Treatment Strategies for Pressure Ulcers

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic), Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Introduction
Pressure ulcers are areas of localized damage to the skin and underlying tissue caused by pressure, shear, friction, excess moisture, incontinence or abrasion. They usually occur over bony prominences such as the sacrum, heels, hips and elbows (Figure 1).

Pressure ulcers are associated with a significant burden of illness in the elderly and a significant financial burden to the health care system. In a recent study of a geriatric unit in Glasgow, the prevalence of pressure ulcers was 41%.¹ The incidence in acute care² has been estimated at 10%, and up to 60% of patients develop ulcers while in acute care hospitals.³ In one study, the prevalence of stage I-IV pressure ulcers in 1,960 acute care facilities in Canada from 1995-1998 was 11.2%.⁴ The incidence rate for home care is 15.4%.⁵ Approximately 45% of all pressure ulcers are probably preventable.

Annually, 1.7 million patients in the U.

Dry Skin in the Elderly Patient

Easy and Inexpensive Management

Dr. Scott Murray, MD, FRCPC, Dermatology, Assistant Professor Dermatology, Dalhousie University, Halifax, NS.

As you observe the geriatric patient, a variety of visual cues--posture, body habits, energy level and hair colour--can provide the observer with clues to the patient's age. However, in many ways it is the skin that is the first giveaway of the effects of aging. The skin is the most accessible organ for treatment and can be considered the parameter of aging most easily affected by intervention--at least cosmetically. As a result, there is huge interest in remedies to reverse age-associated skin changes. This has led to the development of an immense industry, both in medicine and in cosmetics, to defy these effects.

Skin Aging
Some changes to aging skin occur as a result of intrinsic effects such as genetics and racial types. There is little we can do to control these variables.¹ For instance, the variable ability of skin to deal with sun exposure is predetermined to some extent in this way. Some visual changes of the skin also result from sagging of underlying muscles (sagging) and repetitive motion (grooves or "laugh lines"). These lines add to the lines on the skin that we visually identify with advancing years.

Extrinsic factors such as ultraviolet light, nutrition, underlying illness, smoking and stress can also contribute to skin aging.

Bullous Pemphigoid

Marvin Lester, BA, MD, FRCPC, The Fitness Institute, Mississauga, ON.

Bullous Pemphigoid (BP) is essentially a disease of the elderly with the average age of onset usually in the sixties to seventies. However, this is not a hard and fast rule and it can occur in other ages, including children, although rarely.

BP is thought to be an autoimmune reaction, with circulating basement membrane zone (BMZ) and antibodies of the IgG class present in the majority of cases.

BP has occasionally been reported to be associated with other diseases including Ulcerative Colitis, Dermatomyositis, Diabetes Mellitus, Rheumatoid Arthritis and multiple autoimmune diseases involving organs other than the skin. Drugs have also been reported as possible causes for this condition and include medications such as Furosemide, Enalapril, Captopril, Penicillin and Sulfasalazine.

Clinical Features
The disease is characterized by large, tense, very firm, fluid-filled bullae as opposed to the more flaccid lesions that are seen in bullous diseases such as Pemphigus Vulgaris. In Pemphigus Vulgaris these may be widespread over the skin surface or may be localized to one part of the body including the groin, axillae and flexural surfaces of the forearms. Oral involvement has been reported and varies anywhere from 10-40%; usually an average of about 20% is quoted. Involvement of other mucosal surface such as the throat, nose, vulva, urethra and eye are not common.

Skin Cancer: A Review

John E. Adam MD, FRCPC, Professor of Medicine (Dermatology), University of Ottawa, Ottawa, ON.

The annual number of new cases of skin cancers reported in Canada is estimated to be about 40,000. With the aging of the baby boomer generation, this figure is anticipated to increase because of the ease of travel to the south in winter and increased exposure to the sun during outdoor activities. Dermatoheliosis or photodamage is most prevalent in people over 40 years of age who have had excessive sun exposure over their lifetime (Table 1). Epidemiological studies have identified sunlight exposure as the major risk factor for skin cancer.

There are three major types of skin cancer. The most common non-melanocytic skin cancers are Basal Cell Carcinoma and Squamous Cell Carcinoma. The less frequently occurring melanocytic skin cancer is Malignant Melanoma.

Basal cell carcinoma
Basal Cell Carcinoma (BCC) is the most common form of skin cancer but also the least likely to metastasize. It can be very destructive locally if not diagnosed and treated early.

Clinically it presents in several forms on sun-exposed areas (Table 2). The classic and most common presentation is the nodulo-cystic variety--a shiny elevated dome shaped nodule with a raised border often with telangiectatic blood vessels on the surface. The tumour is described as shiny or of a "mother-of-pearl colour.