Geriatric Dermatology - Canadian Healthcare Network

Report
The Pharmacist’s Role
At the end of this session the participant will be able to:
• Describe the dermatological changes that occur as we age
• List some of the common disorders that are prevalent in an
older population
• Describe the risk factors and consequences of decubitus
ulcers
• Describe treatment options for Xerosis
In the Elderly
Intrinsic: occurs in everyone and is related to genetic changes in
cell processes
Extrinsic: produced by external causes (e.g. UV exposure,
smoking, environmental pollutants)
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Decreased mobility
Innate cutaneous age-related changes
Drug induced disorders
Chronic Diseases (e.g. CAD, Diabetes, CHF, HIV)
Cellular changes in the epidermis & underlying structures
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Altered lipid metabolism  impaired ability to recover from injury
Sluggish keratinocytes  impaired ability to recover from injury
Decreased melanocyte density  decreased protection from UV rays
Decreased Langerhans cells density  decreased immune function
Loss of collagen and elastic tissues  wrinkles and skin fragility
Decreased function of cutaneous nerves, microcirculation and sweat
glands  poor thermoregulation and increased risk of burning
Decreased subcutaneous fat in distal extremities  less “padding” to
protect from trauma
• Fragile skin (skin tears, abrasions, cuts)
• Traumatic purpura (bruises)
• Ischemia (cell death, decubiti)
• Xerosis (dry skin)
• Infections
• Skin cancers
• Stage III
Decubitus
Ulcer with
necrosis on
sacrum
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Usually occur over bony prominences
Caused by ischemia, which leads to cell death and tissue damage
Related to the forces of:
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Pressure
Shear
Friction
Frequently complicated by secondary infection, leading to:
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Cellulitis
Osteomyelitis
Sepsis
• Elderly patients, especially those in LTC facilities & hospitals
• Critical care patients
• Oncology patients
• Diabetics
• End stage renal, heart or liver disease patients
• Patients with femoral fractures
• Incontinent patients
• Patients with impaired mental status
• Patients with impaired nutritional status
Stages of Decubitus Ulcers
Stages of Decubitus Ulcers
Stage I
Nonblanching erythema of intact skin
Stage II
Superficial to partial thickness
involvement of the epidermis or dermis
Stage III
Deep necrosis with full-thickness skin
loss that may extend down to, but not
through, underlying fascia
Stage IV
Extensive necrosis to underlying fascia,
possibly extending into muscle, bone,
and supporting structures
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Stage-dependent
Ranges from cleansing and application of protective ointments and
specialized dressings to surgical debridement of necrotic tissue.
The pharmacist should be aware of any topical agents and specialized
dressings being used and encourage compliance to any ordered regimen.
The pharmacist may recommend nutritional, vitamin, and mineral
supplements, after consultation with a nutritionist, when wound healing is
delayed
The pharmacist may recommend appropriate pain management for pain
related to dressing changes and chronic pain which may be decreasing
mobility
Secondary infection should be treated with systemic antibiotics, NOT
topical formulations
• Appropriate treatment should be determined by a wound
care specialist, as use of inappropriate dressings may cause
harm (e.g. occlusive dressings over an infected wound may
lead to sepsis and debriding dressings used on granulating
wound beds may delay healing)
• Wound dressings may be combined in different ways by
different practitioners dependent on the individual case and
prior experience
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Appropriate wound dressings should:
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Maintain a moist wound bed
Control moisture levels on healthy wound margins (to avoid
maceration)
Permit gas exchange (oxygen required for healing)
Provide thermal insulation
Prevent secondary infection and decrease colonization of wound bed
Adhere to body to maintain good wound-dressing contact without
damaging healthy skin when removed
Avoid over-adherence to wound bed to prevent trauma on removal
(unless debridement is needed)
Fill wound cavities to promote healing by primary intention
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Dressings which may be used for outpatient treatment may include
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Gauze (wet to dry dressings)
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mechanical debridement
must be done at least TID (to avoid over-drying)
stop once wound bed is mostly clean or granulation tissue will be removed
Simple occlusive dressings (e.g. Opsite)
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Useful to prevent skin breakdown in vulnerable areas, or prevent further
breakdown in Stage I areas
Semipermeable – allows gas exchange and keeps out microbials
Allows visual inspection of wound area through dressing
Change PRN
Gentle on healthy skin when removed correctly
Never use on an infected wound
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Hydrocolloid dressings (e.g. Duoderm)
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Keep wound bed moist
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Offer some absorption for wounds with minimal exudate
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Offer some thermal protection
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May be changed infrequently depending on wound (q2days –
q7days)
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Semipermeable – allow gas exchange and keep microbials out
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Different shapes available for different body parts (i.e. Sacrum)
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Adhesive is gentle to healthy skin when removed
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Do not use on infected wounds
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Impregnated dressings (e.g. Mesalt,)
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Exert osmotic pressure and dissolve necrotic tissue using
the body’s own fluids
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Provide an environment which discourages bacterial
growth in the wound bed (high salt content)
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Pack the wound to heal by primary intention
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Should only be used in wounds with large amounts of
exudate (in order to avoid drying the wound bed)
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Change at least BID
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May be used on infected wounds
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Absorbent dressings (e.g. foam, calcium alginate)
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Highly absorbent materials to control wound exudate
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Come in various forms and can be used to pack wounds
and/or as an outer layer
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Provide thermal protection to the wound
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Allow dressings on clean wounds to be changed less
frequently
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Frequently used in conjunction with impregnated
dressings to control moisture
• Topical treatments may include:
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Saline
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Used to cleanse the wound and debride necrotic material (wet-to-dry,
syringe irrigation)
Commercial wound cleansers (instead of saline)
Hydrogels/Xerogels
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Keep dry wound beds moist to promote healing
Allow longer periods between dressing changes
Act as gentle packing to encourage healing by intention
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Topical treatments may include:
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Silver sulfadiazine creams/gels/solutions
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Sulfa based antibiotic creams
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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
Antibacterial properties to  wound colonization (not used for true wound
infections)
Help to keep the wound bed moist
Other antiseptics (e.g. Dakin’s Solution, Chlorhexadine) may be ordered
but do not offer any advantage over saline, do not promote wound
healing and should be avoided
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
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 (dry skin) is characterized by:
• Pruritus (itchiness)
• Dryness
• Cracks
• Fissures (like cracked porcelain)
• Occurs mostly on the legs (but sometimes hands and trunk)
• Excoriation (from scratching) leading to infection or
dermatitis
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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
Inherited factors
A skin condition such as atopic dermatitis (eczema), psoriasis or
ichthyosis
Any combination of these
• Occlusive moisturizers and emollients
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Oils, lotions, creams and ointments
• Humectants, keratolytics and keratoplastics
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Urea, ammonium lactate, and alpha hydroxy products
• Non-pharmacologic management
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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
Preferably applied when skin is damp
No EBM comparing different moisturizers.
There is no '‘right’ moisturiser for all patients: the most suitable one
often having to be found by trial and error.
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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
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.
• 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
• Many products have more than one of these properties
• All or some of these may not be tolerated by patients due to
stinging and irritation
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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
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.
• Loosen the glue-like substances that hold the surface skin
cells to each other, therefore allowing the dead skin to peel
off.
• The mechanism of action of topically applied neutralized
lactic acid is not yet known.
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
• 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
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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 soap or better still, a detergent-based cleanser.
Cleansers that have the same pH as the skin (5.5) may be
advantageous.
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)
• Usually found near the mouth or nares, but may be anywhere
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on the body
May be bullous (staphylococal) or nonbullous (streptococcal)
Treated with oral and topical prescription antibiotics
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
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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
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usually appear along one dermatome (nerve path)
• rarely cross the midline
• may crust over after several days
• usually dry out over 2-3 weeks
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
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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
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)
• Tinea Cruris (Jock Itch)
• Onychomycosis (Tinea Unguium nail infections)
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Caused by a combination of an over production of skin oil and
irritation from a yeast called malassezia.
Usually found in sebaceous areas
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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)
• Generally managed with OTC products
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Selenium sulfide
Zinc pyrithione
Coal tar
Ketoconazole 2%
• Low potency topical steroids may be used in more severe
cases
• Found mostly in skin folds where there is warmth,
moisture and skin to skin contact:
• Inguinal
• Between the fingers
• Perianal
• Under the breasts
• Appears as a demarcated “beefy-red” eruption with
satellite pustules
• Often related to:
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Obesity
Diabetes
Immunosuppression
Chronic debilitation
Occlusion under incontinence products
Systemic antibiotic therapy
• OTC Treatments may include
• Exposure to air
• Use of desiccants (Burrow’s solution, Castellani’s paint)
• Zinc oxide (topically)
• Topical azole antifungal agents BID
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Miconazole
Econazole
Ketoconazole
Ciclopirox
Antifungal powders may be used to dry the skin and prevent
maceration
Terbinafine cream is NOT effective against Candida.
• Caused by dermatophytes
• Presents with erythema, scaling and maceration
• 3 types:
• Interdigital – dry scaling between toes
• Moccasin-type – involves entire sole and sides of foot
• Vesiculobullous – plantar surface; usually the arch
• Usually treated with topical azole antifungals:
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Clotrimazole
Ketoconazole
Econazole
Terbinafine
Ciclopirox
• Systemic treatment reserved for extensive/persistent
infections
• Oral treatment may be used for elderly patients who would
have difficulty seeing or reaching their feet to apply cream
• Prevention is key:
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Dry feet thoroughly after washing (especially between toes)
• Avoid walking barefoot in public places
• Wear cotton socks
• Intermittent application of antifungal creams, powders or
sprays may help prevent recurrences
• 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
• Severe or resistant cases may benefit from oral
treatment
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Fungal nail infections usually caused by dermatophytes
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Very few cases caused by Candida or molds
Prevalence increases with age (nearly 20% of patients over 60 are
infected)
Predisposing factors:
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Trichophytons rubrum
Trichophytons mentagrophyte
Trauma
Peripheral vascular disease
Immunosuppression
Diabetes
Contiguous spread of tinea pedis
Cannot be treated with OTC products
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Blistering diseases in the elderly are rare and may be immunemediated, 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
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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
• 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:
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perifollicular hemorrhage
gingival hypertrophy
altered wound healing
Systemic findings may include fatigue, anemia, and joint
swelling.
• 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
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Long term parenteral nutrition
Alcoholics
Patients with cirrhosis
• Zinc deficient patients will present with
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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)
• Pyridoxine (B6)
Patients with Riboflavin deficiency may present with
• Angular cheilitis (Inflammation, burning, redness, and
ulceration or cracks at the corner of the mouth)
• Stomatitis (inflammation of the mouth lining)
• Seborrheic dermatitis
• Patients with Niacin deficiency may present with dermatitis
• Those at risk for niacin deficiency include:
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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 tubes in
the lungs.)
• Patients with Niacin deficiency may present with seborrheic
dermatitis and photosensitivity
• Risk factors include:
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Alcoholism
Cirrhosis
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
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
• Usually caused by UV radiation, sunlight, and HPV
• Melanomas
• Most lethal skin cancer
• Rates increasing dramatically
Most common types are
• BCC (basal cell carcinoma)
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Most common type of skin cancer
Do not metastasize
Usually treated with surgery
• SCC (squamous cell carcinoma)
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Untreated may progress and become invasive
Can metastasize to lymph nodes
Usually treated surgically
• Most lethal skin cancer
• Rates increasing dramatically
• Four main types:
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Superficial spreading (most common)
Nodular
Lentigo (occurs only in the elderly)
Acral lentiginous
• Early excision is the only curative management
All members of the health-care team, including pharmacists
should be aware of the ABCDE’s of melanoma recognition.
How to recognize a melanoma (ABCDE)
A
Asymmetrical in shape
B
Border is irregular
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 (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)
• 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
Author: Lisa S Lewis, MD; Chief Editor:
Russell W Steele, MD
Medscape Reference: Drugs, Diseases and
Procedures
DermNet NZ
Facts about skin from the New Zealand
Dermatological Society Incorporated.
http://www.dermnetnz.org
The Good, the Bad, and the Ugly of Sunscreens
M Berwick
Clinical Pharmacology & Therapeutics 89, 31-33 (January 2011)
Skin Cancer in the Elderly
KONSTANTINOS N. SYRIGOS1, IFIGENIA TZANNOU1,
NIKOLAOS KATIRTZOGLOU1 and EVANGELLOS GEORGIOU2
in vivo 19: 643-652 (2005)
National Center for Biotechnology Information
PubMed Health
A.D.A.M. Medical Encyclopedia.
http://www.ncbi.nlm.nih.gov/pubmedhealth/
National Quality Measures Clearinghouse
Management of Pressure Ulcers: Guideline Synthesis
Registered Nurses' Association of Ontario (RNAO).
Assessment and management of stage I to IV pressure
ulcers. Toronto (ON): Registered Nurses' Association of
Ontario (RNAO); 2007 Mar. 112 p. [118 references]
Wound, Ostomy, and Continence Nurses Society
(WOCN). Guideline for prevention and management of
pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and
Continence Nurses Society (WOCN); 2010 Jun 1. 96 p.
(WOCN clinical practice guideline; no. 2). [341 references]
Decubitus Ulcers Treatment & Management
Author: Don R Revis Jr, MD; Chief Editor: John Geibel, MD, DSc, MA
Medscape Reference: Drugs, Diseases and Procedures

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