Skin Health PowerPoint Presentation

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Common Dermatologic Issues in the Geriatric Population Steve Marchenko, Janelle Marshall and Kristen M. Kelly, M.D. University of California, Irvine

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Objectives: List dermatologic diseases commonly seen in the elderly Identify terms used to describe dermatologic lesions and/or rashes Identify treatment options for common dermatologic conditions seen in the elderly

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Approach to Making Dermatologic Diagnoses Obtain Focused History Time/duration/change over time, initial site and spread/symptoms General health, occupation, family history, medications, previous treatments, allergies Characterize morphology of basic lesion Primary-original lesion Secondary-changes to lesion over time Characterize shape, color, texture, & arrangement of the lesions Determine distribution of lesions Lesion distribution often provides important diagnostic clues

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Approach to Making Dermatologic Diagnoses Diagnostic Testing to consider Shave, punch biopsy KOH for fungal infections Gram stain for bacterial infections Tzanck preparations for herpetic infection (shown) Oil mount of skin scrapings for scabies infection Image courtesy of www.visualdx.com © Logical Images, Inc

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Defining Skin Lesions A primary lesion is the initial lesion that characterizes a dermatologic disorder Being able to recognize primary skin lesions is critical in making the correct diagnosis Over time, primary lesions may continue to develop or be modified, producing secondary lesions Keep in mind, when examining a patient: The primary lesion may have evolved Any combination of primary and secondary lesions may be present

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Primary Skin Lesions *the definition of these lesions vary by the dermatology reference, but usually is 0.5-1.0cm. Note multiple hyperpigmented macular lesions and a single patch found in this patient with neurofibromitosis type 1. A papule is seen above the patch. Image courtesy of www.visualdx.com © Logical Images, Inc

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Primary Skin Lesions

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Primary Skin Lesions Note multiple pustulo-vesicles and plaques in a patient with subcorneal pustular dermatosis Image courtesy of www.visualdx.com © Logical Images, Inc

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Secondary Skin Lesions Scale: White, dry flakes (e.g. dermatophyte infection) Crust: A “scab” formed from dried serum, blood or exudate on skin (e.g. impetigo) Erosion: Focal loss of epidermis not extending below dermal/epidermal junction; heals without scarring (e.g. following blister rupture)

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Secondary Skin Lesions In this patient with pemphigus, superficial blisters have ruptured and formed crusted erosions and scales Image courtesy of www.visualdx.com © Logical Images, Inc

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Secondary Skin Lesions Ulcer: Focal loss of epidermis & dermis extending into hypodermis; heals with scarring (e.g. decubitus ulcer) Fissure: Linear loss of epidermis (+/-) dermis (e.g. “chapping” of fingers) Lichenification: Area of thickened epidermis with accentuated skin lines due to chronic rubbing (e.g. long standing atopic dermatitis)

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Benign Skin Growths Benign skin growths are common, especially in older individuals It is important to differentiate these lesions from skin cancer A clinician should try to categorize any skin lesion as: Most likely benign, most likely malignant, or unclear The last 2 categories should be biopsied Examples of common benign lesions include: Seborrheic keratoses and cherry angiomas

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Benign Skin Growths Seborrheic Keratoses (SKs) SKs are the most common benign tumor in the elderly Clinical: Brown or black raised, waxy spots or wart-like growths that appear “stuck-on” Represent benign thickening of epidermis Epidemiology: Incidence increases with age and tendency to develop SKs can be inherited Tindall JP, Smith JG Jr. Skin lesions of the aged and their association with internal changes. JAMA. Dec 21 1963;186:1039-42 Image courtesy of www.visualdx.com © Logical Images, Inc

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Benign Skin Growths Management of SKs: Always differentiate from cancer – can be confused with pigmented basal cell carcinoma, melanoma SKs appear as multiple lesions Managed with cryotherapy, curettage or shave biopsy if they become irritated or for cosmetic reasons Image courtesy of www.visualdx.com © Logical Images, Inc

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Benign Skin Growths Benign dome-shaped capillary proliferations that blanch with pressure. Usually appear in individuals over 35 on arms and trunk and tend to bleed when injured. Successfully treated with laser or electrocautery Cherry Angiomas Image courtesy of www.visualdx.com © Logical Images, Inc

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Pre-cancerous Skin Growths Actinic Keratoses Clinical: Ill-marginated, reddish, papules with rough, adherent scale More easily felt than seen Can involute or persist Occur on sun-exposed areas as a result of cumulative UV damage Precursors to squamous cell carcinomas (up to 10% may advance to SCC) Criscione, VD, Weinstock, MA, Naylor, MF, Luque, C, Eide, MJ and Bingham, SF. Actinic keratoses natural history and risk of malignant transformation in the Veterans Affairs Tropical Tretinoin Chemoprevention Trial. Cancer 2009; 115: 2523-2530 Image courtesy of www.visualdx.com © Logical Images, Inc

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Differential Diagnosis: Squamous cell carcinoma, SK, superficial basal cell carcinoma Management: Depends on number of lesions and area of involvement For few localized lesions, cryotherapy with liquid nitrogen For multiple, widespread lesions treatment options include: Photodynamic therapy Chemical Peels Topical antineoplastic agents Examples include 5-Fluorouracil (5-FU) Cream Imiquimod Cream Actinic Keratoses

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Skin Cancer Skin cancer is the most common of all human cancers It is diagnosed in more than 1 million people in the United States each year Skin cancers are of three major types: Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma The majority of skin cancers are BCCs or SCCs Although metastatic rate is low, may be locally destructive and disfiguring if not treated early Solar UV radiation is responsible for the majority of BCCs and SCCs Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3):283-287.

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Squamous Cell Carcinoma (SCC) Skin Cancer Epidemiology Second most common skin cancer Most frequently affects Caucasians with extensive sun exposure Risk factors Chronic environmental damage UV/ionizing radiation Tobacco Arsenic exposure History of actinic keratoses HPV infection 6,11,16,18 Chronic immunosupression Image courtesy of www.visualdx.com © Logical Images, Inc

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Squamous Cell Carcinoma Skin Cancer Clinical A scaly patch or warty growth that may crust, bleed, and ulcerate Frequently develops on sun-exposed areas or at sites of chronic injury, e.g., chronically draining sinuses or burns Some types have greater metastatic potential than basal cell carcinoma Management Excision with margins Mohs micrographic surgery in cosmetically sensitive areas Image courtesy of www.visualdx.com © Logical Images, Inc

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Basal Cell Carcinoma (BCC) Skin Cancer Epidemiology Most common human malignancy 800,000 new cases every year in US Risk factors Skin type 1 Blistering sunburns in childhood Family history of skin cancer Immunosuppression Nodular BCC Image courtesy of www.visualdx.com © Logical Images, Inc (NYU, Department of Dermatology). Basal Cell Carcinoma, Nodular. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=51167&imageIndex=0

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Basal Cell Carcinoma Clinical Several subtypes are described Nodulocystic: single shiny, red nodule w/ telangiectasia Superficial: least aggressive erythematous plaques can mimic psoriasis Sclerotic/Morpheiform: most aggressive 5% of all BCC’s. Ill-defined borders Pigmented Shiny, blue-black papule, speckled pigment, rolled borders. Superficial BCC Image courtesy of www.visualdx.com © Logical Images, Inc

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Basal Cell Carcinoma Skin Cancer Management Depends on location, size, histopathology, and patient factors Very low risk/superficial: consider curettage + topical 5-FU or imiquimod Most low risk lesions: curettage and electrodessication For higher risk or recurrent BCC: excision with margins or Mohs micrographic surgery Elderly patients or those in whom surgery contraindicated: consider radiation.

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Basics of Dermatologic Surgery Cryosurgery Electrodessication and curettage Excision Mohs Micrographic Surgery

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Basics of Dermatologic Surgery Cryosurgery Liquid nitrogen -195.8º C To produce adequate treatment, tissue temperature -50º C is needed Fast freeze, slow thaw ; generally 2 cycles PROS: cost effective, no surgery, minimal equipment CONS: no specimen for evaluation, skin discoloration may occur and may be permanent (especially in tanned skin or patients with darker skin types)

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Basics of Dermatologic Surgery Electrodessication and Curettage Only indicated for low-risk lesions PROS: minimal blood loss, ease, convenience for the patient CONS: no specimen for pathology, clinician experience influences cure rate Images courtesy of Margaret Mann, M.D.

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Basics of Dermatologic Surgery Excision PROS Shorter procedure time Closure performed at the same time Less expensive Margins depend on lesion

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Basics of Dermatologic Surgery Mohs Micrographic Surgery Indications: Recurrent or incompletely excised BCC or SCC Primary BCC or SCC with indistinct borders Lesions located in high-risk or cosmetically and functionally important areas (e.g. face) Tumors with aggressive clinical behavior (ie, rapidly growing, >2 cm in diameter) or aggressive histologic subtype Tumors arising in sites of previous radiation therapy Tumors arising in immunosuppressed patients

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Basics of Dermatologic Surgery Mohs Micrographic Surgery Advantages: Low risk of recurrence Exceptionally high cure rates Designed to remove tumor with smallest possible margins Disadvantages: Surgical risks Requires special equipment and technician More technically difficult Not optimal for all tumors

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Basics of Dermatologic Surgery Mohs Micrographic Surgery Step 1: Clinical examination and determination of visible margins Step 2: Visible tumor is surgically removed Step 3: A layer of skin is removed and divided into sections, which are color coded with dyes; reference marks made on skin for orientation; map of surgical site drawn Step 4: Undersurface and edges of each section are microscopically examined for evidence of remaining cancer The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohs-procedure.php Image courtesy of American College of Mohs Surgery

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Basics of Dermatologic Surgery Mohs Micrographic Surgery Step 5: If residual cancer is seen under microscope, surgeon marks location on map and returns to patient to remove another layer of skin where cancer cells remain The removal process stops when there is no longer any evidence of cancer remaining in the surgical site The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohs-procedure.php Image courtesy of American College of Mohs Surgery

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Drug Eruptions Epidemiology Drug eruptions are a frequent cause of skin lesions in the elderly population Drug eruptions occur in approximately 2-5% of inpatients and in greater than 1% of outpatients Older patients have an increased prevalence of drug eruptions due to high incidence of polypharmacy and decreased kidney function Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331:1272

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Drug Eruptions Etiology Often classified as immune and non-immune Immune: type I, II, III IV hypersensitivity reactions Non-immune: cumulative toxicity, overdose, photosensitivity, drug interactions, and metabolic alterations A drug reaction should be considered in any patient on medication with acute onset of an eruption (usually symmetric) Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331:1272

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Drug Eruptions Common morphologies: morbilliform (95%) and urticarial (5%) Less common morphologies include: pustular, bullous and papulosquamous Drug reactions can also cause pruritis without an obvious eruption Drugs most commonly implicated: antimicrobial agents, nonsteroidal anti-inflammatory drugs (NSAIDs), cytokines, chemotherapeutic agents, anticonvulsants, and psychotropic agents Morbiliform eruption Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:355-362 Image courtesy of www.visualdx.com © Logical Images, Inc

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Drug Eruptions Drugs commonly implicated in each type of reaction Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131 Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:355-362

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Drug Eruptions Drugs commonly implicated in each type of reaction Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131 Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:355-362

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Drug Eruptions Benign drug reaction Most patients with a drug eruption complain only of itching Most drug eruptions are mild, self-limited, and usually resolve after the offending agent has been discontinued Look for: absence of systemic manifestations and normal lab values Warning signs of a more serious reaction Skin pain, skin necrosis Fever Conjunctivitis or mucous membrane involvement Blisters Angioedema Palpable purpura Elevated BUN/creatinine or liver function tests Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:355-362

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EM is a spectrum of diseases ( EM minor, EM major) EM Minor (less often due to a drug eruption) May be due to infection (e.g. herpes simplex virus) Characterized by target lesions distributed predominantly on the distal extremities (including palms/soles) Mucous membrane involvement may occur but is not severe Patients recover, but relapses are common Image: Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text, Sanders, CV, Nesbitt, LT Jr (Eds), Williams & Wilkins, Baltimore 1995. Auquier- Dunant A, Mockenhaupt M, Naldi L, et al. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis; results of an international prospective study. Arch Dermatol 2002; 138: 1019. Erythema Multiforme (EM) Drug Eruptions Target lesions

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Erythema Multiforme Major Severe drug reaction requiring immediate medical attention Subcategories include: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) Characterized by epidermal necrosis and sloughing of the mucous membranes and skin In SJS, lesions affect less than 10 % of the body surface; In TEN, greater than 30% affected Image courtesy of www.visualdx.com © Logical Images, Inc

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Etiology: Not completely understood 80% of cases associated with adverse drug reaction Drug Eruptions Erythema Multiforme Major Image courtesy of www.visualdx.com © Logical Images, Inc

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Erythema Multiforme Major Presentation Prodrome of fever, malaise and pain (often like a sunburn) Primary lesions include dusky red macules of irregular size that start on the trunk and spread Always screen for mucosal symptoms including: painful eyes, painful swallowing, dysuria and diarrhea Ocular, oral, and genital mucosa are affected in >90% of cases Mortality Varies with type SJS 1-5% mortality; TEN carries a 25-30% mortality Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep;7(8)598-605.

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Drug Eruptions Work-up Consider alternative etiologies, e.g. viral exanthems and bacterial infections Take a good medication history Review the complete medication list, including over-the-counter supplements Note the interval between the introduction of a drug and onset of the eruption Patients can develop drug eruptions to medications they have been on for prolonged periods Document any history of previous adverse reactions to drugs or foods

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Drug Eruptions Work-up Biopsy can be helpful in confirming the diagnosis (e.g., by showing eosinophils in morbilliform eruptions) CBC with diff, Liver function tests, immunoserology tests may be ordered for suspected drug induced autoimmune rash, cultures if infection is suspected

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Drug Eruptions French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int Immunopharmacol. Apr 2006;6(4):543-9. Treatment of Common Drug Eruption Stop all non-essential meds (for >1 month) Monitor for signs of systemic involvement or SJS/TEN Therapy for most drug eruptions is mainly supportive Morbilliform eruptions can be treated with oral antihistamines and topical steroids Prednisone may be used cautiously in the treatment of hypersensitivity syndrome with heart and lung involvement or severe serum sickness–like reaction Slowly re-introduce other medications after suspected agent is identified

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Erythema Multiforme Major Treatment of Erythema Multiforme Major Transfer to a burn unit with aggressive supportive care is the most critical step in management Consultation with Dermatology and Ophthalmology Rapid identification and withdrawal of offending drug improves survival IVIG may be indicated; efficacy is controversial Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep;7(8)598-605. Image courtesy of www.visualdx.com © Logical Images, Inc

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Other Dermatologic Conditions in the Geriatric Population Several dermatologic conditions have a higher incidence in the geriatric population Examples include: Herpes Zoster Bullous Pemphigoid Venous Stasis Sun - induced skin changes

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Herpes Zoster Etiology Reactivation of Varicella Zoster Virus Clinical Prodrome of radicular pain & pruritus followed by skin eruption consisting of grouped vesicles on erythematous base in dermatomal distribution Postherpetic neuralgia may follow causing debilitating pain in the affected dermatome Image courtesy of www.visualdx.com © Logical Images, Inc

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Herpes Zoster Diagnosis Typically clinical. Can also perform Tzanck smear, viral culture, or direct immunofluorescence Image courtesy of www.visualdx.com © Logical Images, Inc

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Herpes Zoster Prevention Zostavax – live herpes zoster vaccine Reduces Shingles by 51.3% Reduces cases of postherpetic neuralgia by 66.5% Oxman MN, Levin MJ et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2;352(22):2271-84. Image courtesy of www.visualdx.com © Logical Images, Inc

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Herpes Zoster Treatment Best if initiated within 72 hours of start of symptoms Antivirals: Acyclovir, Valcyclovir or Famciclovir Supportive: pain control, sedatives, moist dressings to affected skin Use of gabapentin may reduce the incidence of post-herpetic neuralgia Lapolla W, DiGiorgio C, Haitz K et al. Incidence of portherpetic neuralgia after combination treatment with gabapentin and valacyclovir in patient with acute herpes zoster. Arch Derm; 147:901-907. Image courtesy of www.visualdx.com © Logical Images, Inc

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Bullous Pemphigoid Etiology Autoimmune disorder caused by autoantibodies to hemidesmosomes – attachment complexes anchoring basal keratinocytes to the basement membrane Antibody deposition at the basement membrane leads to inflammatory response and formation of subepidermal blisters Image courtesy of www.visualdx.com © Logical Images, Inc

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Bullous Pemphigoid Clinical Begins as pruritic papular eruption evolving into large, tense oval bullae with serous or hemorrhagic fluid Commonly affected areas include axillae, medial thigh, groin, abdomen and lower leg Mucous membranes are seldomly involved. Image courtesy of www.visualdx.com © Logical Images, Inc

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Bullous Pemphigoid Diagnosis Based on clinical presentation, presence of subepidermal blisters on histology and demonstration of anti-hemidesmosome antibodies by direct and indirect immunofluorescence Image courtesy of www.visualdx.com © Logical Images, Inc

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Bullous Pemphigoid Treatment Immunosupressive therapy with: Prednisone Azathioprine Methotrexate Tetracycline and nicotinamide In refractory cases can use IVIG Image courtesy of www.visualdx.com © Logical Images, Inc

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Venous Stasis Disease Etiology Risk factors include: Age Family History Prolonged Standing Increased BMI Sedentary lifestyle Venous hypertension develops due to one or combination of: Poor muscle pump function Incompetent venous valves Venous obstruction Image courtesy of www.visualdx.com © Logical Images, Inc

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Clinical Severity of symptoms depends on degree of venous reflux. In order of severity: Telangiectasias and Reticular Veins Varicose Veins – dilated, tortuous veins > 3mm in size Chronic Venous Insufficiency Edema Skin discoloration Ulcers Lipodermatosclerosis – fibrosing panniculitis with hyperpigmentation Image courtesy of Margaret Mann, M.D.

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Venous Stasis Disease Diagnosis Venography – gold standard, but invasive, expensive, associated with complications Duplex ultrasound – most frequently used to assess for deep venous thrombosis, venous reflux Ankle-brachial index – used to exclude arterial disease Image courtesy of Margaret Mann, M.D.

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Venous Stasis Disease Treatment Conservative management: Leg elevation, compression therapy Skin cleansing, emollients, and topical steroids Ablation therapy: Liquid and foam sclerotherapy for treatment of telangiectasias, reticular veins and small varicose veins Endovenous laser or radiofrequency ablation as well as mechanical ablation are used to destroy large veins

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Sun-Induced Skin Changes “Sun spots” or “liver spots” are also called lentigines, often on backs of hands and shoulders Caused by the sun and generally harmless, but can be confused with more serious skin growths Can be treated with liquid nitrogen cryotherapy or melanin-targeting lasers (e.g., the Q-switched ruby laser) Image courtesy of www.visualdx.com © Logical Images, Inc

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Sun-Induced Skin Changes Telangiectasias, or dilated blood vessels , can arise as a result of photodamage, rosacea, radiation exposure, long term topical steroid therapy or hereditary causes Mostly benign and can be effectively treated with pulsed dye lasers, other vascular targeting lasers or in some cases, electrocautery Image courtesy of www.visualdx.com © Logical Images, Inc

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Questions 1. Which 2 primary lesions are elevated: a) Macule and Plaque b) Macule and Papule c) Papule and Patch d) Papule and Plaque 2. True or False, drug eruptions occur more frequently in elderly patients? a) True b) False Answers: 1. d, 2. a

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3. The patient is a 75 yo male with no history of skin cancer who presents because his wife became concerned about large “mole-like” growths on his back, which have increased in number over the years. The patient says some of them are itchy. On physical exam the lesions are dark brown symmetric papules and plaques of uniform color with stuck-on waxy appearance. What is the diagnosis? a) Actinic Keratosis b) Solar lentigo c) Seborrheic Keratosis d) Benign Nevus 4. In this patient, what is the most appropriate next step in management? a) Urgent referral to a dermatologist for biopsy b) Photodynamic therapy c) Full body CT scan to look for metastases d) Cryotherapy with application of liquid nitrogen to symptomatic lesions Answers 3. c, 4. d.

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5. The patient is a 60 year-old male with a history of significant sun exposure who presents for a routine skin check. He has a history of multiple rounds of cryotherapy for “pre-cancerous” lesions. On physical exam there are multiple skin-colored papules with rough adherent scale located on his hands and face. What is the diagnosis? a) Actinic Keratosis b) Seborrheic Keratosis c) Basal cell carcinoma d) Melanoma 6. For the patient in question 5, besides cryotherapy what is an additional treatment option a) 5- Fluorouracil cream b) Chemical peels c) Imiquimod Cream d) Photodynamic therapy e) All of the above Answers: 5. a, 6. e

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7. A 55 year old female with a history of a blistering sunburn as a child and family history of skin cancer presents with a lesion on her chest, which she first noticed 1 month ago. She denies any pain but reports the lesion bled with minor trauma last week. On physical exam the lesion is a shiny, red lesion with rolled borders and prominent telangiectasias. The most likely diagnosis is: a. Melanoma in-situ b. Squamous cell carcinoma c. Nodular BCC d. Superficial BCC e. Herpes Zoster f. Pigmented BCC Answer: c

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8. This patient is a 60 year old female who presents with a large, tense bullae, as shown below. Prior to the appearance of the bullae, she noted a pruritic papular eruption in the same distribution. A biopsy was performed, which revealed a subepidermal blister and immunofluorescence demonstrated presence of anti-hemidesmosome antibodies in the serum. What is the diagnosis? a) Herpes Zoster b) Bullous Pemphigoid c) Drug eruption d) Dermatomyositis Answer: b