Module 6 - Dermatological Disorders

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<p>Geriatric Pharmacy Review Module 6: Dermatological Disorders </p> <p>Accreditation Information</p> <p>ASCP is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.</p> <p>This home study web activity has been assigned 3 credit hours. ACPE UPN: 0203-0000-10-004-H01-P Release Date: 3/1/2010 Expiration Date: 3/1/2013</p> <p>To receive continuing education credit for this course, participants must complete an on-line evaluation form and pass the online assessment with a score of 70% or better. If you do not receive a minimum score of 70% or better on the assessment, you are permitted 4 retakes. After passing the assessment, you can print and track your continuing education statements of credit online.</p> <p>Geriatric Pharmacy Review courses have not yet been approved for Florida consultant pharmacy continuing education.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Content Experts</p> <p>Current Content Expert: Kevin W. Chamberlin, PharmD Assistant Clinical Professor of Pharmacy Practice University of Connecticut School of Pharmacy * with support from Jill K. Logan, 2009 PharmD Candidate, University of Connecticut School of Pharmacy*</p> <p>Legacy Content Experts: Nina H. Cheigh, PharmD Clinical Assistant Professor Coordinator, Academic Programs Department of Pharmacy Practice University of Illinois College of Pharmacy Donna M. Lisi, PharmD, BS, CGP Clinical Pharmacist, Geriatrics New Jersey VA Healthcare System Adjunct Faculty Rutger's University College of Pharmacy</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Content Expert Disclosure</p> <p>Kevin W. Chamberlin, PharmD has no relevant financial relationships to disclose. Nina H. Cheigh, PharmD, has no relevant financial relationships to disclose. Donna M. Lisi, PharmD, BS, CGP has no relevant financial relationships to disclose.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Age-related Skin Changes and Pressure Ulcers</p> <p>Learning Objectives</p> <p>By the end of this Review Concept you should be able to: Describe common age-related changes of the skin affecting the elderly. Recognize risk factors which predispose older adults to pressure ulcers and complications which may arise. Describe the pathogenesis and clinical features of different stages of pressure ulcers. Use assessment protocols and preventative measures for patients with pressure ulcers.</p> <p> Describe pharmacologic and non-pharmacologic therapies which may be used to treat pressure ulcers and complications associated with pressure ulcer management.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Two Theories of Skin AgingTwo theories of skin aging: Programmatic theory Stochastic theory</p> <p>There are two basic theories related to aging. One programmatic theory states that like development, skin aging is due to an inherent genetic program. The other programmatic theory states that there is random cumulative environmental damage that occurs over ones lifetime to genes and proteins, which ultimately lead to aging. These include ultraviolet radiation, oxidative damage, and heat shock. Currently, it is thought that both theories affect the process of aging.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Clinical Changes in the Aging SkinClinical changes in the aging skin: Epidermis: Flattened epidermal-dermal junction Keratinocytes - decreased lifespan Melanocytes - decreased number (10-20%) per decade Langerhans cells - decreased number (50%) Decreased vitamin D production Dermis: Atrophy - loss of dermal thickness (20%) Fibroblasts - decreased collagen/elastin Blood vessels - decreased number and wall thickness Mast cells - decreased in number Neutral elements - decreased number (30%) Appendages: Fat alteration in thickness Eccrine glands - decreased number and output Apocrine glands - decreased number and output Sebaceous glands - increased size, decreased output Sensory perception decreased for touch Hair - decreased number of hair follicles and growth rateCopyright 2011 American Society of Consultant Pharmacists</p> <p>Clinical Changes in the Aging Skin</p> <p>Skin changes that occur with aging lead to gradual decline in the skins structure and function. Aged skin typically appears to be drier, wrinkled, less pliant and more prone to trauma. Structural changes are likely responsible for the increased susceptibility to skin disorders. For example, the flattening of the dermal-epidermal junction is responsible for reduced nutrient transfer, and explains the propensity for superficial abrasions following minor trauma. With dermal atrophy, and changes in pigmentation, collagen and elastin, the aged skin is more prone to be wrinkled and dry in appearance. Other changes in the epidermis include a decrease in cell migration and division, variation in the size, shape and staining properties of the keratinocytes, and a decrease in both melanocytes and Langerhans cells. Similar changes occur in the dermis, which undergoes a corresponding decrease in thickness, vascularity, and elasticity. The loss of vascularity accounts for the pallor, easy bruising, and decreased thermoregulation seen in the elderly. Changes in the dermal layer give the characteristic wrinkled, atrophic appearance of aging skin.Copyright 2011 American Society of Consultant Pharmacists</p> <p>Clinical Changes in the Aging SkinThere is alteration in the thickness of fat, with atrophy occurring in the face and upper and lower extremities, and hypertrophy occurring in truncal areas and the thighs. Adnexal structures such as sweat glands, hair bulb melanocytes and hair follicles become distorted and fewer in number. The decline in specialized nerve endings compromises sensation, making the individual more susceptible to thermal and mechanical injury. Finally, there are prolonged reactions to contact dermatitis due to altered elimination of irritant substances.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Functional Changes That Decline in the Aging SkinFunctional changes that decline in the aging skin: Cell replacement Wound healing Thermoregulation Sweat production Sebum production Immune responsiveness Skin permeability Sensory perception</p> <p>As mentioned in the previous slide, there are many structural changes in skin that occur with aging. Functional problems that result from these structural changes include: altered skin permeability, decreased inflammatory and immunologic responsiveness, impaired wound healing, and decreased thermoregulation. These changes also predispose the elderly to injuries and ulcerations, such as pressure ulcers.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Actinically Damaged (photo-aged) Skin AbnormalitiesActinically damaged (photo-aged) skin abnormalities: Dryness Actinic keratoses Irregular pigmentation Wrinkling Coarseness / in-elasticity</p> <p>Actinic keratoses: trophic reticulated and confluent hypopigmented, red and hyperpigmented crusted eroded plaques. Multiple, symmetric, brown, scaly sand paper-like papules and brown macules.</p> <p>A prominent feature of actinically damaged, or photoaged skin is elastosis, or skin coarseness. With age, the photodamaged skin displays inflammatory cells such as mast cells and increased fibroblasts. There is increased skin dryness, and a higher propensity for discolorations with sun damage. Wrinkling of photodamaged skin is also exacerbated by cigarette smoking, and possibly by other environmental factors.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Common Cutaneous Disorders in the ElderlyDisorder / Pathophysiology Neoplasias: UV-induced, cumulative DNA damage which can result in Benign seborrheic keratoses</p> <p>Seborrheic Keratoses: Multiple 0.5-1.0 cm skin colored to light brown stuck on papules. Flat-topped Scaly Can be extremely pruritic and described as generalized eruptive moles. Eruptive seborrheic keratoses have been associated with internal malignancies.</p> <p>Squamous cell carcinoma: Squamous Cell CarcinomaBasal cell carcinoma Malignant melanoma</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Common Cutaneous Disorders in the ElderlyPapulosquamous disorder: disturbance of epidermal maturation which can result in: Psoriasis Multiple, large, confluent, symmetric red plaques with overlying silver scale Dermatitis Atopic Dermatitis: symmetric lichenified, excoriated, scaly red confluent plaques.</p> <p>Pruritus: Result from irritant penetration and cause altered sensation. These can result from: Infections - Result from compromised cutaneous health Ulcers - Result from impaired wound healing and structural changes Leg Ulcer Calciphylaxis: symmetric reticulated violaceous erythema, nodules, and punched out ulcers with central black eschars.</p> <p>Ulceration secondary to stasis dermatitis: diffuse mottled hyperpigmentation, woody edema and multiple punched out ulcers. Bullous pemphigoid - Results from flattening of the dermal-epidermal junction Erythematous urticarial papules and large confluent vesicles and bullae</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Pressure Ulcers: Incidence, Prevalence and MortalityIncidence (stage 2 or greater): Overall, 1.5 to 3 million people affected yearly Hospitals: 1 3% of new admits; 7.7% within 3 weeks LTCs: 5% of new admits after 3 months</p> <p>Prevalence (stage 2 or greater): Hospitals: 28% of patients confined for 1 week or more LTCs: 20-33% of patients</p> <p>Mortality: Accounts for more than 60,000 deaths annually Increased for hospital admits and LTC residents Most caused by infections secondary to ulcers (e.g., sepsis, cellulitis, osteomyelitis, local infections) Worldwide, a lower limb is lost every 30 seconds as a consequence of diabetes</p> <p>Financial Pressure $15,000 - $27,000 per ulcer Estimated costs to healthcare system annually: $5 to $7.5 billion Treatment costs are 2.5 times greater than prevention costs</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Pressure Ulcers: Incidence, Prevalence and MortalityAlso known as decubitus ulcers or bedsores, pressure ulcers are a common and serious problem among the elderly. More than fifty percent of all pressure ulcers occur in persons over seventy. The prevalence of pressure ulcers with secondary skin loss is between twenty and thirty percent of patients in nursing homes, and around twenty-eight percent of patients admitted for a week or more in acute care settings. Increased death rates have been observed in elderly patients who develop pressure ulcers, both in the hospital and nursing home. Many of these deaths result from the complications of sepsis and other infections secondary to the ulcer.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Factors in the Pathogenesis of Pressure UlcersSkin ulceration occurs with greater pressure and contact time.</p> <p>Pressure Constant contact pressure between sixty and seventy millimeters of mercury has been known to cause the degeneration of muscle fibers within one to two hours</p> <p>Shearing forces Friction Moisture</p> <p>A pressure ulcer is a localized area of soft tissue injury resulting from compression between a bony prominence and an external surface. There are four physical factors that contribute to pressure ulcer formation. Constant contact pressure between sixty and seventy millimeters of mercury has been known to cause the degeneration of muscle fibers within one to two hours. Skin ulceration occurs with greater pressure and contact time. The pressure on bony prominence such as the sacrum can be as high as one hundred to one hundred fifty millimeters of mercury for a patient lying on a hospital bed. Along with tissue degeneration, such pressures can reduce transcutaneous oxygen pressure to zero.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Role of Pressure in the Pathogenesis of Pressure Ulcers</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Role of Pressure in the Pathogenesis of Pressure UlcersThe ischemic effects of pressure appear to trigger the development of pressure ulcers. Injury due to pressure alone begins in the deeper tissues and spreads upward. I f the pressure is relieved, hyperemia may be the only response. I f prolonged, pressure-induced ischemia leads to endothelial swelling and vessel leakage. Eventually hemorrhage occurs, leading to nonblanchable erythema of the skin. The accumulation of edema fluid, inflammatory cells, toxic wastes, and invasive bacteria ultimately suffocate the affected muscle tissue.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Other Factors in the Pathogenesis of Pressure Ulcers Pressure Shearing forces Friction Moisture</p> <p>Shearing forces, friction, and moisture also contribute to pressure ulcer formation. Shearing forces occur when two tangential surfaces slide on each other, as when a supine patient slides to the foot of the bed. Shearing forces can lower the amount of pressure necessary to occlude blood vessels and cause damage to the epidermis. Friction, which occurs any time a patient is pulled across a sheet and can cause a loss of epithelial cells. Moderate amounts of moisture increase the amount of friction at the rubbing interface, and lead to maceration and epidermal injury.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Risk Factors for Pressure Ulcers</p> <p>Unrelieved pressure Immobilizing or activity-limiting disease processes, including physical restraints</p> <p>Decreased blood pressure Anemia Circulation deficiencies Diabetes mellitus Diaphoresis Edema Overweight or underweight Pruritus Hypotension Restless legs syndrome</p> <p>Repeated exposure to pressure Incontinence Nutritional factors (e.g., malnutrition, hypoalbuminemia) Altered level of consciousness, including sedating medications Dry skin (xerosis) Increased body temperature / fever</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>Risk Factors for Pressure Ulcers</p> <p>Normal capillary filling pressure is thirty-two millimeters of mercury. Increased unrelieved pressure for a short time or low uninterrupted pressure for a long time can result in pressure ulcers. Age-related changes to the skin and increased susceptibility to disease are important risk factors for the elderly. Any disease or healing process that leads to prolonged immobility increases the risk of pressure ulcers. Other risk factors include fecal incontinence, dry skin, and altered level of consciousness. Nutritional factors that are significantly related to pressure ulcer development include decreased lymphocyte count, hypoalbuminemia, inadequate dietary intake, and decreased body weight. Common pressure ulcer points include the sacrum, greater trochanter, ischium, medial and lateral condyles, malleolus, and heels.</p> <p>Copyright 2011 American Society of Consultant Pharmacists</p> <p>AHRQ Guidelines for the Prevention and Treatment of Pressure Ulc...</p>