Skin associated systemic disease

in elderly
Monsawan miniphan M.D.
3/02/2005
Scope of diseases
Skin associated common systemic
disease
Diabetes
Hyperlipidemia
Endocrine disease
Others

Malignancy of skin
Bacal cell carcinoma
Squamous cell carcinoma
Malignant melanoma



Skin and aging
Two basic theories of aging
Programmatic theory
Inherent genetic program
Stochastic theory
Cumulative environmental damage



Skin aging
Intrinsic aging
Universal
Inevitable change
Attribute to the passage of time alone
Photoaging
Superimpose on intrinsic aging
Attribute to the chronic sun exposure

Histologic features of aging skin
Epidermis
Flatted dermo-epidermal junction
Variable thickness
Variable cell size and shape
Occasional nuclear atypia
Fewer melanocyte
Fewer Langerhans cell
Dermis
Atrophy
Fewer fibroblast
Fewer mast cells
Fewer blood vessels
Abnormal nerve ending
Appendage
Depigmented hair
Loss of hair
Fewer glands
Abnormal nail plates
Histology of skin
Histology of aging skin
Functions of skin decline with age
Cell replacement Thermoregulation
Barrier function Sweatproduction
Chemical clearance Sebumproduction
Sensory perception Vit production
Mechanical protection DNA repair
Wound healing
Immune responsesive
Common skin disease in elderly
Benign neoplasia
Seborrheic keratosis : focal epidermal
homeostasis loss leading to increase
endothelin1
Variants of seborrhoeic keratoses
include
Solar lentigos: flat brown marks in
sun exposed areas
Stucco keratoses: numerous small dry
grey stuck-on lesions usually found
on lower legs and feet
Dermatosis papulosa nigra: numerous
brown warty papules on face and
neck of dark-skinned individuals

Solar lentigene
Stucco keratoses
Treatment
Removed : wish, uncertainty of the
correct diagnosis.
Methods used to remove seborrhoeic
keratoses include:
Cryotherapy. (liquid nitrogen)
Curettage & cautery.
Laser surgery
Shave biopsy (shaving off with a
scalpel)



Malignant neoplasia
Squamous cell carcinoma
Basal cell carcinoma
Malignant melanoma
UV induce DNA damage
Decrease DNA damage repair capacity
Basal cell carcinoma
the most common type of cancer in
humans
Affect adults, more common in elderly
Sun exposure
Grow slowly over months or years
Types of basal cell carcinoma
Nodular BCC
Superficial BCC
Morpgoeic BCC
Nodular BCC
Small translucent growth, rolled edges
May be pigmented
Ofte smaall blood vessels on surface,
bleeding spontaneous
NODULAR BCC
Superficial BCC
Multiple lesions
Upper trunks or shoulders
Slow growing patches, shiny pink, slightly
scaly, bleeding easy
SUPEFICIAL BCC
Morphoeic BCC
Skin-color, waxy, thicken scar
Most difficult to diagnosis
Prone to recurrent


MORPHOIC BCC
Treatment
depends on its type, size and location, the
number to be treated
Excision. The lesion is cut out and the
skin stitched up. This is the most
appropriate treatment for nodular,
infiltrative and morphoeic BCCs. Very
large lesions may require a flap or graft
to repair the defect after excision

Squamous cell carcinoma
Common type of skin cancer
Type of squamous cell carcinoma
In situ SCC
Invasive SCC
In situ SCC
One or more flat red scaly patches up to
several centimetres wide, often found in
large numbers on the lower legs. These
patches are also known as Bowen's disease
Malignant cell confine in epidermis
Causes of in situ SCC
Sun exposure
Immunosuppression
HPV
Arsenic ingestion
Ionizing radiation
BOWEN DISEASE
Invasive SCC
Develop in solar keratosis
Solar or actinic keratoses are common
small scaly lesions arising on the face,
ears and hands of white skinned
people who have spent many years
outdoors
Thickened or tender keratosis may be
developing into invasive SCC. SCCs
are often crusty and may bleed easily
On the lips, SCC is more common in
smokers


Develop in thermal burn scars and
longstanding leg ulcers
In genital areas, SCC are usually related
to infection with papillomavirus (genital
warts) or skin disease such as lichen
sclerosus or lichen planus vulvar cancer
Not usually a threat to life as secondary
spread (metastasis) is uncommon
SCC on the lip or ear appear to be the
sites most likely to metastasise, so
ulcers or lumps in these areas should be
taken particularly seriously
SQUAMOUS CELL CARCINOMA
SQUAMOUS CELL CARCINIMA OF LIPS
Treatment
Excision : the most common
treatment of invasive SCC
Cryotherapy
Radiation

Malignant melanoma
serious skin cancer which is curable if
detected early
Growth from melanocyte in epidermis or
mucous membrane
Common in 50-70 yr
Causes of melanoma
Sun exposure particularly during childhood
Serious sunburn, especially when young -
however, melanoma sometimes occurs on
areas of the body not normally exposed to
the sun
Family history of melanoma
Fair skin that burns easily - melanoma is
common in people with Northern European
ancestry, and is not common among dark-
skinned people
A large number of abnormal moles (called
atypical naevi). These moles are usually
larger than 6mm, with an irregular shape
and multicolours


The ABCDs of melanoma
A : asymmetry
B : border irregularity
C : colour variation
D : diameter > 6 mm
Superficial melanoma
Nodular melanoma
Treatment
Surgical removal
Sentinel node biopsy

Papulosquamous disorders
Psoriasis : change in patient
environment leading to koebnerization
systemic medication
Atypical presentation : flexural psoriasis
Drugs aggravated : b-blocker, NSAIDs, ACEi
Trigger factors : urinary incontinence,
hearing aids, braces



Flexural psoriasis
Xerosis
Disturbance of epidermal maturation
Decrease water content in outer layers
of stratum corneum
Dry , rough, skin
xerosis
Pruritus
Penetration of irritants through the
damage stratum corneum
Alter sensory threshold
Metabolic disorder
Endocrine disorder
Adversr drug reaction
Parasitic infestation : scabies
Infection
Compromised local cutaneous health
predispose to growth of infective
organism
Age-associated decreased immune
response
Underlying systemic disorder associated
with decreased immune response
scabies
Metabolic and endocrine disorder
DM
Renal failure
Thyroid disease
Hepatic disease
Lymphoma, leukemia, PV
Skin problems associated with diabetes
mellitus

Necrobiosis lipoidica
Rare, insulin dependent DM
One or more tender yellowish brown
patches develop slowly on the lower legs
over several months
Round, oval or an irregular shape
The centre of the patch becomes shiny, pale,
thinned
Prominent blood vessels (telangiectasia)
Often painless




Treatment

Tropical steroid, usually under a plastic
occlusive dressing
Intralesional steroid injections or steroid
tablet
Aspirin and dipyridamol combination
Pentoxifylline tablets
Oral cyclosporin
Photochemotherapy (PUVA)

Diabetic dermopathy
Their cause is unknown
Round brown or purple slightly
thinned patches seen on the shins of
diabetic patients
Similar lesions are sometimes seen in
non-diabetics
Treatment is not necessary or useful

Hyperlipidemia
Xanthomata
4 forms : tendinous subcutaneous
nodule found in fascia, ligament and
extensor tendon of hand, knee and elbow
Planar : yellow, soft, macule or plaque found
on the upper eyelids
Tuberous : yellow to reddish nodule at
extensor surface of elbows, knees and
knuckles
Eruptive : sudden, multiple reddish yellow
papule extensor of extremities, buttock

PLANAR XANTHOMA
ERUPTIVE XANTHOMA

Acantosis nigricans
Hyperpigmentation,
hyperkeratosis,velvety distribuion at
intertriginous area
Most common area : axilla, genitaria,
groin, popliteal fossa, anticubital and
neck
Associated condition
Insulin resistant related
Obesity
Pseudoacromegaly
DM
Polycystic ovarian disease
Malignancy related :
Adenocarcinoma : gastric
Melanoma
Sarcroma
Lung carcinoma : small cell,
squamous, bronchoalveolar
Lymphoma
Endocrine malignancy : carcinoid,
pheochromocytoma, thyroid,testicular
Wilm tumor
Drug induce
Somatotrophin
Testosterone
Nicotinic acid
OC
Corticosteroid
Idiopathic

Syndromes
Acromegaly
Addison
Cushing
Dermatomyositis
Down
Cirrhosis
Hypothyroid
SLE
scleroderma

Acanthosis nigrican
Vitiligo
Autoimmune disease, pigment cell are
destroyed
Irregular white patches on the skin
Any part of the body may be affect

Who is prone to vitiligo
At least 1% of all population
In general : good health
Greater risk : DM, thyroid, B-12 def.,
Addison, alopecia areata
Cause of vitiligo
Unknown
Autoimmune against the pigment cell
Treatment
Topical steroid
PUVA
vitiligo
Associated with cancers of the
esophagus, lung, breast, bladder,
stomach, and cutaneous T-cell
lymphoma

Erythroderma
Diffuse erythema of the skin usually
associated with induration and scaling
Associated with the leukemic phase of
cutaneous T-cell lymphoma (Sezary
syndrome)
Other malignancy associations: lung,
liver, prostate, thyroid, colon, pancreas,
stomach
Collagen Vascular Disease:
Dermatomyositis
Heliotrope erythema
Gottrons papules
Dermatomyositis

Malignancy risk may be as high as 15%
in women
No increase in malignancy risk with
polymyositis or childhood
dermatomyositis
Females over age 40 have a 32-fold
increase risk of ovarian cancer

Other disorders associated with malignant
disease
Pruritus
Sister Mary Joseph nodule
Erythema gyratum repens
Subcutaneous fat necrosis
Sweets syndrome

Hypertrichosis lanuginosa acquisita
Necrolytic migratory erythema
Leukoderma
Sign of Leser-Trelat
Sister Mary Joseph Nodule
Sister Mary Joseph nodule
Collective term for a metastatic deposit
at the umbilicus originating from any
primary malignancy
Appearance of this lesion usually heralds
advanced disease and has a poor
prognosis.
Attributed to Sister Mary Joseph
Dempsey who was the first surgical
assistant to William Mayo
Associated malignancies: stomach,
colon, ovary, pancreas

Sweets Syndrome (Acute Febrile
Neutrophilic Dermatosis)

Sweets Syndrome
Subtypes
Classic (71%)
Neoplasia (11%) hematologic
malignancies, usually AML
Inflammatory Disease (16%)
Pregnancy (2%)

Sweets Syndrome
Major Criteria (both required)
Abrupt onset of tender or painful erythematous plaques or nodules
occasionally with vesicles, pustules or bullae
Predominantly neutrophilic infiltration in the dermis without
leukocytoclastic vasculitis

Minor criteria (2 of 4)
1. Preceded by an nonspecific respiratory or gastrointestinary tract
infection or vaccination or associated with:
Inflammatory diseases as chronic autoimmune disorders, infections etc.
Hemoproliferative disorders or solid malignant tumors
Pregnancy
2. Accompanied by periods of general malaise and fever (>38C)
3. Laboratory values during onset (three out of four necessary):
ESR > 20mm n.W.,
C-reactive Protein positive,
segmented-nuclear neutrophils and stabs > 70% in peripheral blood
smear,
leukocytosis > 8.000
4. Excellent response to treatment with systemic corticosteroids or
potassium iodide
Necrolytic Migratory Erythema
(Glucagonoma Syndrome )
Necrolytic Migratory Erythema
Rare syndrome associated with a glucagon
producing alpha cell tumour of the pancreas
Associated findings: glossitis, stomatitis,
weight loss, hyperglycemia, anemia, alopecia,
diabetes
Diagnosis: angiography, octreotide scan
Resection of the tumor clears the eruption
Similar eruption may be seen with cirrhosis,
pancreatitis, celiac sprue, and zinc deficiency
Hypertrichosis Lanuginosa Acquisita
Acquired excessive growth of lanugo
(velus) hairs
Initially covers face and ears; may
involve all hair-bearing skin
Malignancy associations include colon,
rectum, bladder, lung, pancreas, breast.

Sign of Leser-Trelat
Sudden appearance of multiple
seborrheic keratoses
Association with internal malignancy is
unproven

Thank you