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CHAPTER 16: SKIN CONDITIONS

Overview

Symptoms

    Skin Dryness

    Skin Discoloration in Body Folds (Intertrigo)

    Skin Growths

    Itching

Conditions

    Allergic Skin Rash (Contact Dermatitis)

    Fungal Skin Infections

    Infestations

    Pressure Ulcers

    Psoriasis

    Shingles

    Skin Cancers

    Skin Changes Due to Poor Circulation (Stasis Dermatitis)

    Skin Infections


Overview

Significant skin problems affect about two-thirds of older people, but these conditions are often unrecognized or incorrectly labeled and treated.

    Obviously, our physical appearance has a powerful influence on how we interact with other people. Attractive skin has almost universal appeal. Appearance may be related to self-esteem, wellbeing, and possibly even overall health. In fact, one of the earliest pieces of written history, the Sir Edwin Smith surgical papyrus (approximately 1500 B.C.) contains the prescription for a cream to reduce skin wrinkles. Interestingly, the book is entitled How to Turn a Man of 70 into a Youth.

    Youth-oriented stereotypes of beauty and good looks can create considerable problems and anxieties for the aging person. The damaging nature of the stereotypes is that a person starts to believe that the changes represent a personal rather than a societal problem.

    Skin conditions seen with aging result from either loss of elasticity, producing wrinkles and creases, or changes caused by sun damage. Characteristic skin changes are commonly seen in older people with medical illnesses such as diabetes mellitus, poor circulation, kidney disease, and thyroid problems.

    There is a vast array of creams, lotions, cosmetics, and other options to help people deal with their skin concerns.

SYMPTOMS Skin Dryness

Dry skin is a very common problem in older people and is characterized by rough, scaly skin that is worsened by low humidity. It is a difficulty that people frequently encounter in the winter because of low humidity and is worsened by frequent bathing because of the effects of soap. The legs are usually the most severely involved. The cause of this condition is not clear, but the dryness is not simply due to a lack of water or oil in the affected skin.

Treatment of Skin Dryness

It is important to minimize bathing (optimally every two or three days) to prevent soap and water from removing too much of the skin's natural oils. Emollients, or skin moisturizers, are the best treatment and should be applied immediately after the bath while the skin is still moist. Emollients should be used indefinitely to prevent recurrence.

Skin Discoloration in Body Folds (Intertrigo)

Complaints of discoloration, softening, and inflammation in skin folds are common in older people, especially in those who are obese. Intertrigo, the term used for this chronic condition, is characterized by skin folds that are painful and prone to develop cracks and redness. The affected area often smells and is usually accompanied by the presence of various skin bacteria or fungi.

Treatment of Skin Discoloration in Body Folds

When feasible, treatment consists of keeping the skin open to the air, which is best accomplished by removing the clothing and manually separating the skin folds. It is also useful to expose the areas to a fan, hair dryer, or other dry air source for at least 10 to 15 minutes several times a day. Liberal application of absorbent powders in the skin folds after bathing (and as needed to keep the area dry) is also helpful. Sometimes a physician will prescribe an antifungal cream if the affected area appears to harbor a fungal infection. Steroid preparations to the skin are usually not necessary and are best used only under the supervision of a physician or dermatologist because of the risk of added infection and skin atrophy.

Skin Growths

Perhaps one of the best markers of skin aging are the benign skin growths that result from long-term sun exposure, and therfore depend upon the amount of sunlight exposure, clothing styles, and light versus dark complexion. On the other hand, skin tags, small reddish spots called cherry angiomas, and seborrheic keratoses (described below) appear regardless of the degree of sun exposure and whether or not the skin is protected from the sun. The major importance of these skin changes is the amount of distress that they cause people from a cosmetic standpoint, a distress that appears to result from a fear of changed body image due to aging.

    Small skin tags are commonly seen around the neck, under the arms, below the breasts, and in the groin. They are usually between 5 and 15 millimeters (1/4 to 5/8 inch) in diameter and are generally flesh colored. Friction and hereditary factors appear to play a significant role in their development. Skin tags can be rapidly and painlessly removed by a physician. Cherry angiomas are smooth, dome-shaped red spots that are roughly the size of a match-head and commonly are seen on the trunk of the body. They also can be easily treated. Seborrheic keratoses are oily scaly patches, or plaques, that appear from brown to black and may become several centimeters in diameter. They appear to be stuck to the surface of the skin and have an irregular heaped-up appearance. This stuck-on or waxy appearance, as well as their coloration and smooth borders usually distinguish them from malignant growths. Seborrheic keratoses can be left alone or treated depending on a person's preference and a physician's advice. It is important to emphasize that any skin growth or discoloration that changes in appearance, has notched or irregular borders, bleeds easily, or contains a black coloration should be evaluated by a physician to exclude the possibility of a skin cancer.

Itching

Itching produces substantial discomfort for many older people. It sometimes severely compromises one's quality of life, especially by interfering with sleep.

Causes of Skin Itching

Commonly the itching is due to simple dryness that can be treated with frequent applications of moisturizing agents called emollients. For a very small number of elderly people (far less than 10 percent), the itching may be the sign of an underlying disease, which is more likely if the onset of itching appears suddenly and if it is extremely severe. Chronic kidney disease, diseases of the liver, gallstones, thyroid disease, and some malignant conditions (such as Hodgkin's disease) can produce itching.

Evaluation of Skin Itching

Because of the possibility of serious medical illness, the older person with a recent onset of itching needs to see a physician who will usually conduct a careful interview and physical examination to search for signs and symptoms of underlying diseases. Generally, extensive examination is not necessary.

Treatment of Skin Itching

Steroid creams are not usually recommended for the treatment of itching. They should only be used in the presence of a specific skin condition identified by a physician or other health worker. In addition, oral antihistamines should also be avoided, because they rarely help and may actually produce states of confusion in the older person. Aside from applying skin moisturizing agents, the best treatment of itching consists of attempting to improve any underlying disease.

CONDITIONS Allergic Skin Rash (Contact Dermatitis)

Contact dermatitis is probably underrecognized in older persons. It is an easily treated rash caused by skin exposure to substances that may be irritating or allergic in nature. Contact with poison ivy is a familiar example.

Symptoms of Contact Dermatitis

Finding the cause is important because effective treatment must include identification and avoidance of the offending irritant or allergen. Contact dermatitis can produce both immediate and longer-lasting changes to the skin, including redness; small, clear liquid-filled blisters called vesicles; and thickening and scaling of the skin. Because older skin often responds less vigorously and less rapidly than younger skin to an inflammatory stimulus, dermatitis may be subtle. As a result, the cause may be difficult to establish.

Treatment of Contact Dermatitis

Until the cause is found and the symptoms resolved, doctors sometimes treat contact dermatitis with creams or lotions that contain corticosteroids. The severity and location of the dermatitis help the physician to know how strong and what type of preparation to prescribe. Medium- to high-potency steroids are used for initial treatment of the most symptomatic and severe cases and in areas where absorption from the skin is poor. Lower-potency preparations are used on the face, on the genitalia, in body folds, or in other areas where absorption is high. Creams or lotions are useful for cuts or skin breaks that weep fluid or for eruptions in areas that are covered by clothing. Ointments, which are greasier than creams or lotions, are often more soothing and effective for chronic dermatitis.

Fungal Skin Infections

Superficial skin infections caused by common fungi occur frequently, especially in warm climates. One fungus called tinea pedis (athlete's foot) may develop only in the space between the toes or can cause a scaliness over the entire sole of the foot. Fungal disease of the nail usually shows up by a thickened, crumbly, discolored nail but without other symptoms. Sometimes fungal conditions occur in the groin or on the hands.

Symptoms of Fungal Skin Infections

Beyond the itching and the unpleasant odor associated with fungus infections, these fungal infections can cause skin breaks and cracks that in turn predispose the tissue to bacterial infection beneath the skin. Such infections, known as bacterial cellulitis, are serious and require prompt treatment.

Treatment of Fungal Skin Infections

In most circumstances, fungal infection is controlled by the daily application of some broad-spectrum antifungal cream or powder. Four to six weeks is generally required to eliminate a severe fungal infection of the foot, but this condition tends to recur very rapidly, and continued intermittent treatment is often necessary. Longstanding infections involving the nails are common and generally cannot be totally cured. Like fungal disease of the feet, the treatment for these areas consists of twice daily preparations of an antifungal cream. Treatment to prevent recurrence in the groin or hand is usually not necessary, however, because the long-term cure rates are much higher than they are for the feet.

Infestations

An infestation of mites affecting the skin, called scabies, is common among institutionalized people such as nursing home residents.

Symptoms of Infestations

Most people with scabies have severe itching that is really a kind of allergic reaction to the mite. Usually, signs of scratching are found on the hands, wrists, under the arms, on the abdomen, and around the groin. The head and neck are almost never involved. Physicians sometimes confirm the diagnosis by scraping the involved area and observing the mites under a microscope.

Treatment of Scabies

One highly effective treatment that is well tolerated by older people consists of applying 1 percent lindane cream to the entire body below the neck. The cream should stay on for 24 hours and then be washed off in a bath or shower. Because the mite eggs are resistant to this treatment, the treatment should be repeated a week later to kill any newly hatched mites. In the intervening week, all clothing, bedclothes, and towels should either be removed from human contact or thoroughly washed in hot water. Scabies mites can survive for several days away from the human host. This regimen will cure scabies for more than 90 percent of people, but it does not immediately decrease the itching. Skin moisteners, steroid creams, and a great deal of tender loving care usually improve the itching within a few days. Sometimes the skin remains easily irritated for weeks after successful treatment.

    There are no firm guidelines for treating people who have had contact with a person with scabies. It seems reasonable that anyone who has similar itching areas or a history of intimacy with a person with the infestation should be given the same treatment as described above. Casual contacts, such as nursing home attendants, are infrequently affected.

Other Infestations

Body lice are far less common than scabies except in extremely impoverished people. These skin areas have moderate to severe itching and the areas tend to be grouped together. Treatment of body lice consists of dry cleaning or thorough washing and ironing of all clothes, blankets, sheets, and anything else that has come in contact with the person. Because the lice do not remain on the skin for very long, treatment of the individual is not effective.

    Older people may also incur insect bites such as flea or spider bites. It is useful to keep this in mind when any itchy red areas appear on the skin. In these cases, the treatment consists of eradicating the insects or spiders from the person's environment. Topical ointments can relieve the itching.

    If a person seems overly concerned about infestations and only has scratching, one must consider a delusion of being covered with parasites. On questioning people with this condition, they often vividly describe the movement of insects on or in their skin. They characteristically have a collection of scabs, dust, or other small particles that they have identified as the offending insects. This condition is a true psychosis and requires psychiatric management.

Pressure Ulcers

Pressure ulcers are localized areas of injured tissue in or below the skin that develop when these soft tissues are compressed between a bony prominence and another surface for a long time. These ulcers can appear as a red area that does not turn white when it is pushed; a crater formation indicating loss of soft tissue; a blister; or a large, dark area resembling a scab. Other terms for pressure ulcers include pressure sores, decubitus ulcers, or bed sores. Because pressure is mostly responsible for inducing the formation of these skin conditions, pressure ulcer has become the preferred term. The terms decubitus (meaning lying down) ulcer and bed sore imply that the ulcers occur only when one is lying down, but some of the most severe injuries to the skin caused by pressure may result from prolonged sitting.

    The National Pressure Ulcer Advisory Panel has suggested the following system for classifying the extent and severity, or stages, of pressure ulcers (see Figure 13):

    Stage 1: Skin redness that does not turn white with pressure

    Stage 2: Loss of the outer skin layers

    Stage 3: Loss of the full thickness of skin and some of the tissue below the skin

    Stage 4: Deeper loss of the full thickness of skin and the tissue below, extending into muscle or bone

    Pressure-induced blisters may occur on the heels and usually indicate stage 2 or stage 3 ulcers. Any injury manifested by eschar formation, that is, a large, dark crusty area covering raw tissue, is at least a stage 3 ulcer.

Incidence of Pressure Ulcers

More than 50 percent of people with pressure ulcers are 70 years of age and older. This highlights the fact that pressure ulcers are a common problem for older people who are less mobile and less active than younger people. Nearly two-thirds of pressure ulcers first develop in the hospital. About 70 percent of these ulcers occur within the first two weeks of hospitalization. In addition to these, approximately 18 percent of all ulcers occur in the community and about 18 percent in nursing homes.

Pressure Ulcers and Mortality

Hospital patients who develop pressure ulcers have about a fourfold increased risk of death. A similar increase in death rate over a six-month follow-up period has been observed in nursing home individuals who develop pressure ulcers. In addition, nursing home individuals who have a pressure ulcer that fails to heal within six months have a nearly sixfold increase in their death rate. The mortality rate for people discharged from the hospital with a diagnosis of pressure ulcers is about 15 percent, which is over two times higher than the average of about 7 percent for all hospitalized Medicare patients. However, since most of these deaths occur in people with very severe, underlying illnesses, the specific contribution of the pressure ulcers to these deaths is difficult to define.

Risk Factors Leading to Pressure Ulcers

It is clear that pressure ulcers occur most frequently when a person is very limited in mobility and activity. Older people with a reduced number of spontaneous movements during sleep (fewer than 20 movements) have an increased risk of developing pressure ulcers. A low level of albumin in the blood, loss of bowel control, and the presence of a fracture may identify bed- and chair-bound individuals who are at a particularly high risk for pressure ulcers in the hospital. These three characteristics may not be as important in bed- or chairbound nursing home individuals for whom a stroke or impaired capacity for eating appears to be the important risk factor. For people who live in the community, older age, reduced activity, cigarette smoking, dry scaling skin, and poor self-assessment of health appear to be the risk factors related to the development of pressure ulcers over a ten-year period.

    Some additional factors that may predispose a person to develop pressure ulcers include aging changes in the skin and malnutrition. Several simple scales have been developed to assess and identify older people who are at risk for pressure ulcers. Among them, the Braden Scale (see Table 20 for a modified version) is the most reliable and valid.

Table 20. Braden Scale for Predicting Pressure Sore Risk

PATIENT'S NAME________________

EVALUATOR'S NAME____________

DATE OF ASSESSMENT

SENSORY PERCEPTION Ability to respond meaningfully to pressure-related discomfort

1. Completely limited: unresponsive to painful stimuli OR limited ability to feel pain over most of body surface

2. Very limited: responds only to painful stimuli; cannot communicate discomfort OR has a sensory impairment that limits the ability to feel pain or discomfort over 1/2 of body

3. Slightly limited: responds to verbal commands OR has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities

4. No impairment

SKIN EXPOSURE TO MOISTURE

1. Constantly moist due to perspiration, urine, etc.

2. Very moist: skin is often, but not always moist

3. Occasionally moist

4. Rarely moist

DEGREE OF PHYSICAL ACTIVITY

1. Bedfast: confined to bed

2. Chairfast

3. Walks occasionally

4. Walks frequently

ABILITY TO CHANGE BODY POSITION

1. Completely immobile

2. Very limited: makes occasional slight changes in body positions

3. Slightly limited: makes frequent, slight changes in body position

4. No limitations

NUTRITION Usual food intake pattern

1. Very poor OR takes nothing by mouth or is maintained on clear liquids or IVs for more than 5 days

2. Probably inadequate OR receives less than optimum amount of liquid diet or tube feeding

3. Adequate OR is on a tube feeding, which probably meets most of nutritional needs

4. Excellent

FRICTION AND SHEAR

1. Problem: requires moderate to maximum assistance in moving; complete lifting is impossible; frequent repositioning with maximum assistance

2. Potential problem: skin probably slides to some extent against sheets, chair, restraints, or other surfaces, but occasionally slides down in bed

3. No apparent problem: maintains good position in bed or chair at all times

4. N/A

Copyright © 1988 Barbara Braden and Nancy Bergstrom. For additional information on administration and scoring, refer to Braden, B J and Bergstrom N, "Clinical Utility of the Braden Scale for Predicting Pressure Sore Risk," Decubitus, 1989;2(3):44-51.

The Causes of Pressure Ulcers

Four factors contribute to the development of pressure ulcers: pressure, shearing forces (the stretching of tissue layers in opposite directions), friction, and moisture. Muscles and soft tissues below the skin are more sensitive than the skin to pressure-induced injury (see Figure 14). When a person is lying on a regular hospital mattress, the pressure measured under bony prominence such as the lower back can be high enough to decrease the oxygen tension to nearly zero. Such pressures can cause full-skin-thickness ulcers. For people who are seated for long periods, pressure under the buttocks may be even higher.

    When repeated exposure to high pressures has caused a progressive and unnoticed injury deep in the skin tissues, it does not take much ongoing additional pressure or additional time for a full-thickness injury to occur. Shearing forces, which can also disrupt the blood flow in vessels near or in the skin tissues, occur when a seated person slides toward the floor. This can also happen when the head of the bed is elevated and the person slides toward the foot of the bed. The skin surface along the back remains stationary, being temporarily stuck to the sheets, while the blood vessels and soft tissues beneath the skin become stretched and pulled. These shearing forces are three times more destructive in older persons than they are in younger people, probably because of age-related loss of tissue in the skin.

    Friction causes blisters that, when they open, lead to superficial pressure ulcers. This is the kind of injury that can occur when a person is pulled across a sheet or when repeated movements expose a bony area to the forces of friction. Moisture may increase the amount of friction produced between the person and the support surface, and skin moisture may by itself lead to skin injury. In one study, pressure ulcers were 5 1/2 times more likely to occur in incontinent people, presumably because of the extra moisture. Because of the toxins and bacteria in stool, loss of bowel control may cause more skin breakdown than loss of bladder control.

    Pressure ulcers within the tissues that overlie the bones are more likely caused by loss of blood flow and the loss of the ability to drain tissue fluid than to mechanical injury caused by friction. Shearing forces may cause direct injury to the soft tissues below the skin and also to muscle. Typically, the injury due to pressure alone begins in the very deepest tissues and spreads toward the skin surface. If the pressure is relieved, the normal response is a redness, but if it persists, the resulting pressure-induced injury leads to swelling of and leakage from the blood vessels. As fluid leaks into the space around the blood vessels, the skin and blood vessels stretch apart, which ultimately causes bleeding, leading to a stage 1 pressure ulcer (in which the redness of the skin does not turn white when it is pushed on).

    Bacteria in the blood become deposited at sites of deep pressure-induced injury, where they develop into an abscess. This observation may explain why people with deep pressure ulcers may have significant problems even though the skin overlying the ulcer initially appears to be intact. The accumulation of fluid, blood, inflammatory cells, toxic waste products, and possibly bacteria, all combined with the loss of blood flow, ultimately and progressively leads to the death of muscle and the surrounding soft tissue. Eventually, the skin is affected as well.

Complications of Pressure Ulcers

Blood poisoning (septicemia) is the most serious complication of pressure ulcers. In a study of pressure ulcers associated with bacteria in the blood, the mortality rate was nearly 100 percent in people aged 60 and older. About half of people who have pressure ulcers that require significant cleaning (debridement) may have temporary bacteremia (bacteria in the blood) that usually resolves itself without further treatment, other than keeping the ulcer clean.

    Besides blood poisoning, the other infectious complications of pressure ulcers include local infections, skin infections, and bone infections. For about 25 percent of people with nonhealing pressure ulcers, the underlying bone is involved in the infection. More rarely, the infected ulcers may lead to infection of a joint or of the abdominal cavity. Pressure ulcers can also serve as reservoirs for significant infections involving bacteria that are resistant to normal antibiotics.

Prevention of Pressure Ulcers

When a person is identified as being at risk, either because of the presence of multiple risk factors or by other means such as the Braden Scale, preventive measures should be immediately taken. The traditional approach to prevention is to intermittently reposition the person to relieve pressure over the bony prominence. The standard recommendation is to reposition the person every two hours to help prevent these injuries. The frequency of repositioning depends upon whether the support surface decreases the pressure on the bony prominence.

    People who are highly susceptible to pressure ulcers should be repositioned alternately from the back to the right side or to the left side, in such a way that the person's back is at a 30-degree angle to the support surface. This regimen avoids direct pressure on the bony prominence of the lower back, hips, heels, and ankles. These sites account for 80 percent of all pressure ulcers. In contrast, lying with the back at a 90-degree angle to the support surfaces exposes the lower back and ankles to significant pressure. Pillows placed between the legs, behind the back, and supporting the arms can help in maintaining good positioning.

    Although one should not rely on a pressure-relieving device such as a low-pressure mattress or support surface as a substitute for good care, these devices are certainly recommended for all who are at high risk for pressure ulcers. These devices can also reduce the frequency of required repositioning. Even when a device to reduce pressure is used, the skin over a bony prominence should be observed every two to four hours, and at the first sign of redness that does not turn white to pressure, more frequent repositioning or an alternative device should be considered.

    There are a number of products and devices marketed in the United States for the prevention and treatment of pressure ulcers. These include sheepskins, foam pads, air mattresses, water- or gelfilled mattresses, and heel and elbow protectors. Doughnut-type cushions should not be used because they decrease the blood flow to the skin in the center of the cushion.

The Assessment of Pressure Ulcers

The appropriate management of a person with pressure ulcers requires assessment and treatment of underlying conditions that may be contributing to immobility, impaired nutritional status, and incontinence. The size, number, location, and stage of pressure ulcers should be recorded, and any evidence of infection such as a milky drainage, fever, foul odor, or surrounding redness of the skin should be noted. The doctor's and nurse's assessment often includes determining the deepness of the ulcers by gently pushing around the edge and probing with a clean cotton swab.

    Underlying bone infection may also lead to a nonhealing pressure ulcer, but identifying this disorder beneath a pressure ulcer can be difficult. There is no foolproof way other than bone biopsy to determine this condition. Other procedures such as X rays, bone scans, and blood tests are less reliable by themselves. If the white blood cell count is elevated in association with an elevated erythrocyte sedimentation rate (a blood test of inflammation) or an unusual X ray, an underlying bone infection is a strong possibility. If none of these tests is abnormal, an underlying bone infection is highly unlikely.

Treatment of Pressure Ulcers

Attention to the person's nutritional status is especially important in managing pressure ulcers. Protein intake is one of the most important predictors of pressure ulcer healing. The adequate intake of vitamins and minerals, especially zinc and vitamin C, also appears to be an important factor in the healing process. Antibiotics given under a doctor's supervision are required for people with blood poisoning, infections in the skin or of the underlying bone. Antibiotics are also given to prevent the infection of diseased heart valves or in cases that require surgical removal of dead tissue around the ulcer. It is very important that a person use gloves in handling any infected material from the ulcer because of the potential for transmitting infectious organisms from the pressure ulcer.

    Because people with pressure ulcers are at high risk for additional skin breakdown, the relief of pressure at the site of skin ulceration is absolutely essential. Attention to all the preventive measures listed earlier is also particularly important. This approach should help resolve early stage 1 pressure ulcers. The goal of local care for stages 2 through 4 pressure ulcers is to lower the number of bacteria so that healing can take place. Some people have reported dramatic results when granulated sugar is applied to the ulcer. Other ways to remove infected material include irrigating the wounds with whirlpool-type treatments or by means of dental-type irrigation devices.

    As soon as the ulcer is clean and healing begins, a moist environment should be maintained without disturbing the healing tissue. Stage 2 ulcers generally heal by migration of cells from the borders of the ulcer while deeper stages 3 and 4 ulcers heal as tissue fills the base of the ulcer. Various dressings allow vapors to escape and to permit the accumulation of body fluid on top of the wound. To avoid hurting normal tissues, the moist dressing should be kept off the surrounding intact skin.

The Use of Special Beds and Mattresses

The air or foam mattresses used to prevent pressure ulcers should also be used for most people who have pressure ulcers. Some people may require a more expensive special bed such as an air-fluidized one. These beds contain small particles that are suspended in warm, pressurized air so that they take on the characteristics of a fluid. As the person floats on these particles, the pressures underneath a bony prominence are reduced. It is uncommon to achieve complete healing of pressure ulcers with this therapy. These beds can be expensive to buy or rent. There are some special beds available that automatically reposition immobilized people. These tend to be even more expensive than air-fluidized beds.

Surgery for Pressure Ulcers

There are many surgical procedures for the treatment of pressure ulcers, including closing of the ulcer margins, skin grafts, and flaps. The person's ability to tolerate rehabilitation and the surgical procedure should be carefully assessed before considering these procedures.

    A number of experimental treatments have been advocated including high-pressure oxygen and electrical stimulation of the wound margins. In addition, a number of growth factors and nutrient solutions are being developed to stimulate wound healing. Lasers may facilitate removal of dead tissue in or around the ulcer. Despite the potential effectiveness of these treatments, prevention of the pressure ulcer remains the best approach to the problem.

Psoriasis

Psoriasis, a skin condition producing a red patch covered with a silvery scale, affects between 1 and 3 percent of the entire population and probably has a similar incidence rate in older people. The basic problem in psoriasis is that the skin growth is too rapid.

Symptoms of Psoriasis

The first patches of psoriasis may appear at any age, but once they are present, psoriasis usually persists indefinitely with a course that tends to wax and wane. The extent and severity of the disease varies widely among older people. Fortunately, for most people the disease is relatively limited and typically consists of a well-defined scaly red plaque on the elbows or knees. Sometimes this is accompanied by scaling of the scalp or pitting of the fingernails. These pits are small depressions that look as though the nail had been pricked with a pin. Sometimes the areas of psoriasis appear on skin injured several days earlier (for example, on the site of a burn or a surgical scar). This is called Kobner's phenomenon (for the 19th-century German dermatologist, who first described it). In older people, psoriasis commonly develops in body folds such as the buttocks, with or without cracking, and especially in those who are overweight. Such areas can be painful. For some people the plaques of psoriasis are itchy but for most people this is not the case. Extensive disease is marked by the rapid loss and replacement of skin surface layers, which involves a constant shedding of the protein-rich scales from the skin's surface. This can create a substantial increase in the person's dietary protein requirements. The whole body surface may become covered with psoriasis, causing severe chills because the body is no longer able to regulate its temperature. In people with heart disease, congestive heart failure can occur.

Treatment of Psoriasis

Treatment for psoriasis must be individualized and is based on the location and extent of the disease. An additional factor is the person's willingness and ability to comply with the treatment. In limited psoriasis with only a few plaques, topical corticosteroid creams or ointments rapidly decrease the scaling and often provide marked improvement. Usually potent corticosteroids are required for patches on the trunk of the body and the limbs, but nothing stronger than hydrocortisone should be used for areas on the face or body folds. A wide variety of other products derived from tar and anthralin are available. Physician-supervised phototherapy (exposure to artificial light containing ultraviolet and infrared rays) or even casual sun exposure is helpful and avoids the need for applying medication to individual plaques. For very extensive psoriasis, more aggressive therapy is warranted.

Shingles

Shingles is a specific type of painful skin rash caused by the reactivation of the herpes zoster (chickenpox) virus. The rash is most commonly seen in older people or in people with impaired functioning of the immune system.

Symptoms of Shingles

The first signs on the skin are little grouped blisters, called vesicles, that sit (like dewdrops on a rose petal) on a linear patch of reddened skin. After several days, the vesicles begin to form scabs and dry out. These areas begin to heal after about four weeks. Sometimes shingles can be suspected before the skin blisters appear because a person will feel a burning pain or a sense of heightened skin sensitivity that feels as if it follows a thin line along one side of the body. This is, in fact, a line following the distribution of spinal nerves and is called a dermatome (see Figure 15). Shingles usually gets better on its own in older people who otherwise have normal immune function. Significant pain after the skin rash resolves, however, is experienced by many people following an acute attack.

Treatment of Shingles

Soaking these areas with various solutions will help treat the vesicles. Until crusting occurs, a soft cloth dampened with a solution such as Domeboro should be placed over the scabs and vesicles for 10 to 15 minutes several times a day. The area should be carefully observed for evidence of bacterial infection, which requires treatment with antibiotics should it occur.

    Drug therapy for shingles remains controversial, although some experts recommend high doses of corticosteroids. Corticosteroids can help reduce the facial swelling around the eye that is associated with shingles that involves the optic nerve. While the complications of corticosteroids appear to be uncommon, corticosteroid therapy must always be used cautiously in older people. Several studies suggest that acyclovir, a well-tolerated but expensive antiviral drug, can reduce the pain and hasten the healing of shingles. Older people with known problems of their immune system clearly benefit from this treatment.

    The treatment of the residual pain that can linger after a bout of shingles is problematic. Many approaches have been tried, ranging from the use of oral antidepressants to spinal nerve blocks, acupuncture, and capsaicin (a cream derived from red chili peppers), but none has gained wide acceptance.

Skin Cancers

More than 600,000 cases of skin cancers are reported each year in the United States and many more are probably treated without being documented.

Cause of Skin Cancers

Most of these skin cancers appear to be caused by exposure to sun. There is compelling evidence that more than 90 percent of basal cell cancers, about three-quarters of squamous cell cancers, and a large proportion of melanomas are sun-induced. In parts of the South and Southwest, the annual individual risk for developing skin cancer exceeds 3 percent among white individuals over the age of 65. The likelihood of having a skin cancer increases at least through the age of 80. The rapid and continuing increase of all forms of skin cancer, especially melanoma, is attributed to the increased total lifetime sun exposure by a large portion of the population. This probably results from such factors as more revealing bathing suits and winter vacations in sunny climates. This situation could be compounded by a decrease in the earth's ozone layer, which is responsible for absorbing the ultraviolet radiation in sunlight that can cause skin cancer.

Prevention of Skin Cancers

Because of this increase in sun-induced skin cancer, its prevention is a major public health issue. Ideally, protection from the sun should begin in childhood. Since disability and mortality are directly related to the size and depth of a malignancy, early detection is the second most important goal. The entire skin surface should be regularly examined for darkened lesions that are larger than 5 millimeters (1/4 inch) in diameter, having variable color such as red, white, blue, and shades of brown, or having an irregular (notched) contour or surface. Ulcers and bleeding are signs of serious disease. Any suspicious-looking areas should be biopsied. Clearly, a dermatologist or a physician experienced in melanoma diagnosis should be involved. Complete removal constitutes the treatment for potentially curable lesions with the character and location of the melanoma determining the width of the margin.

Types of Skin Cancer

Basal Cell Carcinoma. Basal cell carcinoma, by far the most common human malignancy, is generally found on the body surfaces that have received the most sun. It looks like a pearly dome-shaped growth with prominent small blood vessels. As the tumor enlarges, a central ulcer may occur. This tumor grows by direct extension and hardly ever spreads to distant sites. However, untreated tumors can cause extensive destruction of the surrounding tissues. The treatments are tailored to the site and the cell type. Cure rates exceed 95 percent for most treatments.

Squamous Cell Carcinoma. Squamous cell carcinomas can occur in sites of chronic ulceration and radiation damage, but the vast majority are related to sunlight exposure. These skin cancers show far less tendency to metastasize than those attributed to other causes. Squamous cell cancers may show themselves as a scaly red bump, a plaque, or a nonhealing ulcer. For tumors that have not metastasized, the treatment and outlook are similar to that of basal cell cancers.

Melanoma. Melanoma is the most dangerous form of skin cancer and its prognosis depends strongly upon the depth of invasion. A five-year survival for a melanoma entering but not filling the full skin layer is better than 95 percent. Among people in whom the melanoma has entered the body fat, 40 percent have a five-year survival rate. Melanoma that has metastasized is rarely cured, and the survival rate depends upon the type of melanoma involved. Most melanomas are found in middle-aged people, but the incidence of the disease continues to increase until about the age of 90. As in all age groups, the superficial spreading melanoma is the most common type of melanoma in elderly people. Overall, after correcting for the type of melanoma and the depth of invasions at the time of diagnosis, the prognosis for melanoma does not appear to depend on the person's age.

Skin Changes Due to Poor Circulation (Stasis Dermatitis)

A change in the skin due to poor circulation is called stasis dermatitis. This condition is due to a deterioration in the veins resulting in increased venous pressure.

Symptoms of Stasis Dermatitis

Stasis dermatitis affects the lower legs, and in the early stages the skin has very itchy, small purple dots about the size of a pinhead. These areas represent points where blood has leaked from the capillaries because of the increased pressure in the veins. Over the course of time, the skin surface of the lower legs develops a red-brown color and may become shiny and feel bound down. The legs may swell with fluid, although this is not always the case. The presence of fluid can be detected by pressing a finger onto the skin over the ankle. If a deep fingerprint is left when the finger is taken away, then fluid is present. Sometimes minimal trauma to these skin areas can produce ulcers that do not heal well because of the impaired circulation.

Treatment of Stasis Dermatitis

The ideal treatment of stasis dermatitis would be to correct the increased pressure in the veins, although this is rarely possible. The immediate goal of treatment is to help reduce the pressure in the veins. This is sometimes accomplished by using support stockings or other forms of external pressure to help push the fluid back into the vessels. Raising the legs above the level of the heart intermittently is also helpful. Physicians sometimes prescribe hydrocortisone ointments to improve the itching and the irritation. Using these ointments over a long period of time can actually cause the skin to thin; therefore, their use should be minimized. It is very important to prevent injury to the lower legs to avoid ulcer formation. People who have stasis dermatitis should see their doctors right away for even apparently small ulcers. Treatment of an ulcer in the lower leg is best managed by a physician; home remedies or neglecting these ulcers can lead to rapid enlargement and significant complications.

Skin Infections

Any of the common skin infections that may be seen in the general population, such as boils or fungal disease, may also be seen in elderly people. However, two particular skin infections are especially relevant in the older person. These are erysipelas and cellulitis. (See also Infections in Chapter 26.)

Erysipelas

Erysipelas (from the Greek, meaning "red skin," also known as St. Anthony's fire) occurs usually in very young and very old debilitated people. In older people the infection is especially severe because it usually involves the face. This skin infection can be complicated by significant eye problems, blood clots within the head, or blood poisoning (septicemia). The infection is characterized by a red, warm, tender area that has a raised, swollen, well-defined border. Occasionally, small blisters may be seen. Generally, older people are very ill with fever, chills, headache, and general distress.

    The diagnosis of erysipelas is normally made by a physician recognizing the characteristic appearance of the skin. Blood cultures are often obtained to determine if the infection has spread to the bloodstream. Intravenous antibiotics are immediately given until the results of these cultures are known. Like other infections in older people, this is a serious problem and a physician's supervision is urgently needed.

Cellulitis

Cellulitis is a sudden, red skin rash that initially involves the uppermost layers of the skin. Eventually, it can spread to the deeper structures below the skin. It's found anywhere on the body but is most frequently seen on the legs of older people, usually as the result of trauma, poor circulation, diabetes mellitus, or edema. The source of the infection in the legs is most often a crack in the skin between the toes. It is also a common complication of infected pressure ulcers, bites, scrapes and scratches, puncture wounds, and surgery. Typically, the rash appears red, tender, warm, and swollen, but with no elevation or distinct borders.

    Cellulitis is caused by any number of microorganisms that vary according to circumstances--that is, whether the disorder is associated with pressure ulcers, diabetic foot ulcers, human bites, or surgery. People with very poor immune systems are also at risk for cellulitis.

    A physician will diagnose cellulitis based on the clinical appearance of the involved skin. Blood cultures are warranted in persons sick enough to require hospitalization and intravenous antibiotics. Older persons with cellulitis who are otherwise generally well and do not have involvement of the face, can sometimes be treated without hospitalization. In these cases oral antibiotics are generally given.




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