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The Pharmacist’s Role. At the end of this session the participant will be able to: Describe the dermatological changes that occur as we age List some.

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Presentation on theme: "The Pharmacist’s Role. At the end of this session the participant will be able to: Describe the dermatological changes that occur as we age List some."— Presentation transcript:

1 The Pharmacist’s Role

2 At the end of this session the participant will be able to: Describe the dermatological changes that occur as we age List some of the common disorders that are prevalent in an older population Describe the risk factors and consequences of decubitus ulcers Describe treatment options for Xerosis

3 In the Elderly

4 Intrinsic: occurs in everyone and is related to genetic changes in cell processes Extrinsic: produced by external causes (e.g. UV exposure, smoking, environmental pollutants)

5 Decreased mobility Innate cutaneous age-related changes Drug induced disorders Chronic Diseases (e.g. CAD, Diabetes, CHF, HIV) Cellular changes in the epidermis & underlying structures

6 Altered lipid metabolism  impaired ability to recover from injury Sluggish keratinocytes  impaired ability to recover from injury Decreased melanocyte density  decreased protection from UV rays Decreased Langerhans cells density  decreased immune function Loss of collagen and elastic tissues  wrinkles and skin fragility Decreased function of cutaneous nerves, microcirculation and sweat glands  poor thermoregulation and increased risk of burning Decreased subcutaneous fat in distal extremities  less “padding” to protect from trauma

7 Fragile skin (skin tears, abrasions, cuts) Traumatic purpura (bruises) Ischemia (cell death, decubiti) Xerosis (dry skin) Infections Skin cancers

8 Stage III Decubitus Ulcer with necrosis on sacrum

9 Usually occur over bony prominences Caused by ischemia, which leads to cell death and tissue damage Related to the forces of: Pressure Shear Friction Frequently complicated by secondary infection, leading to: Cellulitis Osteomyelitis Sepsis

10 Elderly patients, especially those in LTC facilities & hospitals Critical care patients Oncology patients Diabetics End stage renal, heart or liver disease patients Patients with femoral fractures Incontinent patients Patients with impaired mental status Patients with impaired nutritional status

11 Stages of Decubitus Ulcers Stage INonblanching erythema of intact skin Stage IISuperficial to partial thickness involvement of the epidermis or dermis Stage IIIDeep necrosis with full-thickness skin loss that may extend down to, but not through, underlying fascia Stage IVExtensive necrosis to underlying fascia, possibly extending into muscle, bone, and supporting structures

12 Stage-dependent Ranges from cleansing and application of protective ointments and specialized dressings to surgical debridement of necrotic tissue. The pharmacist should be aware of any topical agents and specialized dressings being used and encourage compliance to any ordered regimen. The pharmacist may recommend nutritional, vitamin, and mineral supplements, after consultation with a nutritionist, when wound healing is delayed The pharmacist may recommend appropriate pain management for pain related to dressing changes and chronic pain which may be decreasing mobility Secondary infection should be treated with systemic antibiotics, NOT topical formulations

13 Appropriate treatment should be determined by a wound care specialist, as use of inappropriate dressings may cause harm (e.g. occlusive dressings over an infected wound may lead to sepsis and debriding dressings used on granulating wound beds may delay healing) Wound dressings may be combined in different ways by different practitioners dependent on the individual case and prior experience

14 Appropriate wound dressings should: Maintain a moist wound bed Control moisture levels on healthy wound margins (to avoid maceration) Permit gas exchange (oxygen required for healing) Provide thermal insulation Prevent secondary infection and decrease colonization of wound bed Adhere to body to maintain good wound-dressing contact without damaging healthy skin when removed Avoid over-adherence to wound bed to prevent trauma on removal (unless debridement is needed) Fill wound cavities to promote healing by primary intention

15 Dressings which may be used for outpatient treatment may include Gauze (wet to dry dressings) mechanical debridement must be done at least TID (to avoid over-drying) stop once wound bed is mostly clean or granulation tissue will be removed Simple occlusive dressings (e.g. Opsite) Useful to prevent skin breakdown in vulnerable areas, or prevent further breakdown in Stage I areas Semipermeable – allows gas exchange and keeps out microbials Allows visual inspection of wound area through dressing Change PRN Gentle on healthy skin when removed correctly Never use on an infected wound

16 Hydrocolloid dressings (e.g. Duoderm) Keep wound bed moist Offer some absorption for wounds with minimal exudate Offer some thermal protection May be changed infrequently depending on wound (q2days – q7days) Semipermeable – allow gas exchange and keep microbials out Different shapes available for different body parts (i.e. Sacrum) Adhesive is gentle to healthy skin when removed Do not use on infected wounds

17 Impregnated dressings (e.g. Mesalt,) Exert osmotic pressure and dissolve necrotic tissue using the body’s own fluids Provide an environment which discourages bacterial growth in the wound bed (high salt content) Pack the wound to heal by primary intention Should only be used in wounds with large amounts of exudate (in order to avoid drying the wound bed) Change at least BID May be used on infected wounds

18 Absorbent dressings (e.g. foam, calcium alginate) Highly absorbent materials to control wound exudate Come in various forms and can be used to pack wounds and/or as an outer layer Provide thermal protection to the wound Allow dressings on clean wounds to be changed less frequently Frequently used in conjunction with impregnated dressings to control moisture

19 Topical treatments may include: Saline Used to cleanse the wound and debride necrotic material (wet-to-dry, syringe irrigation) Commercial wound cleansers (instead of saline) Hydrogels/Xerogels Keep dry wound beds moist to promote healing Allow longer periods between dressing changes Act as gentle packing to encourage healing by intention

20 Topical treatments may include: Silver sulfadiazine creams/gels/solutions Some antibacterial properties to  wound colonization (biofilm theory) May reduce odour in infected wounds May alleviate some pain in wound bed Help to keep the wound bed moist Sulfa based antibiotic creams Antibacterial properties to  wound colonization (not used for true wound infections) Help to keep the wound bed moist Other antiseptics (e.g. Dakin’s Solution, Chlorhexadine) may be ordered but do not offer any advantage over saline, do not promote wound healing and should be avoided

21 The pharmacist should support the efforts of the healthcare team to prevent decubitus ulcers and encourage caregiver compliance with preventative strategies Encourage mobility as appropriate (manage pain) Turning schedules for bedbound patients (q2h) Pressure reducing mattresses and wheelchair cushions (egg crates and sheepskin are comfort measures only; they do not reduce pressure) Keep skin dry and clean(control wound drainage, incontinence and other sources of moisture) Minimize physical restraint use Assess skin daily and keep intact skin in good condition using barrier creams, moisturizers and emollients


23 Xerosis (dry skin) is characterized by: Pruritus (itchiness) Dryness Cracks Fissures (like cracked porcelain) Occurs mostly on the legs (but sometimes hands and trunk) Excoriation (from scratching) leading to infection or dermatitis

24 Dry air e.g. low winter humidity Exposure to the wind Over-washing Reduction in production of natural moisturisers (sebum) in old age Diuretic medications Underactive thyroid gland Inherited factors A skin condition such as atopic dermatitis (eczema), psoriasis or ichthyosis Any combination of these

25 Occlusive moisturizers and emollients Oils, lotions, creams and ointments Humectants, keratolytics and keratoplastics Urea, ammonium lactate, and alpha hydroxy products Non-pharmacologic management

26 Oils of non-human origin, either in pure form or mixed with varying amounts of water through the action of an emulsifier,to form a lotion or cream. Provide a layer of oil on the surface of the skin to slow water loss and thus increase the moisture content of the stratum corneum. Should be used liberally and frequently Unscented, nonallergenic is preferable Preferably applied when skin is damp No EBM comparing different moisturizers. There is no '‘right’ moisturiser for all patients: the most suitable one often having to be found by trial and error.

27 Bath oil deposits a thin layer of oil on the skin upon rising from the water. Lotions are more occlusive than oils. These are best applied immediately after bathing, to retain the water in the skin, and at other times as necessary. Creams are more occlusive again. Thicker barrier creams containing dimeticone are particularly useful for those with hand dermatitis. Ointments are the most occlusive, and include pure oil preparations such as equal parts of white soft and liquid paraffin or petroleum jelly.

28 The choice of occlusive emollient depends upon the area of the body and the degree of dryness and scaling of the skin: Lotions are used for the scalp and other hairy areas and for mild dryness on the face, trunk and limbs. Creams are used when more emollience is required on these latter areas. Ointments are prescribed for drier, thicker, more scaly areas, but many patients find them too greasy.

29 Humectant: a substance that promotes retention of moisture Keratolytic: a substance that softens keratin and improves the skin's moisture binding capacity Keratoplastic: substances which normalize keratinization Many products have more than one of these properties All or some of these may not be tolerated by patients due to stinging and irritation

30 Hydrating effects – urea is strongly hygroscopic (water-loving) and draws and retains water within skin cells Keratolytic effects – urea softens the horny layer so it can be easily released from the surface of the skin Regenerative skin protection – urea has a direct protective effect against drying influences and if used regularly improves the capacity of the epidermal barriers for regeneration Irritation-soothing effects – urea has anti-pruritic activity based on local anaesthetic effects Penetration-assisting effects – urea can increase the penetration of other substances, e.g. corticosteroids as it increases skin hydration

31 Symptomatic relief of dry skin by increasing moisture capacity of stratum corneum. Have also been shown to reduce excessive epidermal keratinization in patients with hyperkeratotic conditions. Loosen the glue-like substances that hold the surface skin cells to each other, therefore allowing the dead skin to peel off. The mechanism of action of topically applied neutralized lactic acid is not yet known.

32 Possible adverse reactions of both occlusives and humectants/keratolytics include: Irritation (burning sensation, stinging) – usually caused by an ingredient in the cream or lotion base Allergy - true allergies are rare Folliculitis - Over-occlusive emollients can result in blocked hair follicles and painful pustules (folliculitis) or boils

33 Reduce washing to every second day, or less often, although the body folds may be sponged daily if desired. Baths or showers should be kept as brief as possible. Water should be lukewarm. Minimise the use of soap and avoid harsh cleansers. Use a mild soap or better still, a detergent-based cleanser. Cleansers that have the same pH as the skin (5.5) may be advantageous. Reduce the need for bathing by keeping as clean as possible Humidify air in dry environments

34 Skin infections are common in elderly patients due to frequent skin trauma, dermatitis, and impaired immunity, and may be: Bacterial (e.g. impetigo) Viral (e.g. varicella, herpes simplex) Fungal (e.g. seborrheic dermatitis, candida, tinea)


36 Usually found near the mouth or nares, but may be anywhere on the body May be bullous (staphylococal) or nonbullous (streptococcal) Treated with oral and topical prescription antibiotics OTC preparations are not effective Encourage good hygiene to avoid contact spread Confused elderly should be kept isolated until 48 hours of treatment has elapsed


38 Varicella or herpes zoster, also known as shingles, results from reactivation of the dormant varicella zoster virus in adults, the same virus that causes chickenpox in children. Vesicles usually appear along one dermatome (nerve path) rarely cross the midline may crust over after several days usually dry out over 2-3 weeks Post herpetic neuralgia may last from months to years after the rash is gone OTC therapy will not treat the virus but may assist with symptom management

39 NSAIDs may be helpful in pain management in milder cases Antihistamines may be helpful to alleviate itching of the rash Hydrocortisone cream may be helpful to alleviate itching of the rash Antipruritic lotions (e.g. calamine) may also help to alleviate itch Capsaicin cream (e.g. Zostrix) may help with pain once the vesicles have crusted over and also with post herpetic neuralgia Ensure that the patient has sought medical treatment for the virus itself and that OTC treatments are not contraindicated by other medications or pre-existing disease

40 Dermatological fungal infections are highly prevalent in the elderly and include: Seborrheic dermatitis Candida Tinea Pedis (Athlete’s Foot) Tinea Cruris (Jock Itch) Onychomycosis (Tinea Unguium nail infections)


42 Caused by a combination of an over production of skin oil and irritation from a yeast called malassezia. Usually found in sebaceous areas Scalp (called cradle cap in infants) Eyebrows Nasolabial folds Ears Chest Presents a reddened patches or plaque with greasy scales May be pruritic (itchy) May be related to nutritional deficiencies or disease states (eg. Parkinsons, HIV)

43 Generally managed with OTC products Selenium sulfide Zinc pyrithione Coal tar Ketoconazole 2% Low potency topical steroids may be used in more severe cases


45 Found mostly in skin folds where there is warmth, moisture and skin to skin contact: Inguinal Between the fingers Perianal Under the breasts Appears as a demarcated “beefy-red” eruption with satellite pustules

46 Often related to: Obesity Diabetes Immunosuppression Chronic debilitation Occlusion under incontinence products Systemic antibiotic therapy

47 OTC Treatments may include Exposure to air Use of desiccants (Burrow’s solution, Castellani’s paint) Zinc oxide (topically) Topical azole antifungal agents BID Miconazole Econazole Ketoconazole Ciclopirox Antifungal powders may be used to dry the skin and prevent maceration Terbinafine cream is NOT effective against Candida.


49 Caused by dermatophytes Presents with erythema, scaling and maceration 3 types: Interdigital – dry scaling between toes Moccasin-type – involves entire sole and sides of foot Vesiculobullous – plantar surface; usually the arch

50 Usually treated with topical azole antifungals: Clotrimazole Ketoconazole Econazole Terbinafine Ciclopirox Systemic treatment reserved for extensive/persistent infections Oral treatment may be used for elderly patients who would have difficulty seeing or reaching their feet to apply cream

51 Prevention is key: Dry feet thoroughly after washing (especially between toes) Avoid walking barefoot in public places Wear cotton socks Intermittent application of antifungal creams, powders or sprays may help prevent recurrences


53 Presents as an itchy, red rash in the groin area Men are more likely to acquire this infection Treatments include: Reduce and control moisture Topical antifungals Severe or resistant cases may benefit from oral treatment


55 Fungal nail infections usually caused by dermatophytes Trichophytons rubrum Trichophytons mentagrophyte Very few cases caused by Candida or molds Prevalence increases with age (nearly 20% of patients over 60 are infected) Predisposing factors: Trauma Peripheral vascular disease Immunosuppression Diabetes Contiguous spread of tinea pedis Cannot be treated with OTC products


57 Blistering diseases in the elderly are rare and may be immune- mediated, drug-induced, or secondary to systemic illness. It can be fatal, even when treated Cannot be treated with OTC therapies Pharmacists should be aware that blistering diseases may be drug-induced. Medication classes associated with blistering diseases include Antibiotics Diuretics beta-blockers medications containing a thiol group (captopril, penicillamine, piroxicam)

58 Deficiencies in certain vitamins and minerals may present with skin findings, and the elderly are at greater risk of poor nutrition due to: Chronic disease Physical limitations which hamper food preparation Poor food choices due to economic restrictions Delayed gastric emptying Slowed intestinal motility Dry mouth Changes in taste perception Altered dentition

59 Skin manifestations of vitamin C deficiency may be related to defective collagen production. Common dermatologic concerns include: perifollicular hemorrhage gingival hypertrophy altered wound healing Systemic findings may include fatigue, anemia, and joint swelling. Symptoms related to vitamin C deficiency may present after 3 months without vitamin C intake.

60 In the elderly, malabsorption or malnutrition may lead to zinc deficiency Highest risk is found in those with Long term parenteral nutrition Alcoholics Patients with cirrhosis Zinc deficient patients will present with perioral or perianal erythematous, scaling plaques Nonhealing leg ulcers Hair loss

61 Skin findings may present when a patient is deficient in Riboflavin (B2) Niacin (B3) Pyridoxine (B6)

62 Patients with Riboflavin deficiency may present with Angular cheilitis (Inflammation, burning, redness, and ulceration or cracks at the corner of the mouth) Stomatitis (inflammation of the mouth lining) Seborrheic dermatitis

63 Patients with Niacin deficiency may present with dermatitis Those at risk for niacin deficiency include: Alcoholics Patients taking chronic antibiotic therapy Patients with cirrhosis Patients with carcinoid syndrome (Carcinoid syndrome is a group of symptoms associated with carcinoid tumors -- tumors of the small intestine, colon, appendix, and bronchial tubes in the lungs.)

64 Patients with Niacin deficiency may present with seborrheic dermatitis and photosensitivity Risk factors include: Alcoholism Cirrhosis Drug therapy: isoniazid, penicillamine & L-dopa

65 More than 50% of skin cancer-related deaths occur in persons over 65 years of age. Photocarcinogenesis due to sun exposure is a continuous and cumulative process Decreased melanocyte density  decreased protection from UV rays Decreased Langerhans cells density  decreased immune function

66 Can be divided into two main types Non-melanomas Rarely fatal but cause tissue damage and may become invasive Usually caused by UV radiation, sunlight, and HPV Melanomas Most lethal skin cancer Rates increasing dramatically

67 Most common types are BCC (basal cell carcinoma) Most common type of skin cancer Do not metastasize Usually treated with surgery SCC (squamous cell carcinoma) Untreated may progress and become invasive Can metastasize to lymph nodes Usually treated surgically

68 Most lethal skin cancer Rates increasing dramatically Four main types: Superficial spreading (most common) Nodular Lentigo (occurs only in the elderly) Acral lentiginous Early excision is the only curative management

69 All members of the health-care team, including pharmacists should be aware of the ABCDE’s of melanoma recognition. How to recognize a melanoma (ABCDE) AAsymmetrical in shape BBorder is irregular CColour is not uniform; may have different shades of black, brown, gray, red or white DDiameter >6 mm (pencil eraser) EEvolution of colour, shape, elevation, or size in recent months

70 Inconclusive evidence that sunscreen protects against skin cancer – use it, but don’t rely on it this may be partly related to poor application or the fact that people feel protected, so they stay out in the sun longer Intermittent exposure to sun seems to be the biggest risk factor (ie. Weekend exposure after working inside all week) The most effective preventative measures are to minimize sun exposure (avoid sunburn and tanning) -- especially during peak UV-B hours; seek out shade and cover up with hats, long sleeves, and long pants

71 The pharmacist has an important role in Geriatric Dermatology Stress the importance of non-pharmacological management for prevention of decubitus ulcers, xerosis, and fungal infections Include all OTC and topical medications in medication assessments Evaluate and recommend appropriate drug therapy (both prescription and OTC) Monitor for drug-drug/drug-disease interactions Monitor for known dermatological side effects of drug therapy Consider additive effects of combined topical and oral corticosteroid therapy

72 Sep 4, 2009 By: Cristina E. Bello-Quintero, MD, PharmD Drug Topics Overview of geriatric dermatology : Impetigo Treatment & Management Author: Lisa S Lewis, MD; Chief Editor: Russell W Steele, MD Medscape Reference: Drugs, Diseases and Procedures

73 DermNet NZ Facts about skin from the New Zealand Dermatological Society Incorporated. The Good, the Bad, and the Ugly of Sunscreens M Berwick Clinical Pharmacology & Therapeutics 89, 31-33 (January 2011) Skin Cancer in the Elderly KONSTANTINOS N. SYRIGOS1, IFIGENIA TZANNOU1, NIKOLAOS KATIRTZOGLOU1 and EVANGELLOS GEORGIOU2 in vivo 19: 643-652 (2005) National Center for Biotechnology Information PubMed Health A.D.A.M. Medical Encyclopedia.

74 National Quality Measures Clearinghouse Management of Pressure Ulcers: Guideline Synthesis Registered Nurses' Association of Ontario (RNAO). Assessment and management of stage I to IV pressure ulcers. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2007 Mar. 112 p. [118 references] Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. Mount Laurel (NJ): Wound, Ostomy, and Continence Nurses Society (WOCN); 2010 Jun 1. 96 p. (WOCN clinical practice guideline; no. 2). [341 references] Decubitus Ulcers Treatment & Management Author: Don R Revis Jr, MD; Chief Editor: John Geibel, MD, DSc, MA Medscape Reference: Drugs, Diseases and Procedures

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