1

DISCLOSURE OF RELEVANTRELATIONSHIPS WITH INDUSTRY

Robert A Norman DO MPHXerosis & 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 in the Elderly

Dr. Robert A. NormanPresident and CEO

Dermatology Healthcare, LLCTampa, Florida

Clinical Associate InstructorDepartment of Internal Medicine

Division of DermatologyNova Southeastern Medical Center

Ft. Lauderdale, Fl www.drrobertnorman.com

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 AsteatoticEczema.

Xerosis

• Dry, rough, scaly skin

• May crack and fissure• Endogenous and

exogenous causes• Incidence increases

in elderly (age > 60)

Xerosis

Incidence has increased in recent years because of:

• more frequent bathing and showering

• fragranced baths

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.

2

Signs/Symptoms:

The skin splits and cracks deeply enough to disrupt dermal capillaries and bleeding fissures may occur. Itching or pruritisoccurs 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-hydroxyAvoidance of harsh skin cleansers

Xerosis

It is characterized as– pruritic (itchy) – dry – cracked– fissured

Xerosis

Xerosis has a spectrum of clinical findings

normal icthyosisxerosis

3

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

XerosisClassified 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 XerosisEnvironmental agents that lead to xerosisinclude

– hot water– soap & detergents– friction from clothing– frequent air travel– pollution– other chemicals– air conditioning– low humidity– seasonal changes

Stasis dermatitis

4

Stasis dermatitis

Management: includes topical agents such as Alpha-Hydroxy acid moisturizers or steroid cream or ointment (triamcinolonefor 10-14 days).

Stasis Ulcers

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 transepidermalwater 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 sphingoidbase 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

5

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 filaggrinacclimates to varying environmental conditions over a course of several days. In a low-humidity environment, more NMF is produced.

Currently, there is no known method of artificially enhancing filaggrinbreakdown 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.

6

Causes of Xerosis

Xerosis is due in part to:– Decrease in the natural moisturizing

factor in stratum corneum – Defect in permeability barrier

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).

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).

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).

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).

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.

7

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.

Hydration• 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

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.

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 xerosisand 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.

Xerosis Assessment Tool

Xerosis Scale for Measuring Dry, Scaly Skin

I 0: Absent

I 1: Mild dry skin with minimal flaking

I 2: Moderate dry skin with flaking

I 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.

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

8

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 PruritusPatients 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– Lymphomas – Leukemia

• hematologic disease– Polycythemia vera

• human immunodeficiency virus infection

• complication of pharmacologic therapy

• neuropsychiatric diseaseslymphoma

9

Evaluation of PruritusPossible 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

10

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.

PruritusScratching may contribute to

impetigo

Pruritus

lichen simplex chronicus

Chronic scratching may lead to

Treatment of PruritusGeneral measures include• Elimination of factors that aggravate dry

skin• Patient education• Teaching of adequate methods of

interrupting the itch-scratch cycle

Prevention and Treatmentof 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

11

Prevention and Treatmentof 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

• Teaching of adequate methods ofinterrupting the itch-scratch cycle– Application of a cold washcloth– Gentle pressure

scratchscratchscratchscratch

Treatment of Pruritus

Multiple topical and systemic treatments have been recommended for the management of pruritus, as well other modalities

Treatment of Pruritus

• Topical agents– emollients– corticosteroids– anesthetics– doxepin– capsaicin– menthol– topical

immunomodulators

Treatment of Pruritus• Systemic agents

– hydroxyzine hydrochloride– diphenhydramine

– doxepin (tricyclic antidepressant with antihistaminic properties)

– oral corticosteroids

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

12

Figure 1 Figure 2

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.

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.

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-term 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.

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.

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.

6. At least once a year, provide in-services 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.

7. Consider doing a skin cancer screening for patients and employees. It ’s a great service for them and can increase the number of people in your practice.

8. In addition to their clinical skills, long-term 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.

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 specif ic 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.

10. Sometimes patients just have stories and just want to talk. Be patient w ith your patients and enjoy your time together.

Dermatology Consultations in the Nursing Homes—A Ten Year RetrospectiveDr. 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, SKINDRROB@AOL.COM, www.geriatricdermatology.com

Research FindingsDermatologists Beware!!You Are Becoming Even More Important!!

Long-term Care Dermatology

List of recommendations.

References

Top Ten Problems in Nursing Home Dermatology

1. Pruritus

2. Xerosis

Printed by Professional Posters Made Easy

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 unforgivable 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 hich 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.”

Albert M. Kligman, MD in the forew ord to Barbara Gilchrest, MD’s book Skin and Aging Processes CRC Press, Inc. Boca Raton, Florida

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.

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.

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 f loors and hospital patients requiring signif icant 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.

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 life. The food service personnel w ould be cooking for your health and enjoyment and therapists would be busy f ighting an uphill battle against a possibly deteriorating body and mind, and the social services staff would try to help solve problems ranging from financial diff iculties 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.

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.

Long-term Care Dermatology, Continued

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 problemstoprevent stasis dermatitis and ulcer formation.

1 Total sample size = 15562 SD = standard deviation3specif ied and unspecif ied hypertropic and atrophic conditions, keratoderma

3. Psychogenic Disorders

• lLichen Simplex Chronicus

• lPrurigo Nodularis• lNeurotic

Excoriations• lDelusions of

Parasitosis

4. Infections •lDermatophyte•lCandidiasis•lCellulitis, folliculitis, miliaria

76 y/o female cellulitis of the face.

•Herpes Zoster

5. Infestations

6. Autoimmune Disorders81 y/o Male bullous

pemphigoid. 7. Inflammatory Disorders

8. Vascular Disorders

1. Norman R Geriatric Dermatology 2001 Parthenon/CRC Publishing

2. Dharmarajan TS, Norman R Clinical Geriatrics January 2003 Parthenon/CRC Publishing

3. Norman R Dermatologic Therapy November 2003 Guest editor(Issue on Geriatric Dermatology)

4. Norman R Dermatologic Clinics January 2004 Guest editor (Issue on Geriatric Dermatology)

5. Norman 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)

7. Marks, R Skin Disease in Old Age Martin Dunitz 1999

9. Neoplasia

10. Mechanical Disorders

•Skin tears•Wounds

0

200

400

600

800

1000

1200

ICD 9 CMCode

N1 % Male Mean Age(SD)2

Pruritus and otherrelated diseases

Diseases of the sebaceousglands (Xerosis=772)

Other dermatoses 2

Basal or squamous cellcarcinoma of the skin

Scabies

Contact dermatitis andother eczema

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 19995. Norman R. Dermatological problems and treatment in long-

term/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