Perawatan dermatologis usia lanjut*

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Skin layers

Figure 87-1 Skin layers. The skin is composed of two layers: the epidermis and dermis. The epidermis and its appendages (hair, sebaceous, and sweat glands) arise from embryonic ectoderm. The dermis is of mesodermal origin.

Layers of the epidermis

Figure 87-2 Layers of the epidermis. The basal cell layer (stratum basale) is adjacent to the dermis and contains keratin-forming cells. These columnar cells are anchored to a basement membrane. Interspersed in this layer are cells of neural crest origin, the melanocytes, which produce melanin pigment. The prickle cell layer (stratum spinosum) contains polyhedral-shaped acanthocytes with a network of intercellular bridges (desmosomes) imparting a spiked appearance. The granular layer (stratum granulosum) cells are flatter than those in the prickle cell layer and contain granules called keratohyaline granules. The lucid layer (stratum lucidum) is a translucent line of flat cells present only on the palms and soles of the feet. In contrast to the deeper cells of the skin, the horny layer (stratum corneum) consists of dead keratinized cells that are continually shedding. These cells lack nuclei and cytoplasmic organelles.

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Geriatric dermatology is a specialty that will receive particular attention. Since the human population is living longer, chronic diseases will become more prevalent, as will diseases of the skin.

Norman, R.A.; Geriatric dermatology. Dermatologic Therapy; Vol. 16, 2003; 260-268*

Intrinsic aging

Extrinsic aging*

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Epidermal ChangesDermal Changes Skin Changes in Aging Melanocytes* Approximately 15% decline per decade.* Density doubles on sun-exposedskin.* Increased lentigines.

Langerhans' cells* Decreased density.* Decreased responsiveness. -Decreased collagen-Decreased density-relatively acellular, avascular, and less dense with the loss of functional elastic tissue* Loss of elasticity.* Thinning of the skin.* Clinical -- xerosis, laxity, wrinkling,uneven pigmentation,easy tearing, traumatic purpura,neoplasia.* Histology -- dermal atrophy,progressive loss of elastic tissuein the papillary dermis.

*Moist skin is a state in which the stratum corneum is regularly arranged with the right balance between NMF and Epidermal LipidsMoist skinMoist deficient skinLayers are not able to maintain the moisture due to lack of NMF, so the skin becomes dry and rough

Hair color change graying is caused by follicle produces less melanin, begins in the 30s-40sGraying is genetically determined. Nutritional supplements, vitamins, and other products will not stop or decrease the rate of graying*

Hair color is caused by a pigment (melanin) that is produced by the hair follicle. With aging, the follicle produces less melanin*

Aged hair follicles are no longer as prepared for new hair growth*

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*The nails change with aging, growing more slowly, dull & brittleColor change translucent to yellowed & opaque Nails, especially toenails hard & thick and ingrown toenails more common Tips of the fingernails may fragment

Xerosis is characterized by pruritic, dry, cracked, & fissured skin with scaling

Xerosis due to decreased sebaceous & sweat gland activity; this reduced activity predisposes the aged skin to moisture depletion*

Pre-existing situations : radiation, end-stage renal disease, nutritional deficiency (especially zinc and essential fatty acids), thyroid disease & neurological disorders with decreased sweating, anti-androgen medications, diuretic therapy, & malignancies

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Deficits in both skin hydration and lipid content play a key role in xerosisThe xerotic vicious cycle needs to be broken to disable the process and prevent complications. To achieve this goal, keratolytics, moisturizers, and steroids are the primary components of xerosis treatment.use of moisturizers reduce scaling and enhance the corneodesmosome degradation process*

Preventing xerosis involves three key elements: keeping the environment amply humidified, which includes not keeping the temperature excessively high; making sure residents have good fluid intake, which should already be part of the care routine; and moisturizing the skin daily.*

Additional management:Reduced frequency of bathing Minimal use of a irritant soapAvoidance of harsh skin cleansersApplication of moisturizer of choice directly on skin that is still dampAvoidance of friction from washcloths, rough clothing, and abrasivesUse of air humidification in dry environments *

PruritusCharacteristic features of pruritis include scratching and inflammation underlying diseasesUnderlying metabolic conditions that can produce pruritus include renal failure, HIV, diabetes mellitus, thyroid disease, parathyroid disease, hypervitaminosis A, iron-deficiency anemia, neuropathy, hepatic disease, malignancy, and drugsItching evokes the desire to scratch produces an immunology-based inflammatory response*

The goal of pruritis therapy is to optimize treatment efficacy by tailoring the treatment to the underlying etiology

Avoidance of fragrance soap, irritating chemicals, and hot water help reduce pruritus, especially in elderly patients who have the xerotic changes of aging*

Purpura Purpura can be defined as any of a group of conditions characterized by ecchymoses or other small hemorrhages in the skin, mucous membranes, or serosal surfaces. Purpura may be caused by decreased platelet counts (thrombocytopenia), platelet abnormalities, vascular defects, trauma, or drug reactions*

Elderly persons are especially susceptible to hemorrhage into the skin. Aging causes a gradual reduction in the number of blood vessels and elastic fibers, as well as losses in dermal collagen and fat, causing a thinning of the skin and reduced protection from external trauma*

Treatment should focus on the underlying cause Administration of oral glucocorticoids & immunoglobulins , If platelet counts are extremely low (< 10,000/cubic mm), platelet transfusion may be needed

Skin tears most often result from a purpura torn open by inadvertent trauma Important measures include skin protectors and designing living environments to prevent injuries.

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Keep indoor temperatures Too much heat is extremely dryingDrink at least eight glasses of water a day. Water helps lubricate the system and prevents dehydrationUse a moisturizer: emollient petroleum jelly or mineral oil forms an oily barrier on the skin, which seals in moisture and blocks its evaporationhumectant glycerin, sorbitol, or urea attracts and holds water on the surface of the skin To prevent chapped lips, use lip balms, petroleum jelly, or lipstick.

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Avoid long, hot showers or baths washes away natural oils & often leads to itching. Water can be very drying when used to excess. Take short tiped baths or showers. Bathe less often in cold weather

Use a mild soap with moisturizers or extra oil. Avoid harsh deodorant soaps. Soap can be drying and should be used judiciously

Pat dry after bathing, rather than rubbing hard with a towel. Rubbing may initiate itching. Apply a bland emollient (moisturizer) immediately after drying

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Try not to scratch when your skin is itchy. Use moisturizers or mild cortisone lotions if necessary. Apply cool compresses on trigger spots

Use a cool-moist humidifier to combat dry indoor air very high humidity promotes the growth of bacteria, molds, and fungi, which can elicit allergies in sensitive people.

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Wrinkles & elastosisproblems for most of old agesManagement skin care before aging esp topical retinoidChemical peels, collagen implant, facelift operation*

Sunprotection : sun block SPF > 30, anatoher vehicle such as hat, umbrella, sun glasses

Electrocauterization

Comedos extraction

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NailsNails develop pits, ridges, lines, changed shape, or other changes. These can be related to iron deficiency, kidney disease, and nutritional deficiencies

Cutting nails regularly, moisturizer

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