Table Of ContentEvans cover SB 9/30/11 11:24 AM Page 1
With ageing populations, increasing numbers of
H A COLOR HANDBOOK
elderly patients will seek care for a variety of
A
skin conditions, ranging from eczema and NA
DC
psoriasis to benign lesions and skin cancers – BO SKIN DISEASES
OL
conditions that are more prevalent in the elderly OO
KR
and more problematic to treat. In this new color
S
handbook the authors deal systematically with
K
those skin conditions that are particular to or
I IN THE
more common in the elderly, covering testing, N
diagnosis, and treatment options.
D
Following an initial chapter on how the skin I
S
changes with age, the authors discuss in turn
E ELDERLY
inflammatory, neoplastic, infectious and
A
metabolic/nutritional diseases of the skin, plus
S
skin signs of systemic disease in old age. E
S
Skin Diseases in the Elderlyis written in a
I
concise, structured style, and illustrated by a N
COLBY CRAIG EVANS
wealth of top quality color photos. It is intended
T
to help dermatologists in practice and training,
H WHITNEY A. HIGH
geriatricians, primary care physicians, specialist
nurses, and senior medical students. E
E
COLOR HANDBOOK SERIES L
D
Acute Adult Dermatology: Creamer
Dermatology, 2nd edition: Rycroft E
R
Endocrinology and Metabolism: Camacho
L
Gastroenterology, 2nd edition: Boulton
Y
Human Anatomy:McMinn
Oral Medicine: Lewis
Pediatrics and Child Health: Strobel
E
Pediatric Clinical Neurology: Bale V
A
Pediatric Clinical Ophthalmology: Nelson
N
Pediatric Rheumatology: Reed S
(cid:2)
Renal Medicine: Pattison
H
Skin Diseases in the Elderly: Evans IG
H
ISBN 978-1-84076-154-2
MANSON
PUBLISHING
A Color Handbook
Skin Diseases
in the Elderly
Colby C. Evans,
MD
Evans Dermatology Partners
Austin, Texas, USA
Whitney A. High,
MD, JD, MEng
Associate Professor, Dermatology and Pathology
Attending, Denver STD and HIV Prevention Clinic
University of Colorado School of Medicine
Denver, Colorado, USA
MANSON
PUBLISHING
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2012 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20150224
International Standard Book Number-13: 978-1-84076-615-8 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts
have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal
responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views
or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not neces-
sarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for
use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other
professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and
the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant
national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their
websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book
does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is
the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and
treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all mate-
rial reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been
obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any
future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or
utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including pho-
tocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission
from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://
www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923,
978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For
organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
CONTENTS
3
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Other inflammatory conditions
Abbreviations . . . . . . . . . . . . . . . . . . . . . .6 Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Suggested Reading . . . . . . . . . . . . . . . . . .6 Pityriasis rubra pilaris . . . . . . . . . . . . . . . . .46
Seborrheic dermatitis . . . . . . . . . . . . . . . . .47
PART 1 Intertrigo . . . . . . . . . . . . . . . . . . . . . . . . . .48
Skin changes with aging Asteatotic eczema . . . . . . . . . . . . . . . . . . . .49
Age-related atrophy . . . . . . . . . . . . . . . . . . .8 Lichen planus . . . . . . . . . . . . . . . . . . . . . . .50
Solar atrophy . . . . . . . . . . . . . . . . . . . . . . . .9 Contact dermatitis . . . . . . . . . . . . . . . . . . .52
Bruising . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Nummular dermatitis . . . . . . . . . . . . . . . . .54
Xerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Urticaria (hives) . . . . . . . . . . . . . . . . . . . . .55
Varicosities . . . . . . . . . . . . . . . . . . . . . . . . .10 Rosacea . . . . . . . . . . . . . . . . . . . . . . . . . . .56
Lichen sclerosus . . . . . . . . . . . . . . . . . . . . .58
PART 2 Neurodermatitis/Prurigo nodularis/
Inflammatory skin disease Lichen simplex chronicus . . . . . . . . . . . .59
Chondrodermatitis nodularis chronica
Autoimmune helicis . . . . . . . . . . . . . . . . . . . . . . . . . .60
Bullous pemphigoid . . . . . . . . . . . . . . . . . .14
Grover disease . . . . . . . . . . . . . . . . . . . . . . .61
Cicatricial pemphigoid
Erythema annulare
(mucous membrane pemphigoid) . . . . . .16
centrifugum . . . . . . . . . . . . . . . . . . . . . .62
Dermatomyositis . . . . . . . . . . . . . . . . . . . .17
Erythema nodosum . . . . . . . . . . . . . . . . . .63
Acute cutaneous lupus erythematosus
(systemic lupus erythematosus) . . . . . . .18
Subacute cutaneous lupus erythematosus . . .20 PART 3
Neoplasms of the skin
Discoid lupus
erythematosus . . . . . . . . . . . . . . . . . . . .22 Malignant
Scleroderma . . . . . . . . . . . . . . . . . . . . . . . .24 Basal cell carcinoma . . . . . . . . . . . . . . . . . .66
Pemphigus . . . . . . . . . . . . . . . . . . . . . . . . .26 Actinic keratosis . . . . . . . . . . . . . . . . . . . . . .68
Sjögren syndrome . . . . . . . . . . . . . . . . . . . .29 Squamous cell carcinoma . . . . . . . . . . . . . .70
Keratoacanthoma . . . . . . . . . . . . . . . . . . . .72
Neutrophilic dermatoses Malignant melanoma . . . . . . . . . . . . . . . . .74
Sweet syndrome . . . . . . . . . . . . . . . . . . . . .30 Sebaceous carcinoma . . . . . . . . . . . . . . . . .76
Pyoderma gangrenosum . . . . . . . . . . . . . . .32 Angiosarcoma . . . . . . . . . . . . . . . . . . . . . . .77
Kaposi sarcoma . . . . . . . . . . . . . . . . . . . . . .78
Allergic and hypersensitivty processes Cutaneous B-cell
Drug eruptions . . . . . . . . . . . . . . . . . . . . . .33 lymphoma . . . . . . . . . . . . . . . . . . . . . . .79
Acute generalized exanthematous Cutaneous T-cell
pustulosis . . . . . . . . . . . . . . . . . . . . . . . .35 lymphoma . . . . . . . . . . . . . . . . . . . . . . .80
Stevens–Johnson syndrome/Toxic Metastatic tumors and paraneoplastic
epidermal necrolysis . . . . . . . . . . . . . . . .36 syndromes . . . . . . . . . . . . . . . . . . . . . . .82
Photorelated conditions Benign
Polymorphous light Seborrheic keratosis . . . . . . . . . . . . . . . . . .83
eruption . . . . . . . . . . . . . . . . . . . . . . . .38 Sebaceous hyperplasia . . . . . . . . . . . . . . . . .85
Phototoxic/Photoallergic Angioma
reactions . . . . . . . . . . . . . . . . . . . . . . . .38 (cherry angioma) . . . . . . . . . . . . . . . . . .86
Chronic actinic dermatitis (actinic reticuloid)40 Angiokeratoma . . . . . . . . . . . . . . . . . . . . . .87
Porphyria cutanea tarda . . . . . . . . . . . . . . . .42 Milium . . . . . . . . . . . . . . . . . . . . . . . . . . . .88
Skin tags(acrochordons) . . . . . . . . . . . . . . .89 PART 5
Epidermoid cyst . . . . . . . . . . . . . . . . . . . . .90 Metabolic and nutritional disease
Favre–Racouchot Scurvy . . . . . . . . . . . . . . . . . . . . . . . . . . .116
disease . . . . . . . . . . . . . . . . . . . . . . . . . .91
Cheilitis . . . . . . . . . . . . . . . . . . . . . . . . . .117
Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . .92
Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . .118
Syringoma . . . . . . . . . . . . . . . . . . . . . . . . .92
Zinc deficiency . . . . . . . . . . . . . . . . . . . . .119
Dermatofibroma . . . . . . . . . . . . . . . . . . . . .93
Pellagra . . . . . . . . . . . . . . . . . . . . . . . . . .120
Lentigo . . . . . . . . . . . . . . . . . . . . . . . . . . .95
Nevus . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
PART 6
Fibrous papule . . . . . . . . . . . . . . . . . . . . . .99 Skin signs of systemic disease
Verrucas (warts) . . . . . . . . . . . . . . . . . . . .100
Necrobiosis lipoidica
(diabeticorum) . . . . . . . . . . . . . . . . . . .122
PART 4 Acanthosis nigricans . . . . . . . . . . . . . . . . .123
Infestations and infections Granuloma annulare . . . . . . . . . . . . . . . . .124
Parasitic Amyloidosis . . . . . . . . . . . . . . . . . . . . . . .125
Scabies . . . . . . . . . . . . . . . . . . . . . . . . . . .104 Stasis dermatitis . . . . . . . . . . . . . . . . . . . .126
Lice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105 Leg ulcers . . . . . . . . . . . . . . . . . . . . . . . . .128
Leukocytoclastic vasculitis (hypersensitivity
vasculitis) . . . . . . . . . . . . . . . . . . . . . . .130
Viral
Xanthomas . . . . . . . . . . . . . . . . . . . . . . . .131
Herpes simplex . . . . . . . . . . . . . . . . . . . . .106
Erythema gyratum
Varicella zoster . . . . . . . . . . . . . . . . . . . . .108
repens . . . . . . . . . . . . . . . . . . . . . . . . .132
Acrokeratosis neoplastica (Bazex syndrome)133
Bacterial
Bacterial folliculitis . . . . . . . . . . . . . . . . . .109
Bacterial cellulitis/
Erysipelas . . . . . . . . . . . . . . . . . . . . . .111
Fungal
Tinea . . . . . . . . . . . . . . . . . . . . . . . . . . . .112
Candidiasis . . . . . . . . . . . . . . . . . . . . . . . .114
PREFACE
5
Geriatric dermatology and geriatric medicine in These trends foretell enormous change in
general will grow exponentially in importance the practice of medicine. The mix of elderly
during the coming years. As the average age patients in the practice of the average physician
throughout the Western world rises steadily, will surely increase. The number of very elderly
and life expectancies lengthen, more and more patients will also rise, potentially straining
elderly patients will seek care for a variety of resources for geriatricians and long-term care
skin conditions. facilities.
Certainly some of these skin conditions are In dermatology, several trends will result as
particular to, or at least more common in, these changes occur. While skin cancer can
elderly persons. Other conditions may present occur at any age, most forms are decidedly
at any age, but may represent diagnostic and more common after a lifetime of sun exposure.
therapeutic challenges in the aged patient. As Non-melanoma skin cancer, in particular basal
the number of elderly patients rises, these cell carcinoma and squamous cell carcinoma,
challenges will become increasingly common will become more prevalent. As the aging
for both the primary care physician and the process also hinders the retention of moisture
dermatologist. in the skin, conditions exacerbated by dry skin
Demographic data tell a concise story (such as psoriasis and eczema) may worsen.
regarding the population of most Western Aspatients age, they also tend to accumulate
countries – it is aging quickly. The United more benign skin lesions (such as seborrheic
States Administration on Aging reports the keratoses or sebaceous hyperplasia). These
number of persons >65 years of age will more benign lesions may lead to irritated examples
than double to 71.5 million by 2030. In 2000, that require treatment and will need to
persons>65 years of age represented just 12.4% be differentiated from more concerning
of the total population, but this group will lesions.
represent at least 20% of the population Treatment can also be more challenging in
by2030. elderly patients. Older patients tend to take
Similar findings were reported by the more medications, leading to the increased
United Kingdom Office for National Statistics. potential for drug interactions. They may also
In 2006, the fastest-growing segment of the have age- or disease-related decreases in liver or
population in the United Kingdom was those kidney function and, therefore, have difficulty
persons aged 85 years old and older, with a processing the drugs. Topical therapies can also
record-setting 1.2 million people in this be more difficult to apply in the setting of
category. From 1971 to 2006, the overall arthritis or visual decline.
population grew 8% while the population of The purpose of this text is to discuss those
persons>65 grew 31%. dermatologic conditions that occur in the
Both the United States and United elderly patient. Its goal is not only to help the
Kingdom experienced ‘baby booms’ in the practitioner diagnose and treat conditions in
years following World War II. Large spikes in geriatric dermatology, but to also help target
the birth rate at that time have led to large testing and therapy so that it is most useful
numbers of people now preparing to enter in this special and rapidly growing patient
elderly age. Advances in health care and population.
increases in the average lifespan have worked
also to increase the numbers further.
ABBREVIATIONS
6
ABCD criteria asymmetry, border IVIG intravenous
irregularity, color variation, immunoglobulin
and diameter >6mm KOH potassium hydroxide
AIDS acquired immune KTP potassium–titanyl–
deficiency syndrome phosphate (laser)
ANA antinuclear antibody LDH lactate dehydrogenase
AST aspartate aminotransferase LDL low-density lipoprotein
BSA body surface area MED minimal erythema dose
CA-MRSA community-acquired MRI magnetic resonance
methicillin-resistant imaging
Staphylococcusaureus MRSA methicillin-resistant
CBC complete blood count Staphylococcusaureus
CK creatine kinase Nd:YAG neodymium-doped:yttrium
CT computed tomography –aluminum–garnet (laser)
(scan) NSAID non-steroidal
ELISA enzyme-linked anti-inflammatory drug
immunosorbent assay PCR polymerase chain reaction
ENA extractable nuclear antigen PET positron emission
ESR erythrocyte sedimentation tomography (scan)
rate PUVA (oral) psoralen plus
HHV human herpesvirus ultraviolet A
HIV human immunodeficiency SSKI supersaturated potassium
virus iodide
HPV human papillomavirus TMP/SMX trimethoprim/
HTLV human T-cell lymphotropic sulfamethoxazole
virus (co-trimoxazole)
ICU intensive care unit UV ultraviolet
Ig immunoglobulin
SUGGESTED READING
Bolognia JL, Jorizzo JL, Rapini RP. Wolff K, Goldsmith LA, Katz SI, Gilchrest
Dermatology. New York: Mosby, 2007. BA, Paller A, Leffell DJ (eds). Fitzpatrick’s
Burns T, Breathnach S, Cox N, Griffiths C Dermatology in General Medicine.
(eds).Rook’s Textbook of Dermatology. New York: McGraw-Hill Professional,
Oxford: Wiley-Blackwell, 2010. 2007.
Habif TP. Clinical Dermatology: A Color Guide Wolverton SE. Dermatologic Drug Therapy.
to Diagnosis and Therapy. London: Mosby, Philadelphia: WB Saunders, 2007.
2003. www.emedicine.medscape.com
Rietschel RL, Fowler JF. Fisher’s Contact www.dermis.net/dermisroot/en/home/
Dermatitis, 6th edn. PMPH-USA, 2007. index.htm
PART 1
7
Skin changes
with aging
8 PART 1 Skin changes with aging
Although elderly patients are prone to a
1
number of skin diseases, there exist also typical
age-related skin changes that are not disease
associated. Although these changes occur to all
patients, should they live long enough, they can
have profound effects on the proper function of
the skin, and, hence, the patient’s correspon-
ding quality of life.
Age-related atrophy
Skin atrophy is commonly seen in elderly
patients, evidenced by thinning or fine wrinkling,
easy tearing, and bruising. In sun-protected sites,
this atrophy usually results in fine, ‘cigarette
paper’ wrinkling of the skin (1&2). The skin
isoften light in color compared with chronically
sun-exposed skin.
2
Fat loss, especially on the face and hands (3),
is quite common with age. Since the fat layer
provides a cushion for blood vessels, they
become more visible with time and more prone
to bleeding with minor trauma. Fat loss, espe-
cially in the face and hands, is also a common
cosmetic concern for older patients.
3
1–3 Skin atrophy.
