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The skin is the largest organ of the body and there are three layers:

1. Epidermis- outermost layer made up of stratified squamous epithelium cells (keratinocytes and melanocytes). The function is to protect the body against the environment, restrict water loss, and synthesize keratin cells. Accessories include sweat glands, sebaceous glands, hair and nails.
2. Dermis- blood vessels and nerve elements. Elastin, collagen, and reticulin fibers.
3. Subcutaneous- loose connective tissue and fat cells. Provides heat, caloric reserves, insulation, and shock absorber.

Protection

Minimize body fluid loss

Excrete wastes and toxins

Temperature regulation

BP regulation

Tissue repair

Synthesis of Vit.D

Sensory perception

Expression of feelings- through sweating, pallor or flushing.

Skin integrity is a key element in prevention of disease.

Age related changes:

Two types of predictable changes occur

1. Intrinsic aging-
1. Systemic decrease in circulation, loss of cells, loss of elastic collagen fibers, and loss of muscle mass. In addition, pressure and light touch sensors decrease with age predisposing them to mechanical and thermal injuries.
2. Subcutaneous fat atrophies on the face, shin and soles. It hypertrophies on the abdomen (men) and the thighs (women).
3. Decreased production of sweat, sebum, and vit. D
4. Delayed or diminishes cell replacement, response to injury, barrier function, chemical clearance, and sensory perception.
5. Pubic, axillary and scalp hair thins
6. Nails thicken but decrease in growth.

All of these changes can result in dryness, wrinkling, age spots, laxity, uneven pigmentation, and skin tags (acrochordons)

2. Photoaging – profound aging in skin exposed to the environment (sun). Most of the changes are preventable or reversible. Wrinkling, leathery texture, blotchiness.

1. Acrochordons: AKA skin tag- the most common benign skin lesion in the older adult. Usually found in the armpit, groin, or under women’s breasts. They do not pose a risk and can easily be removed.
2. Xerosis: AKA dry skin. It is the most common skin problem in the older adult. Caused by decreased moisture content and altered functioning of the sebaceous glands. Dry air and heat contribute to the problem. Itching can lead to inflammation. Treatment includes emollients with urea or lactic acid, increased humidity via humidifier; the use of bath oils is controversial because of the risk of falling in the tub.
3. Keratoses: Benign epidermal growth made up of keratinocytes and melanocytes. Transmitted as an Autosomal dominant trait and occur more frequently in Caucasians. They occur on the face, trunk and upper extremities they are usually yellow-brown to black. Treatment is optional but consists of topical steroids and cryosurgerical removal. Keep in mind that the occurrence of new or increased numbers of seborrheic keratoses are linked to internal malignancies.

Actinic keratotic lesions- most frequent skin tumor in the older population. Fair skinned people who have been exposed to sun damage are prone to getting this. They are small, light pink scaly patches that range from a few millimeters to centimeters in size. Watch carefully because 1% develops into a carcinoma. Treatment is cryosurgery, liquid nitrogen therapy, or topical treatment with fluorouracil solution or cream over a 2-4 week period. Clients need to avoid sun exposure or use sunscreen if tolerated.

1. Basal cell carcinoma- forms in the epidermis, is slow growing, and usually is detected early and treated. Metastasis is rare and it is associated with chronic sun exposure. They begin as papules, the borders are raised, and it is waxy in appearance. Frequently appear on the nose, cheek, or eyelid but can occur on the trunk. 80% of all skin cancers are basal cell carcinomas. Treatment is based on the location of the tumor, its characteristics and the age of the client. Treatment includes the following:
1. Surgical excision
2. Curettage-desiccation
3. Radiation therapy
4. Cryotherapy
5. Laser treatment
6. Microsurgery- has the highest cure rate, conserves normal tissue, requires only local anesthesia, and is less expensive than other forms of treatment.
2. Squamous cell carcinoma- is slow growing and first appears as a scaly lesion that may bleed or have an irregular shape. If detected early the prognosis is good if not it can metastasize. Treatment is the same as the treatment for basal cell carcinoma.
3. Malignant melanoma- a change in a mole or the development of bleeding should be investigated. Inspect the skin of the elder especially the back and legs because these are target areas. Treatment:
1. Confirm by biopsy
2. Deep surgical removal of the lesion
3. Chemotherapy
4. Possibly radiation therapy
5. Follow up exams

Pressure ulcer- an area of cellular necrosis. They develop when external pressure on the skin covering bony prominences exceeds capillary hydrostatic pressure. Tissue profusion and oxygenation are compromised. @ risk patients are those who are immobile, dependent, malnourished, and subject to friction and shearing force. There are four stages:

Stage 1- nonblanchable redness of intact skin

Stage 2- partial thickness skin loss involving the epidermis and /or dermis. The ulcer is superficial and looks like an abrasion, blister, or small crater.

Stage 3- full thickness skin loss involving damage or necrosis of the subcutaneous tissue.

Stage 4- full thickness skin loss with extensive damage, tissue necrosis, and damage to the muscle, bone and supporting structures.

Treatment of pressure ulcers:

1. Preventative treatment- includes the following:
1. Adequate nutrition and hydration.
2. Keep skin clean and dry
3. Reduce friction and shearing forces
4. Reduce the amount of pressure on any part of the body (they are most commonly found on the sacrum)
5. Turn the patient q 2 hours
6. Lift the patient; don’t pull
7. Shearing force can be reduced by limiting the amount of time the client sits above 30 degree angle
8. Use gel filled cushions, water mattresses and foam mattresses.
2. Treatment of existing pressure ulcers depends on size, location, the severity of the clients condition, and the stage of the ulcer.
1. Constantly monitor to detect changes in healing and the onset of infection.
2. Pressure relief is the key element in any treatment plan.
3. There are general guidelines for each stage.

Occurs when venous blood pools in the lower extremities, causing skin lesions and infections. Most commonly caused by venous insufficiency in older adults. Diffusion and the exchange of nutrients are impaired if untreated.

Preventative treatment:

1. Foot care
2. Elevation
3. Compression stockings to reduce edema- 30mmg/hg below the knee and 40mm/hg at ankles. This is contraindicated in patients will arterial insufficiency.

Treatment:

Is aimed at the correction of factors that impair wound healing.

Nutritional treatment- vit c and zinc if the patient is malnourished

Control of systemic diseases like diabetes, anemia, CHF

Cleanse the ulcer and treat with a steroid ointment and cover with an occlusive dressing

Unna zinc based boot is applied and changed weekly.

The ulcer should heal in 2-3 months

If the ulcer doesn’t heal, pinch grafts may be used

Cultured epidermal cell rafts are being used to treat ulcers that are not successfully treated with other methods.

Antibiotic therapy is usually avoided unless cellulitis is present.

Synthetic occlusive dressings are effective in reducing pain and stimulating granulation tissue. It remains in place for 2-3 weeks and is replaced with a standard dressing.

Usually caused by artherosclerosis.

Occur on legs, ankles and feet.

Characterized by pallor, patchy bluish-purple mottling of the skin and cold, clammy skin.

Muscle or tendon is often exposed.

Arterial pulses may not be present

Distortion of the toenails (onychogryposis)

Treatment:

Aimed at reducing peripheral vascular disease risk factors such as discouraging smoking and controlling HTN, diabetes, obesity, and hyperlipidemia.

The client needs to be referred to a podiatrist for the management of corns, calluses, etc.

Meticulous foot care is essential.

Candida albicans- yeast like fungus that is normally found in the body. Moist skin, antibiotics, corticosteriods, and poor general health lead to candidiasis.

Characteristics: red, itchy, burning sensations and eroded patches of skin at the site.

Treatment: antifungal agents like nystatin. Cool burrows compresses to relieve inflammation. Keeping the skin clean, dry, and changing into clean clothing frequently will help prevent reinfection. The use of cotton underwear and stocking help as well.

Trichophyton rubrum- toenails can be affected with this fungus.

Characteristics: thick, discolored, and dystrophic toenails. Some debris may be found under the nail.

Treatment: creams and ointments such as, miconazole, clotrimazole, or ciclopirox.

In some cases the infection cannot be cured but controlled

If the nail plate is involved then, systemically acting antifungal agents may be used for 2-4 weeks.

Acute, painful infection of the sensory nerve and its nerve path. The causative agent is the varicella-zoster virus. Incidence is closely related to age- 20% of 20 year olds get it, 80% of 80 year olds etc. Herpes zoster can reoccur. In immunosupressed clients, it can cause complications and even death.

The thoracic region is most commonly affected.

Acute phase lasts about 3 weeks

Treatment:

Acyclovir (zovirax)- hastens healing and reduces pain

Systemic acting steroids may be used

Calamine lotion or a vinegar solution to reduce discomfort

Inflammation of the skin and can be manifested as eczema, allergic contact dermatitis, or seborrheic dermatitis. All are characterized by erythema, edema, exudates, erosion, itching, scales, and scabs.

1. Eczema- three categories

1. Acute- red skin, weeping vesicles, exudates, and crusts. Itching is the major complaint. Treatment includes the following:

1. Systemic meds to reduce itching
2. Corticosteriods
3. Antibacterial agents
4. Antifungal agents
5. Soaks and dressings to the affected area
6. Good hygiene measures prevent infections.

1. Subacute and chronic phases

1. Strong corticosteriods
2. Tar preparations
3. Occlusive dressings and compresses

1. Allergic contact dermatitis- Is NOT related to age but when it occurs in an older adult it may be more severe and generalized than in the younger person.

Allergies to rubber, medications, cosmetics and poison ivy (Rhus plants). People being treated with neomycin often develop an allergy therefore medications that have ethylenediamine and neomycin in them should be avoided to treat allergic dermatitis. Instead, use nystatin, myocream, or tri-statin.

Transdermally transmitted drugs have also led to an increase in allergic contact dermatitis. (nitroglycerin, scopolamine, clonidine).

Hair dyes, sunscreens with PABA, fragrances and preservatives are also associated with contact dermatitis.

2. Seborrheic dermatitis- affects the scalp, eyelids, eyebrows and back.

1. Dandruff shampoo to the affected area that contains selenium sulfide 1% or pyrithione zinc 2%.
2. If it occurs on the face then low dose corticosteriods to the affected area.

Pigmentary disturbances:

Nevi- contains melanin and are usually benign. They require no treatment unless they are on an area of the body where they are subject to trauma or a change occurs in their appearance. Cryosurgery or punch biopsy are the treatments of choice.

Vitiligo- a localized area of depigmentation. They are initially in areas that are exposed to the sun but may involve the axillae and perineum. Can be associated with diabetes, thyroid dysfunction, addison’s disease and pernicious anemia.

Treatment:

Protect area from the sun

Pruritus- generalized itching. Decreased sweat gland activity is associated with pruritus.

Treatment is symptomatic and involves removing the offending agent.

Use mild soaps, decrease the frequency of baths, and use lotions. In severe cases, antihistamines may be prescribed.

Psoriasis- disease of keratin synthesis. Outbreaks are sometimes precipitated by stress and some drugs like lithium and beta-blockers. Manifested by dry, well circumscribed, silvery, scaling papules and plaques. Usually occurs on the back, buttocks, knees, and elbows.

Treatment:

Minimize stress

Corticosteriods

Emollients after bathing

Phototherapy

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