Skin associated systemic disease in elderly

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Skin associated systemic disease in elderly

• Monsawan miniphan M.D.
• 3/02/2005

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Scope of diseases

• Skin associated common systemic disease
• Diabetes
• Hyperlipidemia
• Endocrine disease
• Others

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• Malignancy of skin
• Bacal cell carcinoma
• Squamous cell carcinoma
• Malignant melanoma

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Skin and aging

• Two basic theories of aging
• Programmatic theory
• Inherent genetic program
• Stochastic theory
• Cumulative environmental damage

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Skin aging

• Intrinsic aging
• Universal
• Inevitable change
• Attribute to the passage of time alone
• Photoaging
• Superimpose on intrinsic aging
• Attribute to the chronic sun exposure

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Histologic features of aging skin

• Epidermis
• Flatted dermo-epidermal junction
• Variable thickness
• Variable cell size and shape
• Occasional nuclear atypia
• Fewer melanocyte
• Fewer Langerhans cell

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• Dermis
• Atrophy
• Fewer fibroblast
• Fewer mast cells
• Fewer blood vessels
• Abnormal nerve ending

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• Appendage
• Depigmented hair
• Loss of hair
• Fewer glands
• Abnormal nail plates

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Histology of skin
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Histology of aging skin
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Functions of skin decline with age

• Cell replacement Thermoregulation
• Barrier function Sweatproduction
• Chemical clearance Sebumproduction
• Sensory perception Vit production
• Mechanical protection DNA repair
• Wound healing
• Immune responsesive

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Common skin disease in elderly

• Benign neoplasia
• Seborrheic keratosis focal epidermal
  homeostasis loss leading to increase endothelin1

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• Variants of seborrhoeic keratoses include
• Solar lentigos flat brown marks in sun exposed
  areas
• Stucco keratoses numerous small dry grey
  stuck-on lesions usually found on lower legs and
  feet
• Dermatosis papulosa nigra numerous brown warty
  papules on face and neck of dark-skinned
  individuals

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Solar lentigene
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Stucco keratoses
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• Treatment
• Removed wish, uncertainty of the correct
  diagnosis.
• Methods used to remove seborrhoeic keratoses
  include
• Cryotherapy. (liquid nitrogen)
• Curettage cautery.
• Laser surgery
• Shave biopsy (shaving off with a scalpel)

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• Malignant neoplasia
• Squamous cell carcinoma
• Basal cell carcinoma
• Malignant melanoma
• UV induce DNA damage
• Decrease DNA damage repair capacity

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Basal cell carcinoma

• the most common type of cancer in humans
• Affect adults, more common in elderly
• Sun exposure
• Grow slowly over months or years

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• Types of basal cell carcinoma
• Nodular BCC
• Superficial BCC
• Morpgoeic BCC

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• Nodular BCC
• Small translucent growth, rolled edges
• May be pigmented
• Ofte smaall blood vessels on surface, bleeding
  spontaneous

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NODULAR BCC
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• Superficial BCC
• Multiple lesions
• Upper trunks or shoulders
• Slow growing patches, shiny pink, slightly scaly,
  bleeding easy

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SUPEFICIAL BCC
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• Morphoeic BCC
• Skin-color, waxy, thicken scar
• Most difficult to diagnosis
• Prone to recurrent

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MORPHOIC BCC
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• Treatment
• depends on its type, size and location, the
  number to be treated
• Excision. The lesion is cut out and the skin
  stitched up. This is the most appropriate
  treatment for nodular, infiltrative and morphoeic
  BCCs. Very large lesions may require a flap or
  graft to repair the defect after excision

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Squamous cell carcinoma

• Common type of skin cancer
• Type of squamous cell carcinoma
• In situ SCC
• Invasive SCC

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• In situ SCC
• One or more flat red scaly patches up to several
  centimetres wide, often found in large numbers on
  the lower legs. These patches are also known as
  Bowen's disease
• Malignant cell confine in epidermis

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• Causes of in situ SCC
• Sun exposure
• Immunosuppression
• HPV
• Arsenic ingestion
• Ionizing radiation

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BOWEN DISEASE
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• Invasive SCC
• Develop in solar keratosis
• Solar or actinic keratoses are common small scaly
  lesions arising on the face, ears and hands of
  white skinned people who have spent many years
  outdoors
• Thickened or tender keratosis may be developing
  into invasive SCC. SCCs are often crusty and may
  bleed easily
• On the lips, SCC is more common in smokers

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• Develop in thermal burn scars and longstanding
  leg ulcers
• In genital areas, SCC are usually related to
  infection with papillomavirus (genital warts) or
  skin disease such as lichen sclerosus or lichen
  planus vulvar cancer
• Not usually a threat to life as secondary spread
  (metastasis) is uncommon
• SCC on the lip or ear appear to be the sites most
  likely to metastasise, so ulcers or lumps in
  these areas should be taken particularly
  seriously

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SQUAMOUS CELL CARCINOMA
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SQUAMOUS CELL CARCINIMA OF LIPS
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• Treatment
• Excision the most common treatment of invasive
  SCC
• Cryotherapy
• Radiation

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Malignant melanoma

• serious skin cancer which is curable if detected
  early
• Growth from melanocyte in epidermis or mucous
  membrane
• Common in 50-70 yr

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• Causes of melanoma
• Sun exposure particularly during childhood
• Serious sunburn, especially when young - however,
  melanoma sometimes occurs on areas of the body
  not normally exposed to the sun
• Family history of melanoma
• Fair skin that burns easily - melanoma is common
  in people with Northern European ancestry, and is
  not common among dark-skinned people
• A large number of abnormal moles (called atypical
  naevi). These moles are usually larger than 6mm,
  with an irregular shape and multicolours

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• The ABCDs of melanoma
• A asymmetry
• B border irregularity
• C colour variation
• D diameter gt 6 mm

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Superficial melanoma
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Nodular melanoma
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• Treatment
• Surgical removal
• Sentinel node biopsy

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Papulosquamous disorders

• Psoriasis change in patient environment leading
  to koebnerization
• systemic medication
• Atypical presentation flexural psoriasis
• Drugs aggravated b-blocker, NSAIDs, ACEi
• Trigger factors urinary incontinence, hearing
  aids, braces

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Flexural psoriasis
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Xerosis

• Disturbance of epidermal maturation
• Decrease water content in outer layers of stratum
  corneum
• Dry , rough, skin

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xerosis
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Pruritus

• Penetration of irritants through the damage
  stratum corneum
• Alter sensory threshold
• Metabolic disorder
• Endocrine disorder
• Adversr drug reaction
• Parasitic infestation scabies

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Infection

• Compromised local cutaneous health predispose to
  growth of infective organism
• Age-associated decreased immune response
• Underlying systemic disorder associated with
  decreased immune response

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scabies
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• Metabolic and endocrine disorder
• DM
• Renal failure
• Thyroid disease
• Hepatic disease
• Lymphoma, leukemia, PV

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Skin problems associated with diabetes mellitus

• Necrobiosis lipoidica
• Rare, insulin dependent DM
• One or more tender yellowish brown patches
  develop slowly on the lower legs over several
  months
• Round, oval or an irregular shape
• The centre of the patch becomes shiny, pale,
  thinned
• Prominent blood vessels (telangiectasia)
• Often painless

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Treatment

• Tropical steroid, usually under a plastic
  occlusive dressing
• Intralesional steroid injections or steroid
  tablet
• Aspirin and dipyridamol combination
• Pentoxifylline tablets
• Oral cyclosporin
• Photochemotherapy (PUVA)

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• Diabetic dermopathy
• Their cause is unknown
• Round brown or purple slightly thinned patches
  seen on the shins of diabetic patients
• Similar lesions are sometimes seen in
  non-diabetics
• Treatment is not necessary or useful

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Hyperlipidemia

• Xanthomata
• 4 forms tendinous subcutaneous nodule
  found in fascia, ligament and extensor tendon of
  hand, knee and elbow
• Planar yellow, soft, macule or plaque found on
  the upper eyelids
• Tuberous yellow to reddish nodule at extensor
  surface of elbows, knees and knuckles
• Eruptive sudden, multiple reddish yellow papule
  extensor of extremities, buttock

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PLANAR XANTHOMA
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ERUPTIVE XANTHOMA
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Acantosis nigricans

• Hyperpigmentation, hyperkeratosis,velvety
  distribuion at intertriginous area
• Most common area axilla, genitaria, groin,
  popliteal fossa, anticubital and neck

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• Associated condition
• Insulin resistant related
• Obesity
• Pseudoacromegaly
• DM
• Polycystic ovarian disease

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• Malignancy related
• Adenocarcinoma gastric
• Melanoma
• Sarcroma
• Lung carcinoma small cell, squamous,
  bronchoalveolar
• Lymphoma
• Endocrine malignancy carcinoid,
  pheochromocytoma, thyroid,testicular
• Wilm tumor

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• Drug induce
• Somatotrophin
• Testosterone
• Nicotinic acid
• OC
• Corticosteroid
• Idiopathic

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• Syndromes
• Acromegaly
• Addison
• Cushing
• Dermatomyositis
• Down
• Cirrhosis
• Hypothyroid
• SLE
• scleroderma

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Acanthosis nigrican
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Vitiligo

• Autoimmune disease, pigment cell are destroyed
• Irregular white patches on the skin
• Any part of the body may be affect

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• Who is prone to vitiligo
• At least 1 of all population
• In general good health
• Greater risk DM, thyroid, B-12 def., Addison,
  alopecia areata

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• Cause of vitiligo
• Unknown
• Autoimmune against the pigment cell
• Treatment
• Topical steroid
• PUVA

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vitiligo
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• Associated with cancers of the esophagus, lung,
  breast, bladder, stomach, and cutaneous T-cell
  lymphoma

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Erythroderma
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• Diffuse erythema of the skin usually associated
  with induration and scaling
• Associated with the leukemic phase of cutaneous
  T-cell lymphoma (Sezary syndrome)
• Other malignancy associations lung, liver,
  prostate, thyroid, colon, pancreas, stomach

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Collagen Vascular DiseaseDermatomyositis
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Heliotrope erythema
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Gottrons papules
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Dermatomyositis

• Malignancy risk may be as high as 15 in women
• No increase in malignancy risk with polymyositis
  or childhood dermatomyositis
• Females over age 40 have a 32-fold increase risk
  of ovarian cancer

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Other disorders associated with malignant disease

• Pruritus
• Sister Mary Joseph nodule
• Erythema gyratum repens
• Subcutaneous fat necrosis
• Sweets syndrome

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• Hypertrichosis lanuginosa acquisita
• Necrolytic migratory erythema
• Leukoderma
• Sign of Leser-Trelat

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Sister Mary Joseph Nodule
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Sister Mary Joseph nodule

• Collective term for a metastatic deposit at the
  umbilicus originating from any primary malignancy
• Appearance of this lesion usually heralds
  advanced disease and has a poor prognosis.
• Attributed to Sister Mary Joseph Dempsey who was
  the first surgical assistant to William Mayo
• Associated malignancies stomach, colon, ovary,
  pancreas

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Sweets Syndrome (Acute Febrile Neutrophilic
Dermatosis)
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Sweets SyndromeSubtypes

• Classic (71)
• Neoplasia (11) hematologic malignancies,
  usually AML
• Inflammatory Disease (16)
• Pregnancy (2)

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Sweets Syndrome

• Major Criteria (both required)
• Abrupt onset of tender or painful erythematous
  plaques or nodules occasionally with vesicles,
  pustules or bullae
• Predominantly neutrophilic infiltration in the
  dermis without leukocytoclastic vasculitis
• Minor criteria (2 of 4)
• Preceded by an nonspecific respiratory or
  gastrointestinary tract infection or vaccination
  or associated with
• Inflammatory diseases as chronic autoimmune
  disorders, infections etc.
• Hemoproliferative disorders or solid malignant
  tumors
• Pregnancy
• Accompanied by periods of general malaise and
  fever (gt38C)
• Laboratory values during onset (three out of four
  necessary)
• ESR gt 20mm n.W.,
• C-reactive Protein positive,
• segmented-nuclear neutrophils and stabs gt 70 in
  peripheral blood smear,
• leukocytosis gt 8.000
• Excellent response to treatment with systemic
  corticosteroids or potassium iodide

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Necrolytic Migratory Erythema(Glucagonoma
Syndrome )
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Necrolytic Migratory Erythema

• Rare syndrome associated with a glucagon
  producing alpha cell tumour of the pancreas
• Associated findings glossitis, stomatitis,
  weight loss, hyperglycemia, anemia, alopecia,
  diabetes
• Diagnosis angiography, octreotide scan
• Resection of the tumor clears the eruption
• Similar eruption may be seen with cirrhosis,
  pancreatitis, celiac sprue, and zinc deficiency

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Hypertrichosis Lanuginosa Acquisita

• Acquired excessive growth of lanugo (velus) hairs
• Initially covers face and ears may involve all
  hair-bearing skin
• Malignancy associations include colon, rectum,
  bladder, lung, pancreas, breast.

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Sign of Leser-Trelat

• Sudden appearance of multiple seborrheic
  keratoses
• Association with internal malignancy is unproven

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Thank you