Skin associated systemic disease in elderly

Skin associated systemic disease in elderly Monsawan miniphan M.D. 3/02/2005 Scope of diseases • Skin associated common systemic disease – Diabetes – Hyperlipidemia – Endocrine disease – Others • Malignancy of skin – Bacal cell carcinoma – Squamous cell carcinoma – Malignant melanoma Skin and aging • Two basic theories of aging – Programmatic theory • Inherent genetic program – Stochastic theory • Cumulative environmental damage 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 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 • Dermis – Atrophy – Fewer fibroblast – Fewer mast cells – Fewer blood vessels – Abnormal nerve ending • Appendage – Depigmented hair – Loss of hair – Fewer glands – Abnormal nail plates Histology of skin Histology of aging skin Functions of skin decline with age • • • • • • • Cell replacement Barrier function Chemical clearance Sensory perception Mechanical protection Wound healing Immune responsesive Thermoregulation Sweatproduction Sebumproduction Vit production DNA repair Common skin disease in elderly • Benign neoplasia – Seborrheic keratosis : focal epidermal homeostasis loss leading to increase endothelin1 • 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 Solar lentigene Stucco keratoses • 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) • Malignant neoplasia – Squamous cell carcinoma – Basal cell carcinoma – Malignant melanoma • UV induce DNA damage • Decrease DNA damage repair capacity 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 • Types of basal cell carcinoma – Nodular BCC – Superficial BCC – Morpgoeic BCC • Nodular BCC – Small translucent growth, rolled edges – May be pigmented – Ofte smaall blood vessels on surface, bleeding spontaneous NODULAR BCC • Superficial BCC – Multiple lesions – Upper trunks or shoulders – Slow growing patches, shiny pink, slightly scaly, bleeding easy SUPEFICIAL BCC • Morphoeic BCC – Skin-color, waxy, thicken scar – Most difficult to diagnosis – Prone to recurrent MORPHOIC BCC • 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 Squamous cell carcinoma • Common type of skin cancer • Type of squamous cell carcinoma – In situ SCC – Invasive SCC • 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 • Causes of in situ SCC – Sun exposure – Immunosuppression – HPV – Arsenic ingestion – Ionizing radiation BOWEN DISEASE • 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 • 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 SQUAMOUS CELL CARCINOMA SQUAMOUS CELL CARCINIMA OF LIPS • Treatment – Excision : the most common treatment of invasive SCC – Cryotherapy – Radiation Malignant melanoma • serious skin cancer which is curable if detected early • Growth from melanocyte in epidermis or mucous membrane • Common in 50-70 yr • 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 darkskinned people – A large number of abnormal moles (called atypical naevi). These moles are usually larger than 6mm, with an irregular shape and multicolours • The ABCDs of melanoma – A : asymmetry – B : border irregularity – C : colour variation – D : diameter > 6 mm Superficial melanoma Nodular melanoma • Treatment – Surgical removal – Sentinel node biopsy 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 Flexural psoriasis Xerosis • Disturbance of epidermal maturation • Decrease water content in outer layers of stratum corneum – Dry , rough, skin xerosis Pruritus • Penetration of irritants through the damage stratum corneum • Alter sensory threshold • Metabolic disorder • Endocrine disorder • Adversr drug reaction • Parasitic infestation : scabies Infection • Compromised local cutaneous health predispose to growth of infective organism • Age-associated decreased immune response • Underlying systemic disorder associated with decreased immune response scabies • Metabolic and endocrine disorder – DM – Renal failure – Thyroid disease – Hepatic disease – Lymphoma, leukemia, PV 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 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) • 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 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 PLANAR XANTHOMA ERUPTIVE XANTHOMA Acantosis nigricans • Hyperpigmentation, hyperkeratosis,velvety distribuion at intertriginous area • Most common area : axilla, genitaria, groin, popliteal fossa, anticubital and neck • Associated condition – Insulin resistant related • Obesity • Pseudoacromegaly • DM • Polycystic ovarian disease • Malignancy related : – Adenocarcinoma : gastric – Melanoma – Sarcroma – Lung carcinoma : small cell, squamous, bronchoalveolar – Lymphoma – Endocrine malignancy : carcinoid, pheochromocytoma, thyroid,testicular – Wilm tumor • Drug induce – Somatotrophin – Testosterone – Nicotinic acid – OC – Corticosteroid • Idiopathic • Syndromes – Acromegaly – Addison – Cushing – Dermatomyositis – Down – Cirrhosis – Hypothyroid – SLE – scleroderma Acanthosis nigrican Vitiligo • Autoimmune disease, pigment cell are destroyed • Irregular white patches on the skin • Any part of the body may be affect • 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 • Cause of vitiligo – Unknown – Autoimmune against the pigment cell • Treatment – Topical steroid – PUVA vitiligo • Associated with cancers of the esophagus, lung, breast, bladder, stomach, and cutaneous T-cell lymphoma Erythroderma • 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 Collagen Vascular Disease: Dermatomyositis Heliotrope erythema Gottron’s papules 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 Other disorders associated with malignant disease • • • • • Pruritus Sister Mary Joseph nodule Erythema gyratum repens Subcutaneous fat necrosis Sweet’s syndrome • • • • Hypertrichosis lanuginosa acquisita Necrolytic migratory erythema Leukoderma Sign of Leser-Trelat Sister Mary Joseph Nodule 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 Sweet’s Syndrome (Acute Febrile Neutrophilic Dermatosis) Sweet’s Syndrome Subtypes • Classic (71%) • Neoplasia (11%) – hematologic malignancies, usually AML • Inflammatory Disease (16%) • Pregnancy (2%) Sweet’s 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) 1. 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 2. Accompanied by periods of general malaise and fever (>38°C) 3. Laboratory values during onset (three out of four necessary): • ESR > 20mm n.W., • C-reactive Protein positive, • segmented-nuclear neutrophils and stabs > 70% in peripheral blood smear, • leukocytosis > 8.000 4. Excellent response to treatment with systemic corticosteroids or potassium iodide Necrolytic Migratory Erythema (Glucagonoma Syndrome ) 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 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. Sign of Leser-Trelat • Sudden appearance of multiple seborrheic keratoses • Association with internal malignancy is unproven Thank you