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  1. 1. Dermatological problems in older people Pruritus Linda Nazarko Nurse consultant 8th March 2016
  2. 2. Aims and objectives To be aware of:  Why ageing increases vulnerability to skin conditions  The value of listening to the patient  The importance of history taking  The value of physical examination  How to nail the diagnosis  Determining treatment options  The value of nurses practicing at advanced level
  3. 3. Structure & function of skin 1. Protection- barrier this deteriorates with age & increases risk infection and problems 2. Sensation, 3. Heat regulation 4. Storage 5. Absorption. 0 20000 40000 60000 80000 100000 120000 1961 2012 2035
  4. 4. Skin ageing
  5. 5. Skin problems & ageing  70% of older people have a skin problem  One of the most common reasons people present in primary care  Ageing reduces cell replacement, skin thins, melanocytes reduced  Loss of elastin, collagen, fat  Lifestyle factors, smoking, sun damage, nutrition  General health  Skin barrier less effective and skin more vulnerable
  6. 6. Skin changes in older people Change Consequence Skin thins More easily damaged, increase risk of bruising and skin tears Replacement rate slows Takes longer to heal Reduced melanocytes Burns more easily Loss of collagen Saggy wrinkly skin Increased risk of skin tears, increased healing time, wounds more prone to breaking down Loss of fat Prominent veins, increased risk of bruising Reduced protective layer, increased risk of skin damage, increased risk of pressure sores. Loss of lipids and water Dry skin, cracks easily Increased risk of infection
  7. 7. Clinical presentation  Mrs Janina Krol, 85 year old widow  Hypertension  Osteoarthritis both hips  Has declined left hip replacement  Irritating itch last 6 months  GP suggests eczema  Cetirizine didn’t help Please note this picture is of a model with thanks to our model and David Miller Care and Dementia Adviser Anchor Trust who took the photograph
  8. 8. Calgary- Cambridge Model
  9. 9. Medical and social history  Widowed, living alone, caring family  Attends church, great grandson recently Christened  Shops and goes to hair dressers  Declined hip replacement for OA left hip uses wheelchair for distances  Hypertension  Itching and miserable
  10. 10. Presenting problems  Declining mobility due to hip pain  Doesn’t want a hip replacement  Hypertension  Itch affecting sleep and making her miserable
  11. 11. Mrs Krol’s perspective “ I’d like some therapy as I’m struggling to get out of the chair. I want to be able to get in & out of the car, shop and meet friends at church. This itching is driving me mad and affecting my sleep. If only I could sleep”
  12. 12. Mrs Newton’s hopes and aspirations “ A good night’s sleep. I’m exhausted, haven’t slept in months. Its getting me down. To be able to walk a bit better, I’m struggling to get out of my chair and I’m getting stiffer and stiffer”
  13. 13. Pruritus  Pruritus is derived from the Latin verb prurire which means to itch.  Pruritus is the most common skin problem in older people.  Itching may be caused by dry skin but in 50% of cases itching has an underlying systemic cause 
  14. 14. Itching
  15. 15. Causes & consequences pruritus 1. Localised- head lice, hand dermatitis, venous eczema 2. Systemic- renal disease/endocrine, thyroid 3. Pruritic skin disease- contact dermatitis, dry skin, uticaria 4. Exposure related- allergens, insects, infestations, medications 5. Hormone related – pregnancy or menopause
  16. 16. Causes pruritus
  17. 17. The importance of history  Onset, provocation, palliation and comorbidities  Onset – fast likely infestation, medication, allergy. Slow – systemic  Provocation- dry skin bathing, scabies worse evening and night  Is anyone else itching?  New medication? Herbal, OTC, Chinese
  18. 18. Physical examination  Widespread or localised itch?  Local consider contact dermatitis, rubber, nickel, fragrance, preservatives  Widespread consider systemic causes  Check for rash  Check for scratch marks
  19. 19. Clinical findings  Intense itch  Worse when she’s hot and in the evening  Generalised rash, hands, webs of fingers, wrists, elbows, front of chest, between shoulder blades and around waist  Dry crusted scabs& areas fresh bleeding  Small black dots visible with magnifying glass
  20. 20. Differential diagnosis: Scabies  Affects around 130 million worldwide at any time  Caused by Scaroptes Scabei
  21. 21. Classical and hyperkeratoic scabies  Classical – normal immune system= 12-20 mites  Hyperkeratotic- Norwegian, atypical scabies- super-infection – highly infections
  22. 22. Mode transmission  Prolonged skin contact- 5-10 minutes- crawls one to another  Burrows into skin within 30 minutes  Lays eggs, two a day  Around 4-6 weeks after contact symptoms appear- itch then rash  Mite tunnels show fine dark or silvery lines  Itch caused by reaction to faeces of mite
  23. 23. Diagnosis  Can be difficult  Skin scraping with blunt scalpel and checked under microscope  For non experts press selotape over lesion and peel off – send to lab
  24. 24. Treatment considerations  Type of scabies  Is the person at home, in a care home or a hospital  Is this a single case or an outbreak  Do contacts need to be treated
  25. 25. Treatment in hospital or care home
  26. 26. Classical scabies  Usual treatment – permethrin 5% cream or malathion 0.5% lotion  Use gloves  Apply to all parts of body  Adult at least 30g tube larger adults 60g  Lotion at least 100ml  Leave 24 hours and wash off  Repeat in one week – treatment doesn’t kill eggs.
  27. 27. Norwegian scabies  Treated by specialists  May be treated with a combination of an oral product Ivermectin and 2- 3 applications of topical treatment on consecutive days
  28. 28. Laundry?  Launder clothing that is currently worn and towels and bedding in use
  29. 29. Aims of treatment  Treat infestation  Treat itch  Treat sore skin  Provide information, advice and assurance  Improve quality of life
  30. 30. Mrs Krol’s medication  Non sedating anti-histamines ineffective  Chlorphenamine (Piriton) sedative anti- histamine can cause drowsiness, increase risk of falls and the risk of urinary retention  Chlorphenamine 4mg at night if required helped  Hydrocortisone 1% topically BD x 7 days
  31. 31. Patient progress  Treated with permethrin 5% cream twice once and then 7 days later itching resolved after 3-4 weeks  Provided with leaflet – to explain condition  Upset at thought she could have infected family especially great grandson  No family members had symptoms  Able to sleep through the night  Physiotherapy to improve mobility  OT provided chair raisers
  32. 32. Making a difference: The value of nurses practicing at advanced level “I thought I was just going to get worse and worse but now once more I have hope and can have a good life”
  33. 33. Take home messages  We use evidence based practice because it works  All patients regardless of age, cognitive status or discharge destination deserve the dignity of a diagnosis  Working with the patient can enable us to help the person to have the best possible quality of life  And that’s why we do what we do and why we make a difference
  34. 34. Thank you for listening Any questions?