Dermatological Manifestations in the Elderly

Sanjay Siddha

Staff Dermatologist

UHN & MSH

Disclosure

No actual or potential conflicts of interest or

commercial relationships to declare

Objectives

Recognize and manage

• common dermatosis in the elderly

• Melanoma

• Non Melanoma skin cancer

• Benign lesions

Facts about melanoma

• mean age of diagnosis around 50 yrs

• one of the less common forms of cancer

• Canadian life time risk male 1:75

female: 1:90

Melanoma

• Melanoma localized to skin cured by surgical excision

• Patients with advanced disease – poor prognosis

• Cost of treating (20%) stage III &IV : 90% total annual cost for treatment

• Early detection is the key

Early detection

• impractical to screen everyone

• identify & screen high risk patients

• biopsy of melanomas early

• observation/ monitoring of nevi

Risk factors: higher risk (approx. 10-fold)

• >100 normal moles

• >5 atypical moles

• ≥2 cases of melanoma in first degree relatives.

Risk factors: Lower (approx. 2 to 3 fold)

• freckles

• red hair or skin which burns in the sun

• any family history of malignant melanoma

Other risk factors

Relative risk

past personal history of

melanoma

5- 8%

11-25 nevi 1.6%

26-50 nevi 4.4%

51-100 nevi 5.4%

1-5 atypical nevi 3.8%

Skin type Typical Features Tanning ability I Pale white skin, blue/hazel eyes, Always burns, does not tan blond/red hair II Fair skin, blue eyes Burns easily, tans poorly III Darker white skin Tans after initial burn IV Light brown skin Burns minimally, tans easily V Brown skin Rarely burns, tans darkly easily VI Dark brown or black skin Never burns, always tans darkly

Features to look for in the nevi • A –asymmetry

• B- border

• C- colour

• D- diameter/dark

• E- evolving

Clinical Diagnosis of Melanoma

Patients detect 50% of melanomas (new or changing

lesion)

Detecting change is more useful

Ugly duckling sign

• Atypical nevus in a background of normal

appearing nevi

• More normal appearing lesion in a patient

with multiple clinically atypical nevi

Micro staging of cutaneous melanoma

Melanoma

Melanoma

• Early detection is essential and can be life saving!

• Surgical excision with 1 cm margins will cure 90% of patients with early melanoma (< 1 mm Breslow depth)

Location

Women commonly develop on the lower limb (50% of

women, 18% of men)

• Men : SSM or NM commonly develop on the trunk (35%

of men, 14% of women), especially the back.

• chronic sun exposure - head and neck

Melanoma-Types

• Superficial spreading melanoma

• Nodular melanoma

• Lentigo maligna melanoma

• Acral lentiginous melanoma

Types of primary cutaneous melanoma

Type frequency site

SSM 60-70% Lower extremities women

Trunk – men & women

NM 15-30% Trunk, head & neck

LMM 5-15% Face – nose & cheeks

ALM 5-10% Palms, soles & nail unit

Superficial spreading (SMM)

• most common • age 40 -60’s • risk factors :↑ nevi dysplastic nevi intermittent sun

exposure sunburn

Nodular melanoma (NM)

15% of melanomas

• nodule: enlarging,

bleeding/crusting

• elderly (M>F)

Lentigo maligna melanoma

• 10-15% of melanomas

• prolonged radial growth

• changing atypical

pigmented macule

• chronic UV exposure

(outdoor workers, elderly

people)

Acral lentiginous melanoma (ALM)

• 1-3% of melanomas

• flat lesion like SSM

• Common in dark skin

• No relationship to UV exposure

Subungual melanoma

• arises in nail matrix

• hutchinson sign

• more common in dark skin

Melanoma Prevention

• UVR is primary cause of most melanomas

• More risk: Intermittent exposure

Childhood exposure

Tanning beds < age 35yr

Childhood exposure ↑ nevi

Primary prevention

• Protection from the sun: avoidance and clothing

primarily.

• Sun protection factor (SPF) 30 and above,

• Five star: ultraviolet A (UVA) protection as an adjunct

Secondary prevention

• People with higher risk (10-fold) categories:

Refer for risk estimation and education

• Base-line photography: to monitor moles

• Dietary intake of vitamin D

Surgical management

Thickness

Excision margins

In – situ 0.5 cm

< 1 mm 1 cm (AAD 1cm for

<2mm)

1- 4 mm 2 cm (AAD 2 cm for

≥2mm)

> 4 mm 2- 3 cm

When to refer • new mole: growing quickly after puberty

• long-standing mole : changing progressively in shape or colour (any

age)

• any mole ≥ 3 colours or lost its symmetry

• any new nodule: growing and is pigmented or vascular in

appearance

When to refer (cont.) • new pigmented line in a nail

• something growing under a nail

• mole which has changed in appearance and

which is also itching or bleeding

Avoid Sun

• Even on a cloudy day, UV will get through to

the earth’s surface

• Sunlight is tricky - reflect off snow, water &

sand

Stratosphere - Ozone Layer

UVC

100-280

UVB

280-315

UVA

315-400 X-ray Visible Light

400-700

Dead Sea Level Sea Level

Sand

SEA

How much sunscreen?

• One ounce(shot glass)

• 30 ml

• Cover the exposed areas

of the body properly

Myths about sunscreen

• Retinyl palmitate: risk of skin cancer

• Oxybenzone: hormone disruptor

• Mostly in lab animals

Avoid mid day sun

Atmosphere

Surface

EARTH

Midday

Sun Directly Overhead

4pm

Y Y

X

UV Protective Clothing

• The finer the weave, the greater the

protection

• Silk is best

• Nylon stockings SPF of about 2

Sun protection: Save our skin

• Slip on a Shirt

• Seek out Shade

• Step out of the Sun –Ouch!

• Slap on Sunscreens

Case 2

Case 2

Immediate Care

• Speak to a dermatologist

• Topical Dermovate ung b.d.

• Vaseline ung

• Treat any secondary bacterial infection

Severe Bullous Pemphigoid • Widespread tense blisters of skin & mucosa

• Antigen: BPAg1 & 2 (hemidesmosome at the epidermal-

dermal junction)

• Elderly patients, 6-7 new/million

• Rarely drug induced

Management

• clobetasol propionate 0.05% cream (20 g) applied

• 2 times day, including clinically unaffected skin (total

daily dose 40 g),

• oral prednisone 1 mg kg daily

• A significant benefit of the former - extensive disease

(more than 10 new blisters a day) for disease control,

adverse events and mortality.

Management

• Skin biopsy: Lesional for H&E

Perilesional for DIF

• Oral steroids

• Steroid sparing agents

• Tetracycline +/- nicotinamide

Xerotic eczema (eczema craquelé)

Scurvy

Sebaceous gland hyperplasia

Dermatosis papulosa nigra

Stucco Keratosis

Seborrheic Keratosis

Skin Cancer

• Basal cell carcinoma (BCC): most common

• Squamous cell carcinoma (SCC)

• Melanoma: 4% skin cancers

Keratoacanthoma

Basal cell carcinoma - Pigmented

Basal cell carcinoma

Cystic BCC

Sclerosing BCC

Cutaneous Horn

Actinic Keratosis

Bowen’s Disease

Bowen’s disease

Management of AK Cryotherapy 5FU Zyclara (Imiquimod

3.75%)

Curettage

Low No. of AK’S 4 4 3 1

High No. of AK’S 3 4 3 1

Thin AK’S 3 4 3 1

Hypertrophic AK’S 2 1 1 4

Isolated Not responding

2 1 1 4

Scalp, Nose, Ears , Cheeks, forehead

4 4 4 3

Periorbital 3 1 1 3

Below Knee 3 1 1 4

Back of Hands 4 4 3 3

Dermatology MCQ

Sanjay Siddha

1. What is your diagnosis?

What is your diagnosis?

A. Seborrheic Keratosis

B. Pigmented Basal cell carcinoma

C. Melanoma

D. Squamous cell carcinoma

2. What is your diagnosis?

2. What is your diagnosis?

A. Contact dermatitis to Poison Ivy

B. Bullous pemphigoid

C. Herpes Zoster

D. Irritant contact Dermatitis

3. Incidence of Melanoma Which one is true?

A. In increasing across all age groups

B. Is decreasing in the Elderly Population

C. Is increasing in the Elderly population

D. Is increasing in the younger age group 20-

40yrs

4. Bullous Pemphigoid Which one is true?

A. Is a Para neoplastic condition

B. Is an autoimmune blistering condition

C. Common in young adults

D. Common in the Elderly

E. All of the above