Dermatologic

Problems in Geriatrics

Diana Muchsin
PERUBAHAN KULIT
di usia tua
ETIOLOGY

Intrinsik:
muncul pada setiap individu dan
berhubungan dengan perubahan genetik
pada proses sel.
Extrinsik:
dihasilkan oleh penyebab ekstrinsik (yaitu
UV exposure, rokok, polusi lingkungan )
GANGGUAN KULIT DALAM
KAITAN USIA:
BERHUBUNGAN DENGAN....
• Mobilitas berkurang
• Innate cutaneous age-related changes
• Drug induced disorders
• Penyakit Kronis (contohnya Diabetes, CHF,
HIV)
• Perubahan seluler di epidermis dan struktur
di bawahnya
 PERUBAHAN SELULER PADA
PENUAAN KULIT:
• Berubahnya metabolisme lipid lemahnya kemampuan pulih dari
luka
• Keratinosit melempem  lemahnya kemampuan pulih dari luka
• Kepadatan melanosit berkurang menurunnya proteksi terhadap
UVR
• Kepadatan sel-sel Langerhans berkurangfungsi imun berkurang
• Kehilangan jaringan elastik dan kolagen kerutan dan kerapuhan
kulit
• Menurunnya fungsi saraf kulit, mikrosirkulasi and kelenjar keringat
termoregulasi buruk
• Berkurangnya lemak subkutan pada ektremitas distal berkurangnya
“bantalan” untuk proteksi trauma
 FAKTOR YANG
MENINGKATKAN RISIKO
• Kulit rapuh (abrasi, teriris)
• Purpura traumatik (memar)
• Ischemia (kematian sel, decubitus)
• Xerosis (kulit kering)
• Infeksi
• Kanker kulit
• Ulkus Dekubitus
stadium III
dengan
nekrosis
• di sakrum

ULKUS DEKUBITUS
ULKUS DEKUBITUS
• Biasanya muncul di atas prominens tulang
• Disebabkan karena iskemia, sehingga terjadi kematian sel dan
kerusakan jaringan.
• Berkaitan dengan adanya :
• tekanan
• mencukur
• gesekan
• Sering dengan infeksi sekunder, menyebabkan:
• Selulitis
• Osteomyelitis
• Sepsis
 • Lansia, khususnya pasien yang dirawat dan terus berbaring
• Pasien dengan perawatan kritis
• Pasien onkologi
• Diabetes
• Psien dengan penyakit jantung, hati dam ginjal stadium akhir
• Pasien dengan fraktur femoral
• Pasien inkontinensia
• Pasien dengan status mental lemah
• Pasien dengan status gizi kurang/buruk

PASIEN BERISIKIO TINGGI

ULKUS DEKUBITUS
STADIUM ULKUS DEKUBITUS
STADIUM ULKUS DEKUBITUS
Stadium I Eritema tidak pucat pada kulit intak

Stadium II Keterlibatan superfisial atau sebagian

ketebalan dari epidermis atau dermis

Stadium III Nekrosis dalam dengan kehilangan seluruh

ketebalan kulit, namun tidak sampai fascia.

Stadium IV Nekrosis luas hingga ke fascia, dapat meluas

ke otot, tulang, dan struktur yang
mendasarinya,
TATA LAKSANA ULKUS
DEKUBITUS
• Tergantung stadium
• Mulai dari pembersihan dan aplikasi salep pelindung dan
pembalut khusus hingga debridemen jaringan nekrotik secara
bedah.
• Memberi agen topikal dan pembalut khusus yang digunakan
• Memberi suplemen nutrisi, vitamin, dan mineral, setelah
berkonsultasi dengan ahli gizi, ketika penyembuhan luka
tertunda
• penatalaksanaan nyeri yang tepat untuk nyeri yang berkaitan
dengan perubahan pembalut dan nyeri kronis yang dapat
menurunkan mobilitas
• Infeksi sekunder harus diobati dengan antibiotik sistemik,
BUKAN formulasi topikal
• Dressing yang dapat digunakan untuk penderita
rawat jalan, yaitu:
 Kasa (dressing basah hingga kering)
• Debridemen mekanik
• harus dilakukan setidaknya 3x sehari (untuk menghindari
kekeringan yang berlebihan)
• berhenti begitu luka sebagian besar bersih atau jaringan
granulasi akan dihapus
 Dressing Oklusif sederhana (e.g. Opsite)
• Berguna untuk mencegah kerusakan kulit di area rentan, atau
mencegah kerusakan lebih lanjut di area stadium I
• Semipermeable - memungkinkan pertukaran gas dan
mencegah mikroba
• Mengizinkan inspeksi visual area luka melalui pembalut
• Lembut pada kulit yang sehat saat dihilangkan dengan benar
• Jangan pernah gunakan pada luka yang terinfeksi
TATA LAKSANA ULKUS
DEKUBITUS
 Dressing Hydrocolloid (mis. Duoderm)
• Jaga agar tempat tidur tetap lembab
• Memberikan absorban untuk luka dengan eksudat minimal
• Berikan untuk proteksi termal
• Jarang diganti tergantung pada luka (2-7 hari)
• Semipermeable - memungkinkan pertukaran gas dan menjaga
mikroba keluar
• Tersedia dalam bbrp Bentuk berbeda untuk bagian tubuh yang
berbeda (mis. Sacrum)
• Perekat lembut untuk kulit sehat ketika diangkat/diganti
• Tidak digunakan untuk luka infeksi
TATA LAKSANA ULKUS
DEKUBITUS
 Dressing yang diresapi (mis. Mesalt,)
• Berikan tekanan osmotik
• Menyediakan lingkungan yang menghambat pertumbuhan
bakteri di dasar luka (kadar garam tinggi)
• Seharusnya hanya digunakan pada luka dengan eksudat
dalam jumlah besar (untuk menghindari pengeringan luka)
• Ubah setidaknya 2x sehari
• Dapat digunakan pada luka yang terinfeksi
TATA LAKSANA ULKUS
DEKUBITUS
Dressing absorben(mis. Busa, kalsium alginat)
•Bahan dengan daya serap tinggi untuk mengontrol
eksudat luka
•Terdapat berbagai bentuk dan dapat digunakan untuk
mengemas luka dan / atau sebagai lapisan luar
•Memberikan perlindungan termal pada luka
•Biarkan pembalut luka bersih diganti lebih jarang
•Sering digunakan bersama dengan pembalut yang
diresapi untuk mengontrol kelembaban
• Topical treatments may include:
• Saline
• Used to cleanse the wound and debride necrotic material (wet-to-dry,
syringe irrigation)
• Commercial wound cleansers (instead of saline)
• Hydrogels/Xerogels
• Keep dry wound beds moist to promote healing

TREATMENT OF DECUBITUS
•

•
Allow longer periods between dressing changes
Act as gentle packing to encourage healing by intention

ULCERS
• Topical treatments may include:
• Silver sulfadiazine creams/gels/solutions
• Some antibacterial properties to  wound colonization (biofilm theory)
• May reduce odour in infected wounds
• May alleviate some pain in wound bed
• Help to keep the wound bed moist
• Sulfa based antibiotic creams
• Antibacterial properties to  wound colonization (not used for true wound
infections)
• Help to keep the wound bed moist
TREATMENT
• OF
Other antiseptics (e.g. Dakin’s DECUBITUS
Solution, Chlorhexadine) may be
ordered but do not offer any advantage over saline, do not promote
wound healing and should be avoided
ULCERS
The pharmacist should support the efforts of the healthcare team to
prevent decubitus ulcers and encourage caregiver compliance with
preventative strategies
• Encourage mobility as appropriate (manage pain)
• Turning schedules for bedbound patients (q2h)
• Pressure reducing mattresses and wheelchair cushions (egg crates
and sheepskin are comfort measures only; they do not reduce
pressure)
Keep skin dry and clean(control wound drainage, incontinence and
PREVENTION IS KEY…
•
other sources of moisture)
• Minimize physical restraint use
• Assess skin daily and keep intact skin in good condition using
barrier creams, moisturizers and emollients
XEROSIS
Xerosis (dry skin) is characterized by:
• Pruritus (itchiness)
• Dryness
• Cracks
• Fissures (like cracked porcelain)
•
XEROSIS
Occurs mostly on the legs (but sometimes hands and trunk)
• Excoriation (from scratching) leading to infection or dermatitis
• Dry air e.g. low winter humidity
• Exposure to the wind
• Over-washing
• Reduction in production of natural moisturisers (sebum) in old age
• Diuretic medications
• Underactive thyroid gland
• CAUSES OF XEROSIS
Inherited factors
• A skin condition such as atopic dermatitis (eczema), psoriasis or
ichthyosis
• Any combination of these
• Occlusive moisturizers and emollients
• Oils, lotions, creams and ointments
Humectants, keratolytics and keratoplastics
•
TREATMENT OF XEROSIS
Urea, ammonium lactate, and alpha hydroxy products
•

• Non-pharmacologic management
• Oils of non-human origin, either in pure form or mixed with varying
amounts of water through the action of an emulsifier ,to form a lotion
or cream.
• Provide a layer of oil on the surface of the skin to slow water loss
and thus increase the moisture content of the stratum corneum.
• Should be used liberally and frequently
• Unscented, nonallergenic is preferable
OCCLUSIVE MOISTURIZERS &
• Preferably applied when skin is damp
• No EBM comparing different moisturizers.
EMOLLIENTS
• There is no '‘right’ moisturiser for all patients: the most suitable one
often having to be found by trial and error.
• Bath oil deposits a thin layer of oil on the skin upon rising from the
water.
• Lotions are more occlusive than oils. These are best applied
immediately after bathing, to retain the water in the skin, and at
other times as necessary.
• Creams are more occlusive again. Thicker barrier creams
containing dimeticone are particularly useful for those with hand
FORMULATIONS
dermatitis.
• Ointments are the most occlusive, and include pure oil
preparations such as equal parts of white soft and liquid paraffin or
petroleum jelly.
The choice of occlusive emollient depends upon the area of the
body and the degree of dryness and scaling of the skin:
• Lotions are used for the scalp and other hairy areas and for
mild dryness on the face, trunk and limbs.
• Creams are used when more emollience is required on these
latter areas.
•WHICH FORMULATION?
Ointments are prescribed for drier, thicker, more scaly areas,
but many patients find them too greasy.
• Humectant: a substance that promotes retention of moisture
• Keratolytic: a substance that softens keratin and improves the
skin's moisture binding capacity
• Keratoplastic: substances which normalize keratinization
• HUMECTANTS,
Many products have more than one of these properties
• All or some of these may not be tolerated by patients due to
KERATOLYTICS &
stinging and irritation

KERATOPLASTICS
• Hydrating effects – urea is strongly hygroscopic (water-loving) and
draws and retains water within skin cells
• Keratolytic effects – urea softens the horny layer so it can be easily
released from the surface of the skin
• Regenerative skin protection – urea has a direct protective effect
against drying influences and if used regularly improves the
UREA
capacity of the epidermal barriers for regeneration
• Irritation-soothing effects – urea has anti-pruritic activity based on
local anaesthetic effects
• Penetration-assisting effects – urea can increase the penetration of
other substances, e.g. corticosteroids as it increases skin hydration
• Symptomatic relief of dry skin by increasing moisture capacity of
stratum corneum.
• Have also been shown to reduce excessive epidermal
keratinization in patients with hyperkeratotic conditions.
•
AMMONIUM LACTATE &
Loosen the glue-like substances that hold the surface skin cells
to each other, therefore allowing the dead skin to peel off.
•
ALPHA HYDROXY ACID
The mechanism of action of topically applied neutralized lactic
acid is not yet known.
PRODUCTS
Possible adverse reactions of both occlusives and
humectants/keratolytics include:
• Irritation (burning sensation, stinging) – usually caused by an
ingredient in the cream or lotion base
• Allergy - true allergies are rare
•
ADVERSE REACTIONS
Folliculitis - Over-occlusive emollients can result in blocked hair
follicles and painful pustules (folliculitis) or boils
• Reduce washing to every second day, or less often, although
the body folds may be sponged daily if desired.
• Baths or showers should be kept as brief as possible.
• Water should be lukewarm.
• Minimise the use of soap and avoid harsh cleansers. Use a mild
NONPHARMACOLOGIC
soap or better still, a detergent-based cleanser. Cleansers that
have the same pH as the skin (5.5) may be advantageous.
• MANAGEMENT
Reduce the need for bathing by keeping as clean as possible
• Humidify air in dry environments
Skin infections are common in elderly patients due to frequent skin
trauma, dermatitis, and impaired immunity, and may be:
• Bacterial (e.g. impetigo)
• Viral (e.g. varicella, herpes simplex)
• Fungal (e.g. seborrheic dermatitis, candida, tinea)

SKIN INFECTIONS
IMPETIGO
• Usually found near the mouth or nares, but may be anywhere on
the body
• May be bullous (staphylococal) or nonbullous (streptococcal)
• Treated with oral and topical prescription antibiotics
• IMPETIGO
OTC preparations are not effective
• Encourage good hygiene to avoid contact spread
• Confused elderly should be kept isolated until 48 hours of
treatment has elapsed
VARICELLA (HERPES)
ZOSTER
• Varicella or herpes zoster, also known as shingles, results from
reactivation of the dormant varicella zoster virus in adults, the same
virus that causes chickenpox in children.
• Vesicles
• usually appear along one dermatome (nerve path)
• rarely cross the midline
VARICELLA (HERPES)
• may crust over after several days
• usually dry out over 2-3 weeks
• ZOSTER
Post herpetic neuralgia may last from months to years after the rash is
gone
• OTC therapy will not treat the virus but may assist with symptom
management
• NSAIDs may be helpful in pain management in milder cases
• Antihistamines may be helpful to alleviate itching of the rash
• Hydrocortisone cream may be helpful to alleviate itching of the rash
• Antipruritic lotions (e.g. calamine) may also help to alleviate itch
• Capsaicin cream (e.g. Zostrix) may help with pain once the vesicles

•
OTC USE IN SHINGLES
have crusted over and also with post herpetic neuralgia
Ensure that the patient has sought medical treatment for the virus
itself and that OTC treatments are not contraindicated by other
medications or pre-existing disease
Dermatological fungal infections are highly prevalent in the elderly
and include:
• Seborrheic dermatitis
• Candida
• Tinea Pedis (Athlete’s Foot)
•FUNGAL INFECTIONS
Tinea Cruris (Jock Itch)
• Onychomycosis (Tinea Unguium nail infections)
SEBORRHEIC DERMATITIS
SEBORRHEIC DERMATITIS

• Caused by a combination of an over production of skin oil and

irritation from a yeast called malassezia.
• Usually found in sebaceous areas
• Scalp (called cradle cap in infants)
• Eyebrows
• Nasolabial folds
• Ears
• Chest
• Presents a reddened patches or plaque with greasy scales
• May be pruritic (itchy)
• May be related to nutritional deficiencies or disease states (eg.
Parkinsons, HIV)
SEBORRHEIC DERMATITIS

• Generally managed with OTC products

• Selenium sulfide
• Zinc pyrithione
• Coal tar
• Ketoconazole 2%
• Low potency topical steroids may be used in more severe
cases
CANDIDA
• Found mostly in skin folds where there is warmth,
moisture and skin to skin contact:
• Inguinal

• Between the fingers

CANDIDA
• Perianal

• Under the breasts

• Appears as a demarcated “beefy-red” eruption with

satellite pustules
• Often related to:
• Obesity

• Diabetes

• Immunosuppression

CANDIDA
• Chronic debilitation

• Occlusion under incontinence products

• Systemic antibiotic therapy

CANDIDA
• OTC Treatments may include
• Exposure to air

• Use of desiccants (Burrow’s solution, Castellani’s paint)

• Zinc oxide (topically)

• Topical azole antifungal agents BID

Miconazole
Econazole
Ketoconazole
Ciclopirox
• Antifungal powders may be used to dry the skin and prevent
maceration
• Terbinafine cream is NOT effective against Candida.
TINEA PEDIS
(ATHLETE’S FOOT)
• Caused by dermatophytes
• Presents with erythema, scaling and maceration
• 3 types:
• Interdigital – dry scaling between toes

• Moccasin-type – involves entire sole and sides of

TINEA PEDIS
foot
(ATHLETE’S FOOT)
• Vesiculobullous – plantar surface; usually the arch
• Usually treated with topical azole antifungals:
• Clotrimazole
• Ketoconazole
• Econazole
• Terbinafine
• Ciclopirox
• TINEA PEDIS
Systemic treatment reserved for extensive/persistent infections
•
(ATHLETE’S FOOT)
Oral treatment may be used for elderly patients who would
have difficulty seeing or reaching their feet to apply cream
• Prevention is key:
• Dry feet thoroughly after washing (especially between toes)
• Avoid walking barefoot in public places
TINEA PEDIS
• Wear cotton socks
• Intermittent application of antifungal creams, powders or sprays
(ATHLETE’S
may help prevent recurrencesFOOT)
TINEA CRURIS (JOCK ITCH)
• Presents as an itchy, red rash in the groin area
• Men are more likely to acquire this infection
• Treatments include:
• Reduce and control moisture

• Topical antifungals

•
TINEA CRURIS (JOCK ITCH)
Severe or resistant cases may benefit from oral
treatment
ONYCHOMYCOSIS
ONYCHOMYCOSIS
• Fungal nail infections usually caused by dermatophytes
• Trichophytons rubrum
• Trichophytons mentagrophyte
• Very few cases caused by Candida or molds
• Prevalence increases with age (nearly 20% of patients over 60 are
infected)
• Predisposing factors:
• Trauma
• Peripheral vascular disease
• Immunosuppression
• Diabetes
• Contiguous spread of tinea pedis
• Cannot be treated with OTC products
BLISTERING DISEASES
BLISTERING DISEASES
• Blistering diseases in the elderly are rare and may be immune-
mediated, drug-induced, or secondary to systemic illness.
• It can be fatal, even when treated
• Cannot be treated with OTC therapies
• Pharmacists should be aware that blistering diseases may
be drug-induced.
• Medication classes associated with blistering diseases
include
• Antibiotics
• Diuretics
• beta-blockers
• medications containing a thiol group (captopril, penicillamine, piroxicam)
Deficiencies in certain vitamins and minerals may present with skin
findings, and the elderly are at greater risk of poor nutrition due to:
• Chronic disease
• Physical limitations which hamper food preparation
• Poor food choices due to economic restrictions
• Delayed gastric emptying
• Slowed intestinal motility
NUTRITIONAL DEFICIENCIES
• Dry mouth
• Changes in taste perception
• Altered dentition
• Skin manifestations of vitamin C deficiency may be related to
defective collagen production.
• Common dermatologic concerns include:
• perifollicular hemorrhage
• gingival hypertrophy
• altered wound healing
• VITAMIN
Systemic findings C
swelling.
may DEFICIENCY
include fatigue, anemia, and joint

• Symptoms related to vitamin C deficiency may present after 3

months without vitamin C intake.
• In the elderly, malabsorption or malnutrition may lead to zinc
deficiency
• Highest risk is found in those with
• Long term parenteral nutrition
• Alcoholics
• Patients with cirrhosis
•
ZINC•
DEFICIENCY
Zinc deficient patients will present with
perioral or perianal erythematous, scaling plaques
• Nonhealing leg ulcers
• Hair loss
Skin findings may present when a patient is deficient in
• Riboflavin (B2)
Niacin (B3)
•

•
VITAMIN B DEFICIENCIES
Pyridoxine (B6)
Patients with Riboflavin deficiency may present with
• Angular cheilitis (Inflammation, burning, redness, and ulceration
or cracks at the corner of the mouth)
•

•
RIBOFLAVIN (B2) DEFICIENCY
Stomatitis (inflammation of the mouth lining)
Seborrheic dermatitis
• Patients with Niacin deficiency may present with dermatitis
• Those at risk for niacin deficiency include:
• Alcoholics
• Patients taking chronic antibiotic therapy
• Patients with cirrhosis
• Patients with carcinoid syndrome (Carcinoid syndrome is a
group of symptoms associated with carcinoid tumors --
tumors of the small intestine, colon, appendix, and bronchial
NIACIN (B3) DEFICIENCY
tubes in the lungs.)
• Patients with Niacin deficiency may present with seborrheic
dermatitis and photosensitivity
• Risk factors include:
• Alcoholism
• Cirrhosis
PYRIDOXINE (B6) DEFICIENCY
• Drug therapy: isoniazid, penicillamine & L-dopa
More than 50% of skin cancer-related deaths occur in persons over
65 years of age.
• Photocarcinogenesis due to sun exposure is a continuous and
cumulative process
• Decreased melanocyte density  decreased protection from

•
SKIN CANCERS
UV rays
Decreased Langerhans cells density  decreased immune
function
Can be divided into two main types
• Non-melanomas
• Rarely fatal but cause tissue damage and may become
invasive
SKIN CANCERS
• Usually caused by UV radiation, sunlight, and HPV
• Melanomas
• Most lethal skin cancer
• Rates increasing dramatically
Most common types are
• BCC (basal cell carcinoma)
• Most common type of skin cancer
• Do not metastasize
• Usually treated with surgery
•
NON-MELANOMAS
SCC (squamous cell carcinoma)
•Untreated may progress and become invasive
• Can metastasize to lymph nodes
• Usually treated surgically
• Most lethal skin cancer
• Rates increasing dramatically
• Four main types:
• Superficial spreading (most common)
• Nodular
MELANOMA
•

•
Lentigo (occurs only in the elderly)
Acral lentiginous
• Early excision is the only curative management
All members How to health-care
of the recognize a melanoma (ABCDE)pharmacists should
team, including
be aware A
of the ABCDE’s of melanoma
Asymmetrical in shape recognition.
B Border is irregular
MELANOMA
C Colour is not uniform; may have different
shades of black, brown, gray, red or white
D Diameter >6 mm (pencil eraser)
E Evolution of colour, shape, elevation, or size
in recent months
• Inconclusive evidence that sunscreen protects against skin
cancer – use it, but don’t rely on it
• this may be partly related to poor application or the fact that
people feel protected, so they stay out in the sun longer
• Intermittent exposure to sun seems to be the biggest risk factor
SKIN CANCER PREVENTION
(ie. Weekend exposure after working inside all week)
• The most effective preventative measures are to minimize sun
exposure (avoid sunburn and tanning) -- especially during peak
UV-B hours; seek out shade and cover up with hats, long
sleeves, and long pants
 The pharmacist has an important role in Geriatric Dermatology
• Stress the importance of non-pharmacological management for
prevention of decubitus ulcers, xerosis, and fungal infections
• Include all OTC and topical medications in medication
assessments
• Evaluate and recommend appropriate drug therapy (both
prescription and OTC)

THE PHARMACIST’S ROLE

• Monitor for drug-drug/drug-disease interactions
• Monitor for known dermatological side effects of drug therapy
• Consider additive effects of combined topical and oral
corticosteroid therapy
Overview of geriatric dermatology:
Sep 4, 2009
By: Cristina E. Bello-Quintero, MD, PharmD
Drug Topics

Impetigo Treatment & Management

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