1. “THE SKIN SHOW” Aging Dermatology and Disease Module #2
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
UNMC
Omaha, NE
Web: geriatrics.unmc.edu
All photos were reprinted with permission from the American Academy of
Dermatology. All rights reserved.
Slides adapted with permission from GRS 5th edition: Dermatologic diseases and disorders
Welcome to the module two of the “Skin Show”. If you have not completed module one of this series, please close out of this module, complete module one and then return here.

2. PROCESS Series of 4 modules and questions on
Etiologies, Evaluation, & Management
Step #1 Power point module with voice overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or take a break
Our process will be for you to complete this, the second in a series of four modules and questions on geriatric dermatology. These modules will utilize power point with voice overlay. Each module will be followed by case-based questions with answers that will explain the right and wrong responses. Then you will have the option to continue with the next module or take a break at that time. The computerized system will keep track of the modules you have completed so that in the future you may pick up where you left off.

3. Objectives Upon completion the learner will be able to;
List the normal age related skin changes
Identify and treat the common skin disorders of aging
Identify malignant versus non malignant skin conditions in aged
Here we will begin to explore malignant vs. non-malignant skin disorders along with photo damage and the subsequent sequelae of photo damage to the skin.

4. PHOTOAGING The effects of UV exposure on skin
Shorter wavelengths are more biologically active (UVA and UVB)
UV light causes:
DNA damage
Decreased DNA repair
Oxidative and lysosomal damage
Altered collagen structure
Photoaging is primarily mediated by both UVA and UVB radiation. It does this through DNA damage, slowing DNA repair and both oxidative and lysosomal damage which then alters the collagen structure.

5. PHOTODAMAGED SKIN Appears wrinkled, coarse, or rough
Has mottled pigmentation, hypopigmentation, telangiectasias
Here we see photoaged skin that is wrinkled, course and rough. If you look closely, you begin to see a mottled pigmentation with areas that are hypopigmented along with areas that have telangiectasia.

6. PREVENTING PHOTODAMAGE
Use broad-spectrum sunscreens:
SPF 15 or greater
Avoid direct sunlight ( especially 10am -2 pm)
Use protective clothing, including hats
Use sunglasses
The only way to prevent this is through the broad spectrum sunscreens SPF 15 or greater, avoidance of direct sunlight especially during the bright sunlight times, and the use of protective clothing such as hats and sunglasses.

7. TREATING PHOTODAMAGE: TOPICAL AGENTS
Only agent shown to be effective: topical retinoin used at high concentrations for long periods
Increases thickness of superficial skin layers
Reduces pigmentary changes and roughness
Increases collagen synthesis
Claims that other agents decrease photodamage are not well-substantiated
The only treatment that has demonstrated effectiveness is topical retinoin. It thickens the superficial skin layers, reduces pigmentary changes and roughness, and stimulates collagen synthesis. There’s nothing else that has any substantial benefit.

8. PHOTODAMAGED SKIN
1) Actinic keratosis & cutaneous malignancies more common
2) Source of term “red neck”
3) What is the erythematous lesion with central white scale behind his ear?
Here we see on the neck of this patient an area with photodamaged skin. Actinic keratoses and cutaneous malignancies are very common in this area of sun-damaged skin. What is the erythematous lesion with the central white scale behind his ear? (Pause for 5 secs) This is an actinic keratosis.

9. Answer: ACTINIC KERATOSES
macular
hyperkerototic scale overlying erythematous -brown macules
Scale; dry, hard, rough
on sun-exposed skin from chronic UV radiation
premalignant.
Alias: solar keratoses,
“better felt than seen”
Here’s a better quality picture on a different patient. Here you see that it’s more macular and has a central hyperkerototic scale that overlies this erythematous-brown macule. The whole thing is dry, hard and rough. It’s always found on sun-exposed skin and is certainly pre-malignant. These lesions are better felt than seen - you can often feel the roughness with your hands before you see them. The differential would include seborrheic kerotosis, squamous cell carcinoma in situ and verruca vulgaris. Seborrheic keratosis would have more of a greasy, scaly, pigmented lesion with that “stuck on” appearance. Squamous cell ca would be more indurated and erythematous and verruca vulgaris would be hyperkerototic without the erythema.
Used with permission images.MD.

10. ACTINIC KERATOSES Treatment: Cryotherapy with liquid nitrogen
Considered premalignant, but majority resolve without treatment
Up to 20% progress to squamous cell cancer
Prevention: See PREVENTING PHOTODAMAGE
Treatment:
Cryotherapy with liquid nitrogen
Topical 5-fluorouracil
Excision
Treatment can be with cryotherapy or topical 5-fluorouracil.
Cryotherapy can be performed with liquid nitrogen; apply 5-15 seconds depending on degree of hyperkeratoses, creating a “frost ring”.
Topical 5-fluorouracil (Efudex 5 %): cream or ointment applied once or twice a day for two weeks or until erythema or blister occurs ( whichever is first) then stop. Then apply 0.1% triamcinolone cream daily for 10 days to assist in healing and reduction
Although a majority of these resolve, up to 20% will progress to squamous cell cancer. We can prevent them, as talked about earlier, by treating with cryotherapy. Cryotherapy can be performed with liquid nitrogen. Apply it for 5-15 seconds depending on the degree of hyperkerotoses and create a “frost” ring. Warn the patient and family of the subsequent erythema that will occur over the next few weeks in the treated areas.
Another alternative is topical 5-fluorouracil or Efudex 5%. This comes as a cream or ointment that can be applied once or twice daily for two weeks or until an erythema or blister occurs, whichever is first, and then stop. Then we can assist healing by applying 0.1% triamcinolone cream daily for 10 days after stopping 5FU.
used with current mission from images.M.D.

11. What is the lesion on his shoulder?
What is this lesion on his shoulder?

12. Answer: SQUAMOUS CELL CARCINOMA
Description
Chronic erythematous papules, plaques, or nodules with scaling, crusting, or ulceration
Affects people in mid-to-late life
Occurs most commonly in chronically sun-exposed areas
Second most common form of skin cancer
Propensity to occur in longstanding nonhealing wounds and in burn and radiation scars
The answer is squamous cell ca. This lesion consists of chronic erythematous papules, plaques or nodules with scaling, crusting or ulceration. It affects people in mid-to-late life, and it usually occurs in sun-exposed areas. It’s the second most common form of skin cancer and can be found sometimes in nonhealing wounds and in burns and radiation scars.
The other possibilities include; Basal Cell Ca, but this would be more raised and pearl like. Actinic Keratosis but that would look more macular, with a central scale. Seborheic keratoses would look more greasy, “stuck on” and psoriasis would be symmetrical, erythematous with a scaly patch or plague. All of these we will see more of later

13. TREATMENT OF SQUAMOUS CELL CARCINOMA
Surgical excision
Mohs’ micrographic surgery in cosmetically important areas
Cryotherapy or local radiation for patients unable to tolerate surgery
Treatment options include surgical excision with either direct excision or Mohs’ technique. Cryotherapy can sometimes delay or cure some of these along with local radiation for patients who are unable to tolerate surgery.

14. What’s this?
What is this?

15. Answer: Basal cell carcinoma
Nodular: most common
pearly, fleshy, waxy papule
can be ulcerated in the center
has a characteristic rolled border
rarely pigmented
can have overlying telangiectasias
This is Basal cell carcinoma. Nodular type is the most common. It will appear pearly, fleshy, waxy as in the lower photo. It can be ulcerated in the center as in the upper photo. That upper photo also has a characteristic rolled border. It’s rarely pigmented and can have an overlying telangiectasia as seen in the lower picture. The differential includes seborrheic kerotoses, which we can eliminate as it does not have the “stuck on” appearance. Squamous cell carcinoma is possible, but it would be more erythematous, scaly and macular. Actinic keratosis would be much more macular in appearance. Malignant melanoma would have an irregular pigmentation to the lesion and would not have the central depression present and would not have the irregularity of the border.

16. MAJOR CLINICAL PATTERNS OF BASAL CELL CARCINOMA
Description
Nodular
Most common variant: waxy, translucent papule with overlying telangiectasias
Morpheaform
Scar-like appearance: can look atrophic
Superficial
Erythematous macule or papule with fine scale or superficial erosion
Besides the nodular type that we’ve described, there is morpheaform that has more of a scar-like appearance and can also look atrophic. Then there is the superficial type with more of an erythematous macule or papule with fine scale or superficial erosion, which is just a step beyond actinic keratoses.

17. BASAL CELL CARCINOMA Treatment: Most common cancer in United States
Risk factors: Fair skin, chronic sun exposure
Prevention: Sun protection, regular skin examinations
Treatment:
Surgical excision
Mohs’ micrographic surgery may be needed to ensure adequate excision and tissue sparing
When surgery is not feasible, it can also be treated with ablative methods such as cryosurgery, radiation, curettage with electrodesiccation
Basal cell is by far the most common skin cancer in the U.S.
Those at risk are patients with fair skin and chronic sun exposure. We can prevent it not only with sun protection but with regular skin examination. We advise that when your patients visit you, spend some time examining their face, neck and arms while they are chatting. Treatment, like for squamous cell ca, is with surgical excision or radiation, or electrodesiccation for patients who cannot tolerate surgery.
On the next slide there is no narrative, please make your diagnosis and I will return on the following slide.

18. What’s this?
(view slide for 7 secs)

19. A symmetric shape & border
Answer: MELANOMA
A-B-C-D mnemonic for MM
A symmetric shape & border
B order irregular, blends into normal skin
C olor: variation in pigment (shades of brown and blue-black)
D iameter ( usually > 6 mm
The answer is malignant melanoma.
These lesions exemplify the “ABCD” of diagnostic criteria which are:
A: Asymmetric shape
B: Borders are irregular and blend into normal skin as you can see, especially in the lower lesion
C: Color is varied in pigments - shades of blue, brown and black can be seen in the same lesion.
D: Diameter, which you cannot assess here, but is usually more than 6 mm.
Differential of this lesion could be a benign melanocytic type lesion. Some seborrheic keratoses will have pigmentation changes or inflammation that would be characteristic. Occasionally a basal cell can have pigmentation to fool a clinician. However, one should be aggressive in treatment as seen in the next slide.

20. MELANOMA Incidence is increasing; affects adults of all ages
Risk factors: fair skin, family history, dysplastic or numerous nevi, sunlight exposure
Prevention: Sun protection, regular skin examinations and early recognition are key for favorable prognosis
Most common sites: Males: head, neck, trunk. Females: distal lower extremities
Treatment: surgical excision, possibly lymph node dissection or adjuvant therapy
Incidence of this malignancy is increasing in adults of all ages. Risk factors, again, are fair skin, family history, numerous nevi along with sunlight exposure. Prevention is sun protection, regular skin examination and educating your patients to examine their own skin and be aware of changes predictive of malignant melanoma. Interestingly, in males the more common areas affected are head, neck and trunk, and women have distal lower extremities to worry about. Treatment is surgical excision with wide margins initially to ensure clear removal.
On the next slide there is no narrative, please make your diagnosis and I will return on the following slide.

21. What’s this?
(view slide for 5 secs)

22. Answer: ACRAL LENTIGINOUS MELANOMA
dark macular growth
irregular borders
volar surfaces of palms, soles and nails.
more common in women
Acral lentiginous melanoma is a dark macular growth with irregular borders usually seen on the palms, soles and nails. It’s more common in women. Treatment is the same as seen with previous malignant melanoma.

23. The End of “Skin Show” Module Two
This completes our second module on geriatric dermatology, we have more to do but lets review with a question and answer. To access the the question, close out of this window, advance to question 2, answer the question and review the answer.
Then, if you have enough energy, proceed to module 3 where we will complete the dermatology series.
Add question 491

24. Post-test
A 76-year-old man has an erythematous, unpigmented, scaly lesion with a central crust on the forearm. The lesion is 1 cm in diameter and has irregular borders. The scab has come off several times over the past year. The skin on the dorsum of both hands and forearms has irregular pigmentation and numerous areas of roughness. Which of the following is the most likely diagnosis?

25. Which of the following is the most likely diagnosis?
Basal cell carcinoma
Cutaneous horn
Keratoacanthoma
Melanoma
Squamous cell carcinoma
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

26. Answer; E. Squamous cell carcinoma
This patient’s skin disorder is most likely the result of damaging exposure to the sun. The numerous rough areas surrounding the lesion are most likely actinic keratoses, which are common premalignant skin lesions that can progress to squamous cell carcinoma. A lesion that is characterized by erythema and a nonhealing ulcer in a sun-exposed area is most likely squamous cell carcinoma. These lesions begin as thin erythematous patches and progress to nonhealing ulcers. This patient should undergo excisional biopsy. Treatment of the premalignant lesions with 5-fluorouracil cream should be considered. In patients with fewer actinic keratoses, application of liquid nitrogen to the affected areas is appropriate. This patient is at risk for other skin malignancies and should have annual skin examinations.

27. Basal cell carcinoma is characterized by a firm, rolled telangiectatic border. Malignant melanoma is a pigmented lesion that would not have a scaling appearance or ulceration. Keratoacanthomas are pseudo-cancerous lesions that have a nodular appearance with a verrucous central portion. These lesions develop rapidly, have a tendency to spontaneously involute, and would not be present for 1 year. A cutaneous horn has a hornlike appearance and may resolve spontaneously or contain a squamous cell carcinoma at its base. end