Dermatological System

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Problems with the skin tend to either be caused by infection or not. In this section, to keep things simple, we break things up like this.

Infections:

Shingles

This is the reactivation of the chickenpox virus.  To understand this, you could consider that when you contract some infections, like the chickenpox, often times your body never fully gets rid of that infection, rather it keeps it bay for the rest of your life.  In the case of the chickenpox, the virus gets contained, laying somewhat dormant in your nerves located close to your spine.  It is up to your immune system (bodily defence system) to keep it rather locked up there.  However, at times when your immune system may be under pressure or deplete, and basically at times of overall stress, the chickenpox virus may be let out of its cage.   When it does “reactivate” in this way, it travels along the path of a nerve, typically on one side of your body causing pain and producing a rash.  This is referred to as the “shingles”.  You could really get the shingles occur on any location in your body, however the main thing is that it will tend to present rather in a “band” on one side of your body, since it emerges and follows the path of the nerve where it was originally trapped and contained.

Tips:

1. Sometimes you will get pain and tingling of an area of your body long before the rash emerges.
2. The rash presents as red spots which go on to have small vesicles (blisters). These blisters then burst and scab over.
3. You are generally infectious so long as your blisters have not yet scabbed over. And, some groups of people, for example, pregnant women and infants can get badly affected by the herpes virus, so you should avoid these people in particular if you have the shingles.
4. The treatment of the shingles can include a course of antiviral tablets for about a week. That treatment is best started within 3 days of first getting the rash or symptoms. So – get on to it early.
5. Treatment for the shingles early with antivirals, especially during the first episode, can decrease the likelihood of getting “post herpetic neuralgia”. This condition is typified by episodes of intense pain in an area of your skin where you used to get the shingles.  You may not get the rash with it, rather just pain.  Post herpetic neuralgia can be very debilitating, so treating incidences of the shingles early with antivirals can be justified for this reason.
6. If you get the shingles on your face, it can affect the surface of your eye – your cornea. This is called “ophthalmic zoster”.  This can lead to scarring and damage of your eye. Sometimes, the presence of shingles on your nose and also extend into get close to structures related to your brain.  So in these cases, where shingles is on your face, you should especially see a doctor.

Cellulitis

This is an infection of your skin which goes deep enough to involve the fat layer located under the skin itself.  Cellulitis causes inflammation which is seen as an area of skin that is red, swollen, hot and tender.  Sometimes cellulitis can be associated with an open skin wound, insect bite or an areas which has been scratched because has been itchy.  However, where and why it all started may not be clear.  Instead, simply an area of skin can turn red and sore.  Preceding pain and tenderness, that area may well get itchy as an early symptom.

As mentioned, cellulitis can start on any place of your body, however it most readily occurs on legs.  Here it can cause a swollen leg, looking similar at times to a DVT.  It may be hard for you to differentiate the two, so you should get help.  In the case of cellulitis, your legs may leak fluid as the skin breaks open under the pressure and stretch.  In general, cellulitis can be severe enough to make you unwell in general. You may get a fever.

Tips:

1. Get on to it early. Cellulitis can start small, but spread quite rapidly.  So if you see a small area of skin which is suspicious, seek treatment early, before it becomes a big problem.  There are many elderly patients with cellulitis, particularly of the legs, which gets so bad that they end up needing intravenous antibiotics in hospital. However, if you do pick it up early, there’s a very good chance that you can get treated with antibiotics in tablet form at home, and get better quickly.
2. The antibiotics often chosen for cellulitis include cephalexin. Sometimes though, the bacteria can be resistant to standard antibiotics.  So if your legs are oozing or you have some sort of wound which your cellulitis is associated with, it’s a good idea to get a sample of that fluid (a “swab”) to have sent to pathology for testing.  This will help guide antibiotic treatment, should things not improve.  Your doctor can organise this for you.
3. Drink lots of water. As an infection possibly causing you to have a temperature, you will ten to get dehydrated.  Especially if you have cellulitis of the legs, you are at a high risk of getting a DVT, so please lower this risk by staying well hydrated.
4. Elevate your legs. Once again, if you have cellulitis on your legs, they’ll tend to get congested with fluid which could lead to the skin breaking and fluid draining.  This can all be reduced by elevating your legs causing them to drain more easily.  It’s good to keep your legs moving at least a little bit that way too, to reduce the risk of DVT along the way.
5. Monitor the progress of treatment. If you are prescribed antibiotics, it may be for one week or more.  However, you should start seeing some benefit at least by day two.  If after a few days, your cellulitis isn’t improving, you should think whether the diagnosis is correct, or whether you have a resistant form of the condition (likely due to a resistant bacteria).  Something will have to change if your legs are not getting better after a few days.
6. Signs of danger. If you legs are VERY tender, particularly despite antibiotics, and if the colour of your skin is getting darker, the infection may be going deeper than your fat, and starting to involve your deeper tissues.  This could (uncommonly) lead to a condition called necrotising fasciitis.  This is an emergency.  Similarly, if your leg isn’t improving then you may need an ultrasound to make sure you do not have a DVT.  Indeed, if you get any shortness of breath or chest pain which may indicate a PE, see you doctor.
7. Elderly people often may have heart conditions or other chronic diseases which lead to their legs being swollen and filled with fluid usually. In this case, cellulitis will need to be considered when there is a “change” to their usual condition.  For example, apart from the usual swelling and fluid, their legs may become red and hot and start leaking.  Or, they may get a temperature.  So, look and beware of any changes.

Fungal infections of the skin

Fungal infections tend to occur in warm, dark, moist places.  Common places include under the breasts, the groin and feet.  The skin here will get itchy and red, sometimes a little bit flaky or elevated.  The treatment of this is usually an antifungal cream with or without a steroid.  These creams are generally sold over the counter.  The constituents of the cream could be cotrimazole (antifungal) and hydrocortisone (steroid).  Commonly this combination goes under the trade name Hydrozole.

It’s important to consider that a fungal infection can get secondarily infected with a bacteria.  This usually happens from repetitive scratching which causes the skin to break more deeply allowing bacteria to enter.  In this case, you will notice that the skin is not only red, but gets distinctly weepy, more painful (rather than itchy) and can get golden or yellow pus.

Tips:

1. Not too much cream. When you apply antifungal cream, a common mistake is to apply it so thickly that it remains on the skin.  However, creams contain water, and by leaving the cream coated on the skin, you’re effectively making the area even more wet and all that moisture tends to cause the skin to breakdown, to macerate.  This is especially true between the toes.  You need to therefore avoid using too much cream, and really rub it into the skin, making sure it is dry and no coating remains after you’re done.
2. A long enough course. Sometimes people use an antifungal for a few days and stop.  Or a little bit here and there.  This should be avoided, because then the fungal infection won’t be eradicated, rather just dulled down, kept at bay, only to remerge promptly.  Use a fungal cream for a thorough course of treatment, which would be a minimum of two weeks.  It is classically said to use for one further week after the rash disappears.
3. Consider a swab. If your fungal infection isn’t going away, consider seeing your doctor so that a sample can be sent for testing.  This will involve just a cotton bud being rubbed on your skin, and that cotton bud (swab) sent to a pathology laboratory.  Occasionally, you can get a resistant fungal infection or bacteria could be the real cause.
4. Is it cellulitis? If it’s getting worse, you may have a bacterial secondary infection, and you should get a swab, as discussed above.
5. Is sweat or clothing the cause? If you keep getting fungal infection in particular areas, perhaps it’s due to that area getting too sweaty or having too tighter clothing on.  If sweat is contributing, you may have to place gauze or another simple material in position, to absorb that sweat.  Underwear may have to be looser so as not to cut into skin.

Nail fungus

This most commonly affects the toenails, but it can also affect the fingernails.  The nail will get discoloured and disfigured.  It could be darker or lighter in colour when compared to the other nails.  It could be thickened.  Fungal nails (called onychomycoses) are very stubborn to treat.  You can try using various antifungal nail paints and other topical remedies, but often times, they won’t work.  What is required is physically tending to the nail, cutting away any affected areas, and the use of antifungal tablets.  Antifungal tablets do have to be used for an extended period of time, anywhere between 12 to 24 weeks.

Tips:

1. Nail fungus may be a sign of the environment. This is especially true of the foot. If your foot has fungal infection of the skin and various other forms of skin dysfunction such as dermatitis, it’s more likely that you will get fungal nail infection. You should also consider how well you tend to keeping your nails well trimmed, so that they do not attract problems.  So the overall health of your foot, is important.  To this extent, whilst taking antifungal tablets for your nail, you may consider applying antifungal cream to the remainder of your whole foot.  Remember always to rub this in, so that your foot stays dry, as discussed in the section for fungal skin infections.
2. To send a nail sample or not to send a sample? When you go to see a doctor for fungal nail infection, they may suggest sending a sample of your nails (clipping) for testing.  If you choose to do this, you need a really good sample, because an inadequate one is liable to come back falsely negative.  In Australia, if you want to have your antifungal medication paid for by the Government, you will need to send a sample to the pathology laboratory for formal testing and diagnosis.  Your doctor will then have to make a phone call to get authority for the antifungal tablet medication script to be approved.  Yet, not infrequently, the pathology result will be negative when the nail clinically definitely looks to have fungal infection.  In this case, you may still wish to proceed with taking antifungal tablets.  The risk factors of this are the risk of a medication related adverse reaction.  One significant risk of antifungal medication is getting liver dysfunction and failure.  This risk is described as “rare”, meaning that there is a one in 1,000 – one in 10,000 chance of having liver failure.  For this reason, it may be a good idea that you do a blood test after about four weeks of treatment, checking your liver function test, and general parameters. Note that the cost of anti fungal medication is not so high (at the time of writing, about $22 for 42 tablets), so buying the tablets on a private script, despite a negative pathology sample, can most certainly be a viable option.
3. Preventing recurrences. As mentioned, fungal nail infections are stubborn to go.  If you do win the battle, to limit recurrence you may like to apply an antifungal cream to your foot, including your nails, routinely.  However, note that the antifungal of choice for nail infections is terbinafine, whilst the typical antifungal cream (clonea, canestan) for the skin contains the antifungal clotrimazole.  The cream form of terbinafine does exist and is often sold under the trade name Lamisil.  Perhaps consider using it for this purpose.

Wound infections

Wounds happen commonly in the elderly, particularly because of the tendency to fall.  An infected wound can be recognised when it gets red and pussy.  Antibiotic tablets may be needed.  Or, if it is small enough, an antibiotic cream may suffice.

It is important to clean the wound, daily.  This may be best done in the shower.  It’s preferable in this way, to clean a wound in general, rather than try to keep it “dry” under a dressing for long periods of time.  Usually that leads to wounds festering.  After washing your wound well in the shower, pat dry it, apply an antiseptic cream, and cover it.  In general, remember, a wet wound (infected) needs to have a dressing which basically keeps it dry.  I would suggest avoiding dressings which do not breathe and rather try to keep things waterproof, for extended periods of time.  This is because they tend to lead to the wound getting “wet” and boggy under them, particularly if they are left on too long.  Rather, use a dry dressing, wash the wound daily in the shower and start again, daily.

SUN DAMAGED SKIN

Sun damage shows itself usually as red and flaky skin.  Alternately, on elderly people of darker complexion, sun damage can appear as areas where there is increased pigmentation.  Sun damaged skin (solar keratotis), when it is confined to specific spots, can be treated by freezing it off (cryotherapy) with liquid nitrogen.  This has to be conducted by a doctor.  Either that or certain creams can be applied to the area.  This includes diclofenac gel or other chemotherapeutic creams (see below).  Since often sun damage occurs an large patches, and areas, for example the back of the hands, these creams can be really useful to treat such larger areas.  There is also some good evidence for using vitamin V3 (nicotinamide), taken orally, to help with decreasing the extent of sun damaged skin.  This research has been pioneered by Professor Diona Damian in Australia.  The recommended dose of Vitamin B3 is 500mg oral twice a day.  Although it is quite early in the use of this vitamin for sun damaged skin, early data looks very positive and certainly worthwhile investigating if you or someone you care for has significant sun damaged skin.

SKIN CANCER

Skin cancers occur very commonly in the elderly, especially in Australia.  Skin cancers are broadly speaking categorised as melanoma or non-melanoma.  We now discuss either type separately.

Melanoma

Melanomas are usually more dangerous since they more readily spread and can invade internal organs within the body.  Melanoma tend to be dark in colour, either being brown, blue or black.  It can be difficult for the average person to tell the difference between a melanoma and other brown/ black spots on skin that come with age.  In general though, if you have a spot which is new and changing, then you should have a doctor look at it.  The other type of skin change worthwhile considering could be a melanoma is a more large brown patch.  If such a patch has various shades of brown and even black, then it could be a melanoma. In this case, such larger patches may have actually grown very slowly, sometimes over many years.  These more slow growing forms of melanoma tend to occur on the face.  The main point to get through here is that if you’re worried that something could be a melanoma, it’s worthwhile asking your doctor to have a look.

Non Melanoma

These are skin cancers which are far more common than melanoma. They tend to occur on sun exposed areas including the hands, face, forearms, upper chest/ neck area and legs.  They are typically deep pink to red in colour.  Non melanoma skin cancers are either squamous cell carcinoma or basal cell carcinoma.  It would be hard for the average person to tell the difference, except to say that squamous cell carcinomas tend to be more dry and crusty.  Squamous cell carcinomas are generally more dangerous than basal cell carcinomas since they are more likely to become invasive and spread.  Basal cell carcinomas can also do this, but only rarely.

Skin cancer in the elderly – what to do?

As previously stated, skin cancer is very common in the elderly. And, it can sometimes require surgery.  However, even one person may have many skin cancers on their body, and having multiple surgeries may not be the best approach.  It really depends on the type of skin cancer.  If you are worried about a melanoma, then you need to see your doctor sooner rather than later and if you are found to have a melanoma, then having surgery to cut it out may well be the best option.  It usually is.  If however, you have a red spot or multiple spots on your body, which could be non melanoma skin cancer, certainly have your doctor look at them, but in this case, having surgery for all or any of them, may not be the best option.  Sometimes the elderly can become caught in a cycle of having multiple disfiguring operations, for such non melanoma skin cancers, when other treatments could have been considered.

Should I have a biopsy?

Whenever a spot on your body is considered to be a skin cancer, then sending a sample for testing may be a useful thing to do.  This sample is called a “biopsy”.  There are different types of biopsies which your doctor may want to do, but the point of the exercise remains the same, to send a sample, which hopefully represents the problem well enough so that it can be proven whether the skin change is a cancer or not.  With regard to melanoma, it’s generally advisable that a biopsy be sent.  With regard to a suspected non melanoma skin cancer, it may reasonable to treat the spot first, without a biopsy.  That’s appropriate in many cases.

Tips

1. Take a photo of a brown/ black lesion first. Before having a skin spot which may be a melanoma tampered with (biopsied), have a photo taken.  This may help doctors in the future understand the problem and work out what to do.
2. Biopsies do not spread disease. Sometimes, people worry that the process of taking a biopsy, can encourage or even start a skin cancer (or any cancer for that matter) spreading.  There is no evidence for this.  If your doctor recommends a biopsy, then don’t let this thought affect your decision.  The only one thing to mention here is that for melanoma, it is important that the biopsy performed captures a sample of the entire spot.  The reason for this is that it is not reliable to try and only biopsy the “worst” area of a brown/ black lesion to look for melanoma.  Some of the area remaining which is not biopsied may contain cancer.  There are some instances, where it is not possible to biopsy the whole thing, but it should always be strived for.  The same is also true for non-melanoma skin cancer, but it’s generally thought that taking part of a spot there is acceptable and indeed the repercussions of not sampling some parts are less dangerous than for melanoma.
3. Non melanoma skin cancer – often safe to use non surgical treatment first. Before jumping in to have your non melanoma skin cancer surgically removed, consider the option of cryotherapy, that is, to have it frozen off using liquid nitrogen.  This can simply be done at a GP surgery.  Often times, non melanoma skin cancer (SCC and BCC) respond well to this treatment and it is in general less invasive than surgical removal.  Also, it’s often found that after you do a biopsy for a skin cancer (removing a small sample surgically), the remainder of the cancer shrinks, and can even go away all together.  So for small, early, less invasive forms of skin cancer, It could be worthwhile to see whether this happens, before rushing in to do anything else.  Lastly, there are creams which can sometimes be of benefit, used well to treat an area of skin generally affected by sun damage.  These include Flurouracil cream for example. These can be very effective.  Ask your doctor about these options.

ECZEMA AND DERMATITIS

Elderly skin can readily become itchy, and when it does, it can be difficult to get things back to normal.  There are many reasons why elderly skin in particular can become itchy.  So perhaps the best place to start here is to look at those reasons and see what can be avoided.  These are some common causes of itchy skin in the elderly:

• This is especially true on your back but can include your whole torso.  If it’s summer, and you’re getting sweaty, do something to cool down.  As a simple tip, don’t wear too many jumpers and clothes when it’s warm.
• Some medications including blood pressure pills and diuretics can make your skin itchy.  Ask your doctor about the possible contribution of your medications to any skin conditions.
• If you sit too close to a heater for too long, the skin on your legs in particular can get very dry and subsequently start to itch.  Take it easy on the changes in temperature and especially that sitting close by a heater in the winter.  Preferentially wear more clothes, including thick socks, during winter.
• Varicose veins. Legs often times struggle with circulation problems.  In this case, the problem of gravity causing blood to pool in the veins of your legs, causing swelling and congestion of your legs and ultimately contributing to them becoming itchy.  The skin may then be red and warm.  Try not to sit in a chair, with your legs dangling for too long during the day.  If you have to sit, then elevate your legs.  Consider also wearing compression stockings to limit the amount of blood which can collect in your legs.
• Sometimes, your mental state can cause you to scratch and pick at your skin.  This could affect any part of your body.  The point is there though, that a tense person will tend to pick and scratch their skin more readily.  So, consider that, and whether techniques in relaxation may help you scratch less.
• Itchy skin can indicate an infection – fungal, bacterial or parasitic (in the case of scabies).  If you’re not sure about whether infection is the cause, please see your doctor.
• Dry skin. As we age, our skin tends to get drier.  Drier skin is generally more itchy.

These are some common causes of itchy skin.  The processes above can start as an episode, but the resultant damage to your skin can cause it to be itchy for a long time after, sometimes even, forever.  To avoid that outcome, you need to get on and treat any of the above causes when they happen, so your skin doesn’t change in any major or irreversible way.  During the way, a key factor is to avoid the temptation to scratch your skin.  We all know this.  But how to stop scratching?  Medically, a steroid based ointment or cream can help lessen the itch.  This will need to be applied once to twice a day to affected areas.  You will likely need a strong (potent) variety of this cream if it is to help.  This could for example be mometasone cream. There are many other steroids to choose from, and they do a similar job.  However, different people do react differently to various creams (any drug for that matter), so if one steroid cream doesn’t work, it may well be worthwhile trialling another.  Ideally though, try not to use a steroid cream long term, they do have their side effects.  Use it for a stint when necessary, perhaps two weeks as a maximum, then stop.

We mentioned dry skin.  Signs that your skin could be too dry include flaking and it easily being torn or bleeding.  These things can happen anyway to the skin with age, but they are worsened by dryness.  To help with this you need to make sure that you are always well hydrated, have a good balanced diet in general and apply moisturiser, perhaps twice a day.  There are many moisturises out there to choose from.  Once again, you may find one that you particularly find agrees with your skin.  It’s worth searching for this.  Sometimes the simpler the better, rather than the fancy expensive medicalised versions.  For example, Nivea cream is generally fine.  Otherwise, a good Vitamin E cream may help.  Try what works for you, but keep it simple.  Consider also changing the creams you use sometimes.  Your skin can develop an allergy to a cream if you use it for a very long time.  This tends to happen if the cream has more ingredients and is more complicated.  Some people are fine however using the same cream long term.  When you apply a moisturising cream, its better to rub it in, into the skin, rather than leaving it as an “oily film” on the skin surface.  After all, the idea is for the cream to penetrate your pores, and work there, rather than remaining as a barrier on the skin surface.  When creams are left on the skin surface, sometimes they can become as problematic, stopping the skin from breathing, than beneficial.  Rub in the cream, so your skin feels supple and bouncy, but not oily or wet to touch.

SKIN TEARS

Elderly skin can be very fragile.  This is generally part of the normal process of aging.  Keeping your skin well moisturised can help with this.  However, despite best attempts, at times, often related to falling or other trauma, the skin will tear.  When it does, it can lead to infection.  In treating a skin tear, we need to remember that each side of the tear can either live or die.  That’s to say, that the skin has been torn away from its usual blood supply, and so, even if we paste it back down where it was, that part of the skin may die because it doesn’t re-establish a blood supply.  So, in that way, let’s delve into what steps can help a skin tear heal:

1. Wash the area clean with chlorhexidine solution, then feel free to finish off with normal saline. Remember, more chemicals may help to clean, but too many harsh chemicals equally can hamper healing.
2. Please the edges of skin into their original place. You can at this stage apply “steristrips” which are pieces of tape especially designed for the skin, to hold apposing edges together.
3. On top of this, apply a vasoline impregnated gauze, and on top of this apply gauze and a crepe bandage.

You will have to keep this wound and dressing dry.  Some people use clear waterproof dressings.  However, if that waterproof dressing does start to allow water in, the wound will get macerated and start to fester, all increasing the likelihood of infection.

It’s important that you keep this area free from movement or other sheer stress.  The skin tear now under the dressing, needs to be kept still so that the flaps of skin can importantly re-establish their blood supply.  In this way, treatment of a skin tear is similar to the treatment of a skin graft.  Some pressure and immobilisation.

WHEN TO CHANGE THE DRESSING.

In keeping with the idea of keeping the wound still to start to regrow, we should avoid the urge of changing the dressing too often since every time we change the dressing, we interrupt the healing process.  Try to therefore keep the dressing on for one week.  A reason to change the dressing would be because there are signs of infection.  This is usually indicated by a dressing that has excessive fluid.  The pain of the wound itself could be increasing.  The person may get a fever or the wound get smelly.  If these things are happening, infection could be setting in.  In this case, the dressing needs to be changed, and should be changed daily or at least second daily depending the amount of ooze.  The wound needs to be kept dry.  If infection occurs, you may ultimately find that the original skin dies and peels off.  In this case, the area, now devoid of skin, will heal from the bottom up, purely as scar tissue.  This may take longer, but in general, will occur, unless the original wound was very deep.

ANTIBIOTICS OR NOT?

With any break to the skin, there is a chance of infection.  One important consideration is to consider when the last tetanus immunisation has been had.  If it’s more than 10 years ago, it is likely worthwhile to have a booster.  Antibiotics could be considered for skin tears which:

1. Are extensive and the risk of infection is therefore high
2. Receive delayed treatment (cleaned and dressed greater than 4 hours after the incident)
3. For patients who have conditions such as diabetes which impair their immune system.

TIPS:

1. Wear socks at home. Lots of elderly people get skin tears on their legs.  Wearing socks can offer protection for your legs and lessen the chance of the skin tearing should you knock them.
2. Is it useful to get a doctor to stitch the wound together? Generally, no because the skin is so fragile that it tends to tear and fray whilst trying to bring the edges together.  However, for deeper wounds, there may be more tissue to grasp and bring together, making stitching it together more viable.  If you’re not sure, see a doctor.  Perhaps if you are able, send the doctor a photograph.
3. Dressings – what to use? The main principle is that apart from steristrips, try to use a dressing that doesn’t get stuck to the wound.  For this reason, we do recommend using a vasoline impregnated gauze or similar material, with gauze on top of that.
4. If there is a large collection of blood under a skin tear (a “haematoma”) then it needs to be thought of whether it should be drained or not. Not draining it could increase the risk of infection, since bacteria thrive on eating blood.  You could consider draining it simply using a sterile needle.  After you drain it, you will need to have a dressing which places sufficient pressure on the area, so that it doesn’t recollect.
5. Should I continue my blood thinning (anticoagulant) medication? If you have a skin tear, generally the bleeding will settle and you can continue your anticoagulant medication such as aspirin and warfarin.  You should not stop such medications too readily or quickly since you may well be on them for a very good reason such as to avoid having a stroke.  Stopping them abruptly could lead to a much larger problem that way, than the bleeding from a skin tear.  However, this needs to be balanced with how large the wound is.  If it is a skin tear, and nothing deeper, then you should be able to continue taking your anticoagulant medication.