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Geriatrics. Apr;48(4), , Common skin disorders of aging: diagnosis and treatment. Kurban RS(1), Kurban AK. Author information.
Table of contents
- Pruritus in the elderly – a guide to assessment and management
- NEWS & VIDEOS
- Ambiguous Itching
- Skin disease
Often, the visibility and accessibility of skin make it the first organ of the body to show detectable signs of underlying disease. Abnormalities of the skin frequently suggest metabolic, malignant, and glandular diseases. Like other tissues, skin is afflicted by all types of pathological changes, including hereditary, inflammatory, benign and malignant neoplastic , endocrine, hormonal, traumatic, and degenerative processes.
Emotions affect the health of the skin as well. The reaction of the skin to these diseases and disorders differs from that of other tissues in many ways. For example, extensive inflammation of the skin may affect metabolism within other organs and systems of the body, causing anemia, circulatory collapse, disorders of body temperature, and disturbance of water and electrolyte balance in the blood. The skin has such vigorous healing properties, however, that widespread injury, as in thermal burns, may be followed by a marked degree of regrowth of the injured or diseased areas, with a disproportionally small degree of scarring.
The skin has an inherent region-specific anatomical diversity that may profoundly modify the appearance of a rash.
This is apparent when skin transplanted from one area of the body to another other than a symmetrically opposite area retains the morphological characteristics of the donor area. Thus the morphology of eczema or lichen planus on the palms and soles may bear little or no resemblance to the same disease in the same individual on the face or scalp. In these instances a biopsy shows the abnormalities of the cells of the skin and the pattern and distribution of any invading cells. The ability to identify immunoreactants immunoglobulins, or antibodies, that react with specific invading agents, or antigens in skin biopsies has greatly increased the accuracy of the diagnosis of inflammatory disorders and has clarified their immunologic basis, especially in the blistering disorders.
The classification of hereditary skin disorders generally has been based upon gross morphological, histological, and electron microscopic findings; however, because a skin disease may not always have a characteristic presentation, the specific diagnosis sometimes has been in doubt. Better understanding of the biochemical defects underlying hereditary skin disorders now allows these conditions to be diagnosed with more precision.
One subset of the ichthyoses , a group of sometimes disabling genetic skin disorders, may thus be delineated from other members of the group, based on biochemical detection of a specific enzyme defect reduced steroid sulfatase enzyme. The distribution of a rash depends on factors both intrinsic and extrinsic to the body. Mechanical factors such as trauma, environmental agents, fungal or viral infections , and drugs are among the most common extrinsic determinants of distribution.
Environmental influences, such as sunburn and light-sensitive, drug-induced reactions, may also play a major role. Psoriasis and the rare hereditary blistering disorders collectively called epidermolysis bullosa owe their distributions to local trauma; lesions that show a predilection for the elbows, knees, and lower back are common in psoriasis , and those found in the hands, feet, knees, and mouth of children are indicative of epidermolysis bullosa.
A lesion of an eruption that subsequently develops where a mechanical or other physical trauma was applied is termed an isomorphic reaction. Alternatively, anti-BP induced proinflammatory effects, such as granulocyte influx, could trigger pruritus. In pruritus, scratching lesions can cause the development of anti-BP, and ultimately, bullous pemphigoid; this process is termed a spreading epitope 42, The role of histamine. Antihistamines are often the first treatment for pruritus, including senile pruritus. Although the placebo effects of these drugs can be very important 68 , there is an interest in searching for a link between senile pruritus and histamine A prick test with codeine and histamine under antihistamines found a significant persistence of skin reaction in elderly people with pruritus by comparison with an unaffected group This suggests that patients with senile pruritus have and maintain a tendency towards mast cell degranulation.
Therefore, there is an increased ability to release histamine, probably associated with other mediators escaping the antihistamine treatment. These others mediators could be targets for treatment.
Pruritus in the elderly – a guide to assessment and management
Thirty-five patients with senile pruritus were treated with oxatomide and a control group treated with a placebo. The first group observed improved management of pruritus. Oxatomide is an anti-allergic agent that not competes only with histamine or serotonin, but which also inhibits the release of mediators by mast cells This product is not avialable in all countries. However, some studies confirmed the non-effect of antihistamines for senile pruritus.
Antihistamines are often used more for the sedative effect than the antipruritic effect. Senile pruritus is due mainly to nervous deafferentiation in elderly people. Some modifications of the epidermis and the skin immune system could be also involved. Further research is needed in order to gain a real understanding of senile pruritus and consequently propose adequate treatments.
There is no specific recommendation for the treatment of senile pruritus, and management can be a challenge All treatments in elderly patients should be used with caution due to altered metabolism and the possibility of higher toxicity compared with younger people. A study 5 of the management of senile pruritus by senior dermatologists reported typical treatments.
These physicians thought xerosis was the most common cause of itching in elderly people. Therefore, the first treatment proposed was an emollient, sometimes including menthol, phenol or camphor. The second reported treatment was a topical corticosteroid. This study showed many propositions by physicians to treat pruritus, but none was really effective.
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Therapeutic education accompanied this treatment, especially regarding bathing conditions These included treatments such as aloe juice, autohemotherapy, ocean bathing, psychotherapy and vitamins. A psychosocial approach seemed to be important, with active lifestyle, exercise and personal development. This article illustrated the fact that there was no specific therapeutic approach. Dermatologists therefore need further information about the treatment of senile pruritus 5.
Each patient with senile pruritus needs a personalized approach to management, taking into account their age, disease, medications, and the quality and intensity of pruritus 30, Topical treatment. Specific changes in the stratum corneum have been reported in patients with senile pruritus with clinically drier skin as a consequence Hence, first-line treatment could be an emollient, since authors suggest that a low pH may be of further benefit through reduction in the activity of serine proteases mast cell tryptase Topical treatments are frequently used against pruritus, but none has been studied specifically in senile pruritus.
Topical corticosteroids are not recommended in the absence of inflammation and enhanced skin atrophy in elderly people. Systemic treatments. Currently, no systemic treatment can be recommended for guidelines for senile pruritus due to the absence of clinical trials In senile pruritus, the efficacy of antihistamines is questionable. Although 2 studies 69, 70 have suggested their efficacy, other studies have suggested other mediators that do not respond to antihistamines. In a study by Guillet et al. Antihistamines mainly first-generation with an anticholinergic effect must be used with caution in elderly people due to their sedative effects and putative side-effects of glaucoma and urinary retention Two papers have reported the efficacy of gabapentin for senile pruritus.
Both patients had an excellent response, with complete control of itching after 1 month. All of the patients within these 2 studies were monitored for 9 months, and no relapse or side-effects were observed 31, Efficacy seemed to extend after discontinuation of treatment, and, indeed, no relapse was observed 3 months after the treatment ended Major adverse effects of cyclosporin A are high blood pressure and renal failure, which limits the use of cyclosporine in elderly people.
In this study, 2 patients needed a dose adjustment to control blood pressure and no laboratory changes were observed.
NEWS & VIDEOS
Physical treatments. Ultraviolet B UVB phototherapy can be interesting because it has few side-effects and drug interactions. However, this treatment requires coordination with family or caregivers. Phototherapy requires bi- or tri-weekly treatments Monk 74 reported the efficacy of transcutaneous electrical nerve stimulation TENS in 2 cases of senile pruritus that were resistant to other treatments.
The relief of itching was not confined to the area of the stimulated skin. Indeed, TENS was applied only to the chest, but the generalized pruritus disappeared. TENS may be helpful in the treatment of itchy skin disorders. No side-effects were observed for these patients who used this treatment for a long time. Patient education. The emollient may be applied directly after bathing when the skin is still wet. This treatment could be using to avoid the drying process by water evaporation from the skin Frequent washing and the use of astringent soaps may exacerbate itching.
Avoiding alkaline soaps, excessive bathing, hot baths, irritant fabrics for example wool , dry air conditions and use of occlusive bandaging might help Pruritus is responsible for a vicious cycle of itching and scratching, and these measures, as well as emollients and anti-pruritic creams, may help to break this cycle. An educational multidisciplinary training programme was successfully proposed to many retired patients Pruritus is frequent in the elderly population, although an interesting study 76 showed that age was not significantly associated with chronic pruritus when the outcome was current pruritus or pruritus within the last 12 months.
However, a significant association of age with lifetime pruritus was observed. Interestingly, in this study there was a peak in the age-group 51—60 years. Another study from the same team 77 showed that the incidence of chronic pruritus was significantly associated with age. These data derived from the general population are of importance because not all persons with chronic pruritus are automatically patients, as not all of them seek medical help.
Senile pruritus is poorly understood, probably multifactorial, and difficult to treat. Senile pruritus is a diagnosis of exclusion. It can be determined after a specific check-up, but the pathophysiology is still unclear. It is likely that age-related changes in the skin, cutaneous nerves or immune system play a role. These theories suggest a new approach to this disorder.
However, the treatment of senile pruritus remains a challenge for dermatologists and non-dermatologists. No topical or systemic treatment can be recommended; the literature proposes only anecdotal solutions. We propose an algorithm Fig. Patients must be provided with follow-up, support and education to enable better compliance and monitoring. Elderly people comprise a fragile population and may have a history of high levels of treatment.
Senile pruritus and its impact on quality of life could foster comorbidities. The lack of data on senile pruritus emphasizes the difficulties for physicians in treating this condition; thus, further research is urgently needed.
Proposals for an algorithm for the treatment with a 4-step-approach. TENS: transcutaneous electrical nerve stimulation. Conflict of interest: CJC had no conflict of interest.
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