Evans cover SB 9/30/11 11:24 AM Page 1 With ageing populations, increasing numbers of H A COLOR HANDBOOK elderly patients will seek care for a variety of A skin conditions, ranging from eczema and NA DC psoriasis to benign lesions and skin cancers – BO SKIN DISEASES OL conditions that are more prevalent in the elderly OO KR and more problematic to treat. In this new color S handbook the authors deal systematically with K those skin conditions that are particular to or I IN THE more common in the elderly, covering testing, N diagnosis, and treatment options. D Following an initial chapter on how the skin I S changes with age, the authors discuss in turn E ELDERLY inflammatory, neoplastic, infectious and A metabolic/nutritional diseases of the skin, plus S skin signs of systemic disease in old age. E S Skin Diseases in the Elderlyis written in a I concise, structured style, and illustrated by a N COLBY CRAIG EVANS wealth of top quality color photos. It is intended T to help dermatologists in practice and training, H WHITNEY A. HIGH geriatricians, primary care physicians, specialist nurses, and senior medical students. E E COLOR HANDBOOK SERIES L D Acute Adult Dermatology: Creamer Dermatology, 2nd edition: Rycroft E R Endocrinology and Metabolism: Camacho L Gastroenterology, 2nd edition: Boulton Y Human Anatomy:McMinn Oral Medicine: Lewis Pediatrics and Child Health: Strobel E Pediatric Clinical Neurology: Bale V A Pediatric Clinical Ophthalmology: Nelson N Pediatric Rheumatology: Reed S (cid:2) Renal Medicine: Pattison H Skin Diseases in the Elderly: Evans IG H ISBN 978-1-84076-154-2 MANSON PUBLISHING A Color Handbook Skin Diseases in the Elderly Colby C. Evans, MD Evans Dermatology Partners Austin, Texas, USA Whitney A. High, MD, JD, MEng Associate Professor, Dermatology and Pathology Attending, Denver STD and HIV Prevention Clinic University of Colorado School of Medicine Denver, Colorado, USA MANSON PUBLISHING CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2012 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20150224 International Standard Book Number-13: 978-1-84076-615-8 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. 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Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com CONTENTS 3 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Other inflammatory conditions Abbreviations . . . . . . . . . . . . . . . . . . . . . .6 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Suggested Reading . . . . . . . . . . . . . . . . . .6 Pityriasis rubra pilaris . . . . . . . . . . . . . . . . .46 Seborrheic dermatitis . . . . . . . . . . . . . . . . .47 PART 1 Intertrigo . . . . . . . . . . . . . . . . . . . . . . . . . .48 Skin changes with aging Asteatotic eczema . . . . . . . . . . . . . . . . . . . .49 Age-related atrophy . . . . . . . . . . . . . . . . . . .8 Lichen planus . . . . . . . . . . . . . . . . . . . . . . .50 Solar atrophy . . . . . . . . . . . . . . . . . . . . . . . .9 Contact dermatitis . . . . . . . . . . . . . . . . . . .52 Bruising . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Nummular dermatitis . . . . . . . . . . . . . . . . .54 Xerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Urticaria (hives) . . . . . . . . . . . . . . . . . . . . .55 Varicosities . . . . . . . . . . . . . . . . . . . . . . . . .10 Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Lichen sclerosus . . . . . . . . . . . . . . . . . . . . .58 PART 2 Neurodermatitis/Prurigo nodularis/ Inflammatory skin disease Lichen simplex chronicus . . . . . . . . . . . .59 Chondrodermatitis nodularis chronica Autoimmune helicis . . . . . . . . . . . . . . . . . . . . . . . . . .60 Bullous pemphigoid . . . . . . . . . . . . . . . . . .14 Grover disease . . . . . . . . . . . . . . . . . . . . . . .61 Cicatricial pemphigoid Erythema annulare (mucous membrane pemphigoid) . . . . . .16 centrifugum . . . . . . . . . . . . . . . . . . . . . .62 Dermatomyositis . . . . . . . . . . . . . . . . . . . .17 Erythema nodosum . . . . . . . . . . . . . . . . . .63 Acute cutaneous lupus erythematosus (systemic lupus erythematosus) . . . . . . .18 Subacute cutaneous lupus erythematosus . . .20 PART 3 Neoplasms of the skin Discoid lupus erythematosus . . . . . . . . . . . . . . . . . . . .22 Malignant Scleroderma . . . . . . . . . . . . . . . . . . . . . . . .24 Basal cell carcinoma . . . . . . . . . . . . . . . . . .66 Pemphigus . . . . . . . . . . . . . . . . . . . . . . . . .26 Actinic keratosis . . . . . . . . . . . . . . . . . . . . . .68 Sjögren syndrome . . . . . . . . . . . . . . . . . . . .29 Squamous cell carcinoma . . . . . . . . . . . . . .70 Keratoacanthoma . . . . . . . . . . . . . . . . . . . .72 Neutrophilic dermatoses Malignant melanoma . . . . . . . . . . . . . . . . .74 Sweet syndrome . . . . . . . . . . . . . . . . . . . . .30 Sebaceous carcinoma . . . . . . . . . . . . . . . . .76 Pyoderma gangrenosum . . . . . . . . . . . . . . .32 Angiosarcoma . . . . . . . . . . . . . . . . . . . . . . .77 Kaposi sarcoma . . . . . . . . . . . . . . . . . . . . . .78 Allergic and hypersensitivty processes Cutaneous B-cell Drug eruptions . . . . . . . . . . . . . . . . . . . . . .33 lymphoma . . . . . . . . . . . . . . . . . . . . . . .79 Acute generalized exanthematous Cutaneous T-cell pustulosis . . . . . . . . . . . . . . . . . . . . . . . .35 lymphoma . . . . . . . . . . . . . . . . . . . . . . .80 Stevens–Johnson syndrome/Toxic Metastatic tumors and paraneoplastic epidermal necrolysis . . . . . . . . . . . . . . . .36 syndromes . . . . . . . . . . . . . . . . . . . . . . .82 Photorelated conditions Benign Polymorphous light Seborrheic keratosis . . . . . . . . . . . . . . . . . .83 eruption . . . . . . . . . . . . . . . . . . . . . . . .38 Sebaceous hyperplasia . . . . . . . . . . . . . . . . .85 Phototoxic/Photoallergic Angioma reactions . . . . . . . . . . . . . . . . . . . . . . . .38 (cherry angioma) . . . . . . . . . . . . . . . . . .86 Chronic actinic dermatitis (actinic reticuloid)40 Angiokeratoma . . . . . . . . . . . . . . . . . . . . . .87 Porphyria cutanea tarda . . . . . . . . . . . . . . . .42 Milium . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 Skin tags(acrochordons) . . . . . . . . . . . . . . .89 PART 5 Epidermoid cyst . . . . . . . . . . . . . . . . . . . . .90 Metabolic and nutritional disease Favre–Racouchot Scurvy . . . . . . . . . . . . . . . . . . . . . . . . . . .116 disease . . . . . . . . . . . . . . . . . . . . . . . . . .91 Cheilitis . . . . . . . . . . . . . . . . . . . . . . . . . .117 Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . .92 Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . .118 Syringoma . . . . . . . . . . . . . . . . . . . . . . . . .92 Zinc deficiency . . . . . . . . . . . . . . . . . . . . .119 Dermatofibroma . . . . . . . . . . . . . . . . . . . . .93 Pellagra . . . . . . . . . . . . . . . . . . . . . . . . . .120 Lentigo . . . . . . . . . . . . . . . . . . . . . . . . . . .95 Nevus . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96 PART 6 Fibrous papule . . . . . . . . . . . . . . . . . . . . . .99 Skin signs of systemic disease Verrucas (warts) . . . . . . . . . . . . . . . . . . . .100 Necrobiosis lipoidica (diabeticorum) . . . . . . . . . . . . . . . . . . .122 PART 4 Acanthosis nigricans . . . . . . . . . . . . . . . . .123 Infestations and infections Granuloma annulare . . . . . . . . . . . . . . . . .124 Parasitic Amyloidosis . . . . . . . . . . . . . . . . . . . . . . .125 Scabies . . . . . . . . . . . . . . . . . . . . . . . . . . .104 Stasis dermatitis . . . . . . . . . . . . . . . . . . . .126 Lice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 Leg ulcers . . . . . . . . . . . . . . . . . . . . . . . . .128 Leukocytoclastic vasculitis (hypersensitivity vasculitis) . . . . . . . . . . . . . . . . . . . . . . .130 Viral Xanthomas . . . . . . . . . . . . . . . . . . . . . . . .131 Herpes simplex . . . . . . . . . . . . . . . . . . . . .106 Erythema gyratum Varicella zoster . . . . . . . . . . . . . . . . . . . . .108 repens . . . . . . . . . . . . . . . . . . . . . . . . .132 Acrokeratosis neoplastica (Bazex syndrome)133 Bacterial Bacterial folliculitis . . . . . . . . . . . . . . . . . .109 Bacterial cellulitis/ Erysipelas . . . . . . . . . . . . . . . . . . . . . .111 Fungal Tinea . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 Candidiasis . . . . . . . . . . . . . . . . . . . . . . . .114 PREFACE 5 Geriatric dermatology and geriatric medicine in These trends foretell enormous change in general will grow exponentially in importance the practice of medicine. The mix of elderly during the coming years. As the average age patients in the practice of the average physician throughout the Western world rises steadily, will surely increase. The number of very elderly and life expectancies lengthen, more and more patients will also rise, potentially straining elderly patients will seek care for a variety of resources for geriatricians and long-term care skin conditions. facilities. Certainly some of these skin conditions are In dermatology, several trends will result as particular to, or at least more common in, these changes occur. While skin cancer can elderly persons. Other conditions may present occur at any age, most forms are decidedly at any age, but may represent diagnostic and more common after a lifetime of sun exposure. therapeutic challenges in the aged patient. As Non-melanoma skin cancer, in particular basal the number of elderly patients rises, these cell carcinoma and squamous cell carcinoma, challenges will become increasingly common will become more prevalent. As the aging for both the primary care physician and the process also hinders the retention of moisture dermatologist. in the skin, conditions exacerbated by dry skin Demographic data tell a concise story (such as psoriasis and eczema) may worsen. regarding the population of most Western Aspatients age, they also tend to accumulate countries – it is aging quickly. The United more benign skin lesions (such as seborrheic States Administration on Aging reports the keratoses or sebaceous hyperplasia). These number of persons >65 years of age will more benign lesions may lead to irritated examples than double to 71.5 million by 2030. In 2000, that require treatment and will need to persons>65 years of age represented just 12.4% be differentiated from more concerning of the total population, but this group will lesions. represent at least 20% of the population Treatment can also be more challenging in by2030. elderly patients. Older patients tend to take Similar findings were reported by the more medications, leading to the increased United Kingdom Office for National Statistics. potential for drug interactions. They may also In 2006, the fastest-growing segment of the have age- or disease-related decreases in liver or population in the United Kingdom was those kidney function and, therefore, have difficulty persons aged 85 years old and older, with a processing the drugs. Topical therapies can also record-setting 1.2 million people in this be more difficult to apply in the setting of category. From 1971 to 2006, the overall arthritis or visual decline. population grew 8% while the population of The purpose of this text is to discuss those persons>65 grew 31%. dermatologic conditions that occur in the Both the United States and United elderly patient. Its goal is not only to help the Kingdom experienced ‘baby booms’ in the practitioner diagnose and treat conditions in years following World War II. Large spikes in geriatric dermatology, but to also help target the birth rate at that time have led to large testing and therapy so that it is most useful numbers of people now preparing to enter in this special and rapidly growing patient elderly age. Advances in health care and population. increases in the average lifespan have worked also to increase the numbers further. ABBREVIATIONS 6 ABCD criteria asymmetry, border IVIG intravenous irregularity, color variation, immunoglobulin and diameter >6mm KOH potassium hydroxide AIDS acquired immune KTP potassium–titanyl– deficiency syndrome phosphate (laser) ANA antinuclear antibody LDH lactate dehydrogenase AST aspartate aminotransferase LDL low-density lipoprotein BSA body surface area MED minimal erythema dose CA-MRSA community-acquired MRI magnetic resonance methicillin-resistant imaging Staphylococcusaureus MRSA methicillin-resistant CBC complete blood count Staphylococcusaureus CK creatine kinase Nd:YAG neodymium-doped:yttrium CT computed tomography –aluminum–garnet (laser) (scan) NSAID non-steroidal ELISA enzyme-linked anti-inflammatory drug immunosorbent assay PCR polymerase chain reaction ENA extractable nuclear antigen PET positron emission ESR erythrocyte sedimentation tomography (scan) rate PUVA (oral) psoralen plus HHV human herpesvirus ultraviolet A HIV human immunodeficiency SSKI supersaturated potassium virus iodide HPV human papillomavirus TMP/SMX trimethoprim/ HTLV human T-cell lymphotropic sulfamethoxazole virus (co-trimoxazole) ICU intensive care unit UV ultraviolet Ig immunoglobulin SUGGESTED READING Bolognia JL, Jorizzo JL, Rapini RP. Wolff K, Goldsmith LA, Katz SI, Gilchrest Dermatology. New York: Mosby, 2007. BA, Paller A, Leffell DJ (eds). Fitzpatrick’s Burns T, Breathnach S, Cox N, Griffiths C Dermatology in General Medicine. (eds).Rook’s Textbook of Dermatology. New York: McGraw-Hill Professional, Oxford: Wiley-Blackwell, 2010. 2007. Habif TP. Clinical Dermatology: A Color Guide Wolverton SE. Dermatologic Drug Therapy. to Diagnosis and Therapy. London: Mosby, Philadelphia: WB Saunders, 2007. 2003. www.emedicine.medscape.com Rietschel RL, Fowler JF. Fisher’s Contact www.dermis.net/dermisroot/en/home/ Dermatitis, 6th edn. PMPH-USA, 2007. index.htm PART 1 7 Skin changes with aging 8 PART 1 Skin changes with aging Although elderly patients are prone to a 1 number of skin diseases, there exist also typical age-related skin changes that are not disease associated. Although these changes occur to all patients, should they live long enough, they can have profound effects on the proper function of the skin, and, hence, the patient’s correspon- ding quality of life. Age-related atrophy Skin atrophy is commonly seen in elderly patients, evidenced by thinning or fine wrinkling, easy tearing, and bruising. In sun-protected sites, this atrophy usually results in fine, ‘cigarette paper’ wrinkling of the skin (1&2). The skin isoften light in color compared with chronically sun-exposed skin. 2 Fat loss, especially on the face and hands (3), is quite common with age. Since the fat layer provides a cushion for blood vessels, they become more visible with time and more prone to bleeding with minor trauma. Fat loss, espe- cially in the face and hands, is also a common cosmetic concern for older patients. 3 1–3 Skin atrophy.