
- The most common sites for SCC are those most exposed to the sun e.g. backs of the hands and forearms, the upper part of the face, the lower lip and the ear.
- SCCs usually grow more quickly than BCCs
- Treatment usually involves supervficial removal
Signs and Symptoms
- Melanoma – new or changing pigmented or dark lesions that have any of the “ABCD” features
- BCC - Small, translucent or pearly, raised and rounded areas that slowly increase in size
- SCC - Red, scaly lumps Tender