Skin Ulcers in Older Patients

Christopher Frank, MD, CCFP, Department of Medicine, Division of Geriatrics, Queen’s University, Kingston, ON.

Skin ulcers are common among older adults, especially those in hospital or in long-term care facilities. Prevention of ulcers is important in all clinical settings. Clarifying the cause(s) and exacerbating factors is the first step in management. Pressure and venous insufficiency are the most common causes among older adults. Poor nutrition, edema, arterial insufficiency, and anemia may impair wound healing. Adequate debridement and cleaning is important to decrease infection risk and to promote healing. The choice of dressings depends on the needs of the individual wound but should emphasize the provision of a moist wound environment. Options for dressings are summarized.
Key words: skin ulcers, treatment, wound healing, older adults, pressure ulcers.

Nonmalignant Photodamage

Joseph F. Coffey, BSc, MD, PGY4 Dermatology, University of Alberta, Edmonton, AB.
Gordon E. Searles, OD, MD, MSc, FRCPC, Assistant Clinical Professor; Program Director, University of Alberta, Edmonton, AB.

As the population ages, the corresponding rise in incidence of skin cancer and photodamaged skin necessitate skin assessments of older patients in the dermatology clinic. Sallowness, wrinkles, solar lentigos, and other benign conditions reflect extensive ultraviolet damage to the skin, and provide a background of mutagenesis for skin cancer formation. Some treatments available for photodamaged skin are cosmetic and only available in a dermatology or plastic surgery office setting. However, there are many treatments that improve sun-damaged skin as well as prevent progression to skin cancer formation; these tools are available in the primary care physician’s office. This article addresses ablative and nonablative treatment options for sun-damaged skin and encourages the promotion of sun-safe behaviours, including use of protective clothing and sunscreen.
Key words: photoaging, therapy, prevention, cosmetic, nonablative, ablative.

Common Skin Infections in the Older Adult

Chamandeep Thind, MRCP, Department of Dermatology, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.
Simone Laube, MD MRCP, Department of Dermatology, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK.

Skin and soft tissue infections are an important cause of morbidity and mortality in older adults. Decreased immunity, changes in skin anatomy, and comorbidities contribute to an increased susceptibility to infections. Methicillin-resistant Staphylococcus aureus is an increasingly common problem in both the community as well as hospitals. Clinical features and management of some common skin infections encountered in this population are reviewed here. Local microbiological guidelines and drug susceptibilities should be taken into account in the treatment.
Key words: bacterial skin infections, cellulitis, MRSA, fungal infection, scabies.

Skin Neoplasias in Older Adults

John Kraft, HBSc, Medical Student, University of Toronto, ON.
Carrie Lynde, HBSc, Medical Student, University of Toronto, ON.
Charles Lynde, MD, FRCPC, Assistant Professor, Dermatology, University of Toronto, Toronto; Dermatology Consultant for Metropolitan Homes for the Aged in Toronto, Markham-Stouffville Hospital, and Scarborough Grace Hospital; Dermatologist, Dermatology Practice, Markham; Former President, Canadian Dermatology Association.

Skin neoplasias are more commonly seen in older patients. These skin diseases can frequently be more severe, particularly in long-term care residents. Common nonmelanoma skin cancers seen in these individuals include actinic keratoses, squamous cell carcinomas, and basal cell carcinomas. Benign neoplasias that are seen in older patients include seborrheic keratoses, skin tags, and classical Kaposi’s sarcoma. Treatment for neoplasias in the older adult are often not as aggressive as in younger patients.
Key words: actinic keratosis, squamous cell carcinoma, basal cell carcinoma, seborrheic keratosis, skin tag, classical Kaposi’s sarcoma.

Second Malignant Neoplasms

Miguel N. Burnier Jr., MD, PhD, FRCSC, Chairman, Ophthalmology, McGill University, Montreal, QC.
Vinicius S. Saraiva, MD, PhD, Fellow, Ocular Oncology & Pathology, McGill University, Montreal, QC.

Second malignant neoplasms (SMN) are nonmetastatic malignancies occurring in patients previously diagnosed with another malignant neoplasm. This clinical entity is becoming increasingly more frequent with the aging of the overall population and better diagnosis and treatment of cancers. Although a reasonable percentage of cases may be explained by genetic, iatrogenic, and/or shared environmental exposure, it is estimated that the majority of cases are sporadic. Recognizing the possibility of SMNs is essential for appropriate and timely diagnosis and treatment, but even more important for the development of preventive strategies.
Key words: oncology, second malignant neoplasms, ophthalmology, eye tumours.

Detection and Diagnosis of Cutaneous Melanoma

Patricia K. Long, FNP-C, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
David W. Ollila, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.

The incidence of melanoma continues to rise. The clinician needs to be familiar with characteristics of lesions more likely to be melanoma and be able to apply the “ABCDE” criteria. Additional imaging techniques such as digital photography and dermoscopy aid the clinician in deciding which nevi require biopsy. The techniques for biopsying cutaneous lesions vary, and clinicians need to be familiar with the various techniques. Once a cutaneous melanoma is diagnosed, the most important histologic feature of the primary is Breslow thickness.
Key words: melanoma, pigmented nevi, digital imaging, dermoscopy.

Preventive Skin Care for Older Adults

Barbara Brillhart, RN, PhD, CRRN, FNP-C, Arizona State University, College of Nursing, Tempe, Arizona, USA.

Prevention of and assessment for pressure ulcers and skin tears are the responsibilities of the client, family, caregivers, and the health care team. Prevention will avoid discomfort, disfigurement and decreased quality of life, and decrease health care expenses. Assessment includes use of the Braden, Gosnell, Norton, or Waterlow Scales for pressure ulcers and the Payne-Martin classification for skin tears. Factors to prevent pressure ulcers are pressure relief, prevention of shearing and friction, skin cleansing, plus adequate nutrition and hydration. Variables to prevent skin tears include nonbinding clothing, careful transfers, environmental protection, adequate nutrition and hydration, and individualized skin care.
Key words: pressure ulcers, skin tears, assessment, prevention.

Rosacea: Relieving a Chronic Inflammatory Facial Disorder

Maeve A. Mc Aleer, MRCP(UK), Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin, Ireland.
Frank C. Powell, MD, FRCPI, Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin, Ireland.

Rosacea is a common, but frequently misunderstood, skin condition. As it affects the face and is unsightly, rosacea can cause considerable social distress, especially because of the historical belief that alcohol is involved in its causation. This article outlines the clinical features of rosacea and the standard subtype classification of the condition. The theories of pathogenesis are outlined and the management approaches are discussed.
Key words: rosacea, classification, rhinophyma, ocular disease, management.

Care for the Skin of Aging Adults

It is common knowledge that the eyes are the key to a person’s soul. However, common knowledge is frequently wrong. Our first impression most likely comes from a person’s general appearance, particularly his or her skin. One just has to speak to a teenager with acne to understand the importance of skin to one’s self-image and that image as it is projected to others. The importance of “good” skin does not diminish with advancing age; hence, the increasing demand for cosmetic surgery and BoTox injections. Dermatologists and plastic surgeons can even become media personalities.

However, the skin is also a serious organ. Drs. Frank Powell and Maeve Mc Aleer have contributed our CME article on one of the commoner skin disorders afflicting older adults: “Rosacea: Relieving a Chronic Inflammatory Facial Disorder.” The skin is our largest organ and the first line of defence against a sometimes hostile environment. As with our other organs, it is also prone to dysfunction and disease, particularly if we do not care for it appropriately. We now know that environmental exposures are an important cause of skin dysfunction, and Barbara Brillhart gives us advice on how to prevent skin damage in her article “Preventive Skin Care for Older Adults.” John Kraft, Carrie Lynde, and Dr. Charles Lynde have contributed a general review article on “Skin Neoplasias in the Older Adult,” while Dr. David Ollila and Patricia Long discuss skin malignancy in their piece “Detection and Diagnosis of Cutaneous Melanoma.” Our final focus article covers “Second Malignant Neoplasms” by Drs. Miguel N. Burnier and Vinicius S. Saraiva.

As usual, we have a collection of articles on other topics. In our Cardiovascular Column, Drs. P.N. Sylaja and Philip Barber discuss “Thrombolysis for Acute Ischemic Stroke.” Our Nutrition Column, by Fatim Ajwani and Maria Ricupero, tackles the question “What’s the Skinny on Trans Fat?” Finally, Dr. Wilbert Aronow has provided our case study this month, entitled “An Older Woman with Peripheral Arterial Disease.”

Enjoy this issue,
Barry Goldlist

Malignant Photo Damage

Joseph F. Coffey, BSc, MD, Currently PGY4 Dermatology, University of Alberta, Edmonton, AB.
Gordon E. Searles, OD, MD, MSc, FRCPC, Assistant Clinical Professor; Program Director, University of Alberta, Edmonton, AB.

Accumulation of sun exposure is an important factor resulting in aging of the skin and development of cutaneous malignancy. Unfortunately, most people think of suntanning as a healthy, natural process, and damaging effects of the sun are not experienced until 15-20 years after the initial damage has been done. By the time we see patients in our clinic, the majority of our older clientele has extensive, irreversible photo damage and precursors of skin cancer. It is difficult to treat many of these patients as multiple lesions are frequently present, and patients are sometimes unwilling to initiate sun-protective measures, are not ideal surgical candidates, and may not comply with treatments suggested by the dermatologist due to financial burden. We emphasize the critical role of sun exposure as a cause of skin aging, benign stigmata of aging, and development of skin cancers. Treatment options including topical therapies, oral medications, surgery, and new-age technologies are discussed.
Key words: photo-aging, therapy, skin cancer, dermatoheliosis, melanoma.