The Pharmacist’s Role. At the end of this session the participant will be able to: Describe the...
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Transcript of The Pharmacist’s Role. At the end of this session the participant will be able to: Describe the...
Geriatric DermatologyThe Pharmacist’s Role
ObjectivesAt 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
Skin ChangesIn the Elderly
EtiologyIntrinsic: occurs in everyone and is related to genetic changes in cell processesExtrinsic: produced by external causes (e.g. UV exposure, smoking, environmental pollutants)
Age related skin disorders are related to:• 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
Cellular changes in aging skin:
• 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
All these factors lead to increased risk of:• Fragile skin (skin tears, abrasions, cuts)• Traumatic purpura (bruises)• Ischemia (cell death, decubiti)• Xerosis (dry skin)• Infections • Skin cancers
Decubitus Ulcers• Stage III
Decubitus Ulcer with necrosis on sacrum
Decubitus Ulcers• 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
High Risk Patients• 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
Stages of Decubitus UlcersStages of Decubitus Ulcers
Stage I Nonblanching erythema of intact skin
Stage II Superficial to partial thickness involvement of the epidermis or dermis
Stage III Deep necrosis with full-thickness skin loss that may extend down to, but not through, underlying fascia
Stage IV Extensive necrosis to underlying fascia, possibly extending into muscle, bone, and supporting structures
Treatment of Decubitus Ulcers• 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
Treatment of Decubitus Ulcers• 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
Treatment of Decubitus Ulcers• 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
Treatment of Decubitus Ulcers• 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
Treatment of Decubitus Ulcers
• 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
Treatment of Decubitus Ulcers
• 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
Treatment of Decubitus Ulcers
• 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
Treatment of Decubitus Ulcers• 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
Treatment of Decubitus Ulcers• 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
Prevention is key…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
Xerosis
XerosisXerosis (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
Causes of xerosis• 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
Treatment of Xerosis• Occlusive moisturizers and emollients
• Oils, lotions, creams and ointments
• Humectants, keratolytics and keratoplastics• Urea, ammonium lactate, and alpha hydroxy products
• Non-pharmacologic management
Occlusive moisturizers & emollients
• 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.
Formulations• 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.
Which formulation?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.
Humectants, keratolytics & keratoplastics• 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
Urea• 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
Ammonium Lactate & Alpha Hydroxy Acid Products• 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.
Adverse ReactionsPossible 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
Nonpharmacologic Management• 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
Skin InfectionsSkin 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)
Impetigo
Impetigo• 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
Varicella (Herpes) Zoster
Varicella (Herpes) Zoster• 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
OTC use in Shingles• 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
Fungal Infections 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)
Seborrheic dermatitis
Seborrheic dermatitis• 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)
Seborrheic dermatitis• Generally managed with OTC products
• Selenium sulfide• Zinc pyrithione• Coal tar• Ketoconazole 2%
• Low potency topical steroids may be used in more severe cases
Candida
Candida• 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
Candida• Often related to:
• Obesity• Diabetes• Immunosuppression• Chronic debilitation• Occlusion under incontinence products• Systemic antibiotic therapy
Candida• OTC Treatments may include
• Exposure to air• Use of desiccants (Burrow’s solution, Castellani’s
paint)• Zinc oxide (topically)• Topical azole antifungal agents BID
MiconazoleEconazoleKetoconazoleCiclopirox
• Antifungal powders may be used to dry the skin and prevent maceration
• Terbinafine cream is NOT effective against Candida.
Tinea pedis (Athlete’s Foot)
Tinea pedis (Athlete’s Foot)• 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
Tinea pedis (Athlete’s Foot)• 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
Tinea pedis (Athlete’s Foot)• 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
Tinea Cruris (Jock Itch)
Tinea Cruris (Jock Itch)• 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
Onychomycosis
Onychomycosis• 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
Blistering Diseases
Blistering Diseases• 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)
Nutritional DeficienciesDeficiencies 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
Vitamin C Deficiency• 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.
Zinc Deficiency• 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
Vitamin B DeficienciesSkin findings may present when a patient is deficient in• Riboflavin (B2)• Niacin (B3)• Pyridoxine (B6)
Riboflavin (B2) DeficiencyPatients 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
Niacin (B3) Deficiency• 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.)
Pyridoxine (B6) Deficiency• Patients with Niacin deficiency may present with
seborrheic dermatitis and photosensitivity• Risk factors include:
• Alcoholism• Cirrhosis• Drug therapy: isoniazid, penicillamine & L-dopa
Skin CancersMore 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
Skin CancersCan 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
Non-MelanomasMost 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
Melanoma• 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
MelanomaAll members of the health-care team, including pharmacists should be aware of the ABCDE’s of melanoma recognition.
How to recognize a melanoma (ABCDE)
A Asymmetrical in shape
B Border is irregular
C Colour is not uniform; may have different shades of black, brown, gray, red or white
D Diameter >6 mm (pencil eraser)
E Evolution of colour, shape, elevation, or size in recent months
Skin Cancer Prevention• 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
The Pharmacist’s RoleThe 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
ReferencesSep 4, 2009By: Cristina E. Bello-Quintero, MD, PharmDDrug Topics
Overview of geriatric dermatology:
Impetigo Treatment & ManagementAuthor: Lisa S Lewis, MD; Chief Editor: Russell W Steele, MD Medscape Reference: Drugs, Diseases and Procedures
DermNet NZFacts about skin from the New Zealand Dermatological Society Incorporated. http://www.dermnetnz.org
The Good, the Bad, and the Ugly of SunscreensM BerwickClinical Pharmacology & Therapeutics 89, 31-33 (January 2011)Skin Cancer in the ElderlyKONSTANTINOS N. SYRIGOS1, IFIGENIA TZANNOU1,NIKOLAOS KATIRTZOGLOU1 and EVANGELLOS GEORGIOU2in vivo 19: 643-652 (2005)
National Center for Biotechnology InformationPubMed HealthA.D.A.M. Medical Encyclopedia.http://www.ncbi.nlm.nih.gov/pubmedhealth/
National Quality Measures ClearinghouseManagement 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