DISCLOSURE OF RELEVANT
RELATIONSHIPS WITH
INDUSTRY
Robert A Norman DO MPH
Xerosis & Pruritus in the Elderly
Consultant – JSJ, Allergan.
Advisory Board – Coloplast, Connetics, Coria,
Abbott, Galderma
Honoraria – Allergan, Amgen, Coloplast,
Connectics, Coria, Abbott, Novartis.
Xerosis and Pruritus
(Dry Skin And Itching)
Abstract
Xerosis (dry skin) is a common
dermatological skin condition. Dry
Skin, or Xerotic Eczema, can be
labeled as Xerosis, Eczema craquele,
Dyshidrotic Eczema, or Asteatotic
Eczema.
Xerosis
Incidence has
increased in recent
years because of:
• more frequent
bathing and
showering
• fragranced baths
Xerosis and Pruritus in the Elderly
Dr. Robert A. Norman
President and CEO
Dermatology Healthcare, LLC
Tampa, Florida
Clinical Associate Instructor
Department of Internal Medicine
Division of Dermatology
Nova Southeastern Medical Center
Ft. Lauderdale, Fl
www.drrobertnorman.com
Xerosis
• Dry, rough, scaly skin
• May crack and fissure
• Endogenous and
exogenous causes
• Incidence increases
in elderly (age > 60)
Xerosis
The condition is characterized by
pruritic, dry, cracked and fissured
skin with scaling.
Xerosis occurs most often on the legs
of elderly patients.
These skin cracks or fissures are
present from epidermal water loss.
1
Signs/Symptoms:
The skin splits and cracks deeply enough to
disrupt dermal capillaries and bleeding
fissures may occur. Itching or pruritis
occurs leading to secondary lesions.
Scratching and rubbing activities produce
excoriations, an inflammatory response,
lichen simplex chronicus and even
edematous patches.
Differential diagnosis: stasis dermatitis
Treatment—Moisturizers, alpha-hydroxy
Avoidance of harsh skin cleansers
Xerosis
It is characterized as
– pruritic (itchy)
– dry
– cracked
– fissured
Xerosis
Xerosis has a spectrum of clinical findings
normal
xerosis
icthyosis
2
Ichthyosis
• Ichthyosis is derived from the Greek word
ichthys which means “fish”
• Describes a group of diseases
characterized by abnormal differentiation
of the epidermis
• Manifests clinically as scaling of the skin
• Can be inherited or acquired
Xerosis
Classified as:
•
Acquired
•
Congenital
Causes of Xerosis
• Endogenous Causes
–
–
–
–
–
–
Asteatotic eczema
Venous dermatitis
Atopic dermatitis
Aging
Hereditary conditions (ie. Ichthyosis)
Acquired conditions
• Exogenous causes
– Excessive exposure to water, dry climate, detergents
Causes of Xerosis
Environmental agents that lead to xerosis
include
–
–
–
–
–
–
–
–
–
hot water
soap & detergents
friction from clothing
frequent air travel
pollution
other chemicals
air conditioning
low humidity
seasonal changes
Stasis dermatitis
3
Stasis dermatitis
Stasis Ulcers
Management: includes topical agents such
as Alpha-Hydroxy acid moisturizers or
steroid cream or ointment (triamcinolone
for 10-14 days).
The stratum corneum of the skin is
surrounded by a lipid bilayer composed
primarily of ceramides, fatty acids, and
cholesterol.
When these constituents are present in
the proper proportion, they form the “skin
barrier,” which functions like a brick wall
(keratinocytes) covered by mortar (the
lipid bilayer). This barrier protects the skin
and keeps it watertight.
Defects in the stratum corneum or
barrier can result in transepidermal
water loss, which dehydrates the
skin and imparts a dry appearance.
An impaired barrier may also make
skin more susceptible to damage
from exogenous sources such as
plants, chemicals, and even water.
Ceramides (Cer)
Cer is an amide-linked fatty acid
containing a long-chain amino alcohol.
This amino alcohol is named as sphingoid
base or sphingol. Cer is the backbone of
all sphingolipids.
Uchida Y, Hamanaka S Stratum
Corneum ceramides: Function, Origins,
and Therapeutic Applications in Elias P,
Feingold K Skin Barrier Taylor and
Francis 2006
4
Frequent eruptions of erythema and
pruritus typify dry, sensitive skin and
indicate a likely defect in the stratum
corneum. People with such skin are
at higher-than-average risk for
eczema.
Natural moisturizing factor (NMF), a
substance that retains water inside
keratinocytes and renders them
plump, also plays an important role
in the pathophysiology of dry skin.
NMF is derived from the hydrolysis of
the protein filaggrin, which confers
structural support to the dermal
layers and breaks down as NMF in
the epidermal layers, exhibiting a
strong capacity to bind water and
hold it inside the cell.
The breakdown of filaggrin
acclimates to varying
environmental conditions over a
course of several days. In a lowhumidity environment, more
NMF is produced.
Currently, there is no known method
of artificially enhancing filaggrin
breakdown in order to elevate NMF
levels. In the 1970s, UV light was
demonstrated to disrupt the
enzymatic hydrolysis of filaggrin to
NMF, suggesting that reduction of
sun exposure might improve skin
dryness.
5
Causes of Xerosis
Xerosis is due in part to:
– Decrease in the natural moisturizing
factor in stratum corneum
– Defect in permeability barrier
Sebum-derived fats form lipid films on the
skin surface that help to prevent water
loss. However, low sebaceous gland
activity is not correlated with xerosis.
Not all people with xerosis have decreased
sebum production, which is affected by
diet, heredity, stress, and hormones
(Br. J. Dermatol. 1988;118:393–6).
Hyaluronic acid (HA), which can bind 1,000
times its weight in water, also helps retain
water in the skin. Aged skin is
characterized by reduced HA levels, which
causes dryness and makes the skin appear
older and less plump.
Glucosamine supplements may help increase
HA production, although HA does not
penetrate the skin when applied topically
(Cosm. Toil. 1998;113:35–42).
The reduced production of sebum
also may play a role in dry skin.
Sebum contains wax esters,
triglycerides, and squalene, all of
which protect the skin from the
environment.
(Clinics Dermatol. 1995;13:307–21).
The influence of sebum on dry skin is
not well understood
A deficiency of NMF and low sebum
levels may cause dry skin and may
increase skin sensitivity.
(J. Invest. Dermatol. 1987;88:2s–6s).
Diet
Replenishing the three key components of
the stratum corneum--ceramides, fatty
acids, and cholesterol--is the aim of some
skin care formulations.
Diet also plays an important role in
maintaining a healthy skin barrier; fatty
acids and cholesterol are derived from the
diet. Certain individuals receiving
cholesterol-reducing drugs exhibit dry
skin.
6
Hydration
The addition of evening primrose oil,
borage oil, or omega fatty acids to
the diet may contribute to
ameliorating dry, sensitive skin by
replenishing essential components of
the stratum corneum.
Therapy
-Adequate hydration
-Avoid foaming detergents and soap
found in laundry cleansers, body
cleansers, and face cleansers
-Avoid prolonged baths, particularly in
hot or chlorinated water.
-Use humidifiers in low-humidity
environments
-Consider taking omega-3 fatty acid
supplements
-Moisturize two or three times daily.
Xerosis Assessment Tool
Xerosis Scale for Measuring Dry, Scaly Skin
0: Absent
1: Mild dry skin with minimal flaking
2: Moderate dry skin with flaking
3: Severe dry skin with or without cracking/fissures
Skin health interventions for xerosis includes
appropriate bathing and moisturization strategies to
minimize the likelihood of a break in skin integrity.
Developing an individualized plan of care for the
patient with xerosis is essential in restoring skin health
and greatly improving patient outcomes.
• Water helps maintain
a healthy stratum
corneum
• Water increases the
permeability of the skin
– Mechanism is not known
– Relationship between
permeability and
overhydration is not
known
Skin Assessment: Xerosis (Dry Skin)
Coloplast Skin Health Division developed the following
Xerosis Assessment Tool to be utilized when assessing
and documenting patient skin conditions. It is derived
from documented clinical studies assessing xerosis
and review of clinical literature.
The purpose of this tool is to provide clinicians with a
tool to assess, document and establish interventions
for xerotic (dry) skin before the patient develops
scratching and/or develops skin complications.
What is Pruritus?
• Pruritis or itch is a
common complaint
• Can be due to many
dermatological and
medical illnesses
• Can occur with or
without skin lesions
7
Pruritus
• Also known as “itch”
• Dominant symptom of many skin diseases
• May be the initial sign of many systemic
diseases
• Originates in the skin or in the central nervous
system
• Transmitted by unmyelinated C nerve fibers
• Elicited by physical and chemical stimuli
• The receptor for pruritic stimuli are located in the
epidermis
Mediators of Pruritus
• Inflamed skin causes the release of a
number of chemicals (histamine,
prostaglandin, substance P, interleukins,
tryptase, serotonin, and opioid peptides)
which mediate pruritus
• Pruritus in skin disease is multifactorial;
neurogenic components may play a role in
some skin diseases
Evaluation of Pruritus
• Examination of the
skin
• Assessment
– primary and secondary
lesions
– morphology and
distribution
– presence of
lichenification
Evaluation of Pruritus
Patients with severe pruritus that does not respond to
conservative therapy should be evaluated for
•
metabolic or endocrine disorders
–
–
–
–
Diabetes mellitus
Renal failure
Thyroid disease
Hepatic disease (obstructive)
•
malignant neoplasm
•
hematologic disease
•
human immunodeficiency
virus infection
complication of
pharmacologic therapy
neuropsychiatric diseases
–
–
–
•
•
Lymphomas
Leukemia
Polycythemia vera
lymphoma
8
Evaluation of Pruritus
Possible diagnostic tests to be performed
– complete blood count with differential and platelets
– thyroid-stimulating hormone
– serum bilirubin, liver transaminases, alkaline
phosphatase
– fasting glucose
– serum creatinine and
blood urea nitrogen levels
– chest radiography
– HIV
9
The "itch-scratch" cycle is the
dermatologic equivalent of chronic pain
syndrome, and should be treated as such.
Just as with chronic pain, there is a
"reduced threshold" phenomenon that
occurs in patients with chronic itch.
Chronicity not only lowers the threshold
for the sensation of itch, it also increases
the intensity of itch. Also, as with chronic
pain, short bursts of spontaneous itch may
occur, even when the skin is clear.
Pruritus
Scratching may contribute to
Pruritus
Chronic scratching may lead to
lichen simplex chronicus
impetigo
Treatment of Pruritus
General measures include
• Elimination of factors that aggravate dry
skin
• Patient education
• Teaching of adequate methods of
interrupting the itch-scratch cycle
Prevention and Treatment
of Pruritus
• DOs
– Wear cotton or silk clothing
– Take short, lukewarm baths/showers
– Dry gently after bathing
– Apply topical emollients immediately after
bathing
– Keep nails short
– Stop the Itch-Scratch cycle
10
Prevention and Treatment
of Pruritus
• DON’Ts
– Wear wool or synthetic clothing
– Take long, hot showers/baths
– Live in cold, dry climates
– Use soaps excessively
– Scrub habitually
– Have prolonged exposure to water
– Scratch
Treatment of Pruritus
Treatment of Pruritus
• Teaching of adequate methods of
interrupting the itch-scratch cycle
– Application of a cold washcloth
– Gentle pressure
scratch
Treatment of Pruritus
• Topical agents
Multiple topical and systemic treatments
have been recommended for the
management of pruritus, as well other
modalities
Treatment of Pruritus
• Systemic agents
– hydroxyzine hydrochloride
– diphenhydramine
– doxepin (tricyclic antidepressant with
antihistaminic properties)
– oral corticosteroids
– emollients
– corticosteroids
– anesthetics
– doxepin
– capsaicin
– menthol
– topical
immunomodulators
new t-shirt to prevent itching in children and
adults.
--to be sold by Hill Pharmaceutical based on a fabric
developed by Milliken.
--It has an extremely low coefficient of friction and
wicks sweat better than cotton.
--close up pictures of cotton vs. this microfiber long
filament polyester.
--"We were able to show a statistically significant
reduction in itching between cotton and this
fabric in 60 subjects in a 4 week cross over study"
From Dr. Zoe Draelos
11
Figure 1
Figure 2
Dermatology Consultations in the Nursing Homes—A Ten Year Retrospective
Dr. Robert A. Norman, Clinical Associate Instructor, Department of Internal Medicine, Division of Dermatology, Nova Southeastern Medical School, Ft. Lauderdale,
Florida and Private Practice, Tampa, Florida, 8002 Gunn Hwy, Tampa, Fl 33626, [email protected], www.geriatricdermatology.com
Dermatologi sts Beware!!
You Are Becoming Even More Important!!
The vast majority of people older than 70 years of age have at least one bothersome skin
condition, and approximately ten percent have 3-4 dermatological problems.
“This traditional neglect of the skin is w ell-nigh unforgiv able and has cruel consequences for
the w ell being of the elderly. The great majority of persons over 70 have at least one, often
tw o or three, skin conditions w hic h would benefit from the attentions of a know ledgeable
doctor. These diseases do not kill but they are persistent pestilences which spoil the quality of
life…It is the skin more than any other organ w hich most clearly reveals the cumulative losses
which time prints on the visage of the high and low alike.”
Re search Findings
I completed a study of the nursing home patients I treat, and found the tw o most common
problems are overw helmingly xerosis and pruritus (Table Four includes age and gender
distribution). Given these results, attention needs to be paid to the recognition and treatment
of these entities. Of ultimate importance is the comprehensive treatment of these problemsto
prevent stasis dermatitis and ulcer formation.
List of recommendations.
Long term care dermatology is a grow ing specialty, and w e all must w ork together to
improve the care of our patients.
Treatment Recommendations
Keep in mind the ten tips below .
1. Whenever possible, identify the reason for each prescribed medication and treatment.
Top Ten Problems in Nursing Home Dermatology
1. Pruritu
s
2. Xerosi
s
2. Begin treatment w ith the low est possible dose and prescribe short courses of treatment.
Continually re-evaluate the clinical outcome. Check on the “prn” or routine medications
no longer clinically indicated for a resident and eliminate unnecessary treatments.
Albert M. Kligman, MD in the forew ord to Barbara Gilchrest, MD’s book Skin and Aging
Processes CRC Press, Inc. Boca Raton, Florida
3.
4. Infections
•lDermatophyte
•lCandidiasis
•lCellulitis,
• lLichen Sim plex
folliculitis, m iliaria
Chronicus
• lPrurigo Nodularis 76 y/o female cellulitis of
the face.
• lNeurotic
•Herpes Zoster
Excoriations
• lDelusions of
Parasitosis
3. Assume the treatment w ill not be provided as often as prescribed. Workload, time
restraints, and poor compliance are all issues which effect the treatment of skin
conditions in the long-ter m care patient. If you prescribe Triamcinolone cream 0.1% for
tw o weeks for an eczematous dermatitis, I recommend w riting it TID w ith the hope that it
will get applied at least once a day.
1000
Diseases of the sebaceous
glands (Xerosis=772)
800
4. Work w ith the nursing staff and attending physician on neuropharmacological agents,
checking to make sure the prescribed drugs do not interfere w ith current treatments.
Long-term Care Dermatology
Pruritus and other
related diseases
1200
Psychogenic Disorders
5. Do not forget the simple preventions, such as antibacterial soaps, frequent handwashing,
proper shoes, supports and devices for wound prevention, adequate hydration and
humidity, proper lighting, and eliminating high-fall risks.
Long-term care dermatology is truly its own art form. And it is a growing specialty, draw ing from
the realm of both dermatology and geriatrics.
6. At least once a year, provide in-servic es to the nursing home staff on dermatology
issues. The staff require CEU’s and are generally very appreciative of your time. You
are a crucial part of the team in improving the residents’ treatment, and face-to-face
encounters are crucial in maintaining an ongoing quality of care.
Those of us that work in long-term care serve a population composed of over 2.7 million patients,
the total estimated population in nursing homes and ALF’s.
Why the shortage of high quality skin care? Not enough attention is given to skin problems and
delay in care and treatment often occurs. Other problems include little access to specialists and
delayed disease recognition, especially for certain diseases seen more prominently in the elderly
population in nursing homes such as bullous pemphigoid.
Other dermatoses 2
5.
Infestations
7. Consider doing a skin cancer screening for patients and employees. It’s a great servic e
for them and can increase the number of people in your practice.
The w orld of today's hospital can be described as "high tech, low touch," in that the patient may
be poked and probed, treated and then “streeted.” Nursing homes are certainly not hospitals,
although many have sub-acute floors and hospital patients requiring significant post-op care are
sent to live in nursing homes until able to be sent home. Nursing homes are mostly “low tech
with high touch.” What the resident did for himself/herself in the past is now done with the
assistance of others.
8. In addition to their clinical skills, long-ter m care medical directors and consultants have a
need to know w hat their ethical and legal obligations are. A comprehensive grasp of
important issues, including end of life, restraints, and informed consent are important for
medical directors and consultants decision-making in long-term care. All of these
principles and issues must be addressed in the spotlight of cost containment and
litigation.
Think about it. What happens if you were in a situation w here you are now put into a facility such
as a nursing home? The nurses and aides would help you get out of bed in the morning, toilet,
bath, dress, eat and take your medications. The activities' staff would be around you attempting
to stimulate your interest and zest for lif e. The food service personnel w ould be cooking for your
health and enjoy ment and therapists would be busy fighting an uphill battle against a possibly
deteriorating body and mind, and the social servic es staff would try to help solve problems
ranging from financial diffic ulties to unpleasant roommates. Although many social service people
act as marketing operatives, w ith the primary function of recruiting residents, most social service
directors that I have encounter help educate families about themselves, their needs, and the
resources that are available in the community to serve these needs.
The goals of care in an institutional setting may differ from those of the acute hospital.
The emphasis is placed on maximizing function, maintaining quality of life, and comfort
care rather than curing disease. Communicate w ith the resident’s family to address
their fears and concerns and ensure their participation in the development of the care
plan.
9. Follow -up care includes interventions to handle acute events, periodic reassessments of
the patient’s status and implementation of preventative programs to meet specific
treatment and maintenance goals. Regular evaluations provide an opportunity to review
the resident’s and staffs concerns, monitor vital signs including w eight, identify changes
in the physical examination, re-examine the medication list and review the care plan.
6. Autoimmune Disorders
81 y/o Male bullous
pemphigoid.
7. Inflamm atory
Disorders
600
Basal or squamous cell
carcinoma of the skin
400
8. Vascular
Disorders
9. Neoplasia
10. Mechanical
Disorders
•Skin tears
•Wounds
200
Scabies
10. Sometimes patients just have stories and just want to talk. Be patient w ith your
patients and enjoy your time together.
0
ICD 9 CM
Code
Long-term Care Dermatology, Continued
References
1. Nor man R Geriatric Dermatology 2001 Parthenon/CRC Publishing
As a health care provider, we enter into the resident's home, a place that is often new and
sometimes permanent. It is important to keep that in mind. In order to become part of the
resident's life and therapeutic family, you must keep a respect for the resident and his/her
environment. Many move into nursing homes from their ow n residents or those of family and
friends and the rest are transferred directly from hospitals to nursing homes. The patient and
family are under considerable pressure. Very often a long period of adjustment is needed,
coming to grips w ith the fact that many of these residents w ill never return to their previous
homes or lifestyle.
2. Dhar marajan TS, Nor man R Clinical Geriatrics January 2003 Parthenon/CRC Publishing
N1
% Male Mean Age
(SD)2
Contact dermatitis and
other eczema
3. Nor man R Dermatologic Therapy November 2003 Guest editor(Issue on Geriatric
Der matology)
4. Nor man R Dermatologic Clinics January 2004 Guest editor (Issue on Geriatric Dermatology)
5. Nor man R. Causes and Management of Xerosis And Pruritis in the Elderly. Annals of Long
Term Care 2001; 9(12): 35-40
6. MD Live http://www.mdlive.net (w eb) Norman, R (Geriatric Dermatology)
1 Total sample size = 1556
2 SD = standard deviation
3specif ied and unspecified hypertropic and atrophic conditions, keratoderma
7. Marks, R Skin Disease in Old Age Martin Dunitz 1999
Printed
by
Professional Posters Made Easy
References
1. Norman, R ed Geriatric Dermatology (book) Parthenon
International Publishing London/New York (2001)
2. Norman, R A Dermatologist’s Guide to Nursing Home
Consultations Skin and Aging (The Journal of Geriatric
Dermatology) January 1998 pp 62-72
3. Young EM, Newcomer VD, Kligman AM. Geriatric Dermatology,
Lea Febiger, Philadelphia 1993
4. Marks R Skin Disease in Old Age Martin Dunitz London 1999
5. Norman R. Dermatological problems and treatment in longterm/nursing home care in Norman R. (ed) Geriatric
Dermatology 2001 Parthenon/CRC Publishing pp.5-15.
6.
Norman R. and Townsend R. Dermal manifestations of
diabetes in Norman R. (ed) Geriatric Dermatology 2001
Parthenon/CRC Publishing
7.
Dermatologic Therapy November 2003 Guest editor Geriatric
Dermatology
8. Norman R. Causes and Management of Xerosis And Pruritus in
the Elderly Annals of Long-Term Care Volume 9 Number 12
December 2001 pp 35-40
9. Clinical Geriatrics Norman, R (book; co-editor with T.S.
Dharmarajan) January 2003 Parthenon/CRC Publishing
10. Pruritus, Itch Mechanisms, and Treatments Dermatologic
Therapy July/August 2005 Volume 18 Number 4
12