1. THE SKIN SHOW “Critters VS the Hide Module #4
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
UNMC
Omaha, NE
Web: geriatrics.unmc.edu
All photos were reprinted with permission from the American Academy of
Dermatology. All rights reserved.
Slides adapted with permission from GRS 5th edition: Dermatologic diseases and disorders
Welcome to Skin Show Module 4. The Critters vs The Hide.

2. PROCESS Series of 4 modules and questions on
Etiologies, Evaluation, & Management
Step #1 Power point module with voice overlay
Step #2 Case-based question and answer
Step #3 Proceed to additional modules or take a break
Our process will be for you to complete the fourth in a series of 4 modules and questions on geriatric dermatology. If you have not completed the first 3 modules, please do so at this time and then return to this module. These modules will utilize power point with voice overlay. Each module will be followed by case-based questions with answers that will explain the right and wrong responses. Then you will have the option to continue with the next module or take a break at that time. The computerized system will keep track of the modules you have completed so that in the future you may pick up where you left off.

3. Objectives Upon completion the learner will be able to
1. Identify common infectious dermatologic diseases in the elderly.
2. List treatment modalities for common infectious dermatologic diseases in the elderly

4. What’s this?
What do you think this is? Delicious isn’t it?

5. Candidiasis ( intertrigonal)
Intertrigonal: commonly found in the web space between the 4th and 5th toes. Moist erythema, maceration and superficial erosion is apparent. More common in older adults because of increased skin folds from decreased dermal elasticity Often associated with secondary candidal or mixed bacterial colonization
Candidiasis intertrigonal. Most commonly found in the web space between the 4th and 5th toes. It presents as moist erythema, with superficial erosions, more common in older patients because of increased skin folds from reduced dermal elasticity. Often associated with secondary candida or mixed bacterial colonization.

6. TREATMENT OF INTERTRIGO
Keep area dry, open to air
Use topical antifungal powder or lotion (eg, 2% miconazole powder or 1% clotrimazole lotion)
Use mild topical corticosteroid occasionally to reduce inflammation
For treatment you have to keep it dry. Also treatment with topical antifungal powders or 1% clotimazole lotion ( which is my favorite). Sometimes you will need initial corticosteroids (0.1% triamcinolone) to reduce inflammation. ( if using with lotion or powder, apply the triamcinolone cream on top.)

7. What’s this?
Seen this before?

8. Answer: Candidiasis
rash may resemble intertrigonal but have peripheral satellite papules and pustules
At risk: older persons with decreased mobility, increased skin moisture or friction, poor hygiene, diabetes mellitus
Oral thrush may develop in those on corticosteroid inhalers, antibiotics, immunosuppressants, or with concomitant illness (diabetes)
Yes –it’s Candida. The rash may resemble intertrigonal, but this will have peripheral satellite papules and pustules. Older persons are at risk due to reduced mobility, moisture, friction, poor hygiene, diabetes. Candida that infects humans is Candida Albicans. It’s a normal inhabitant in the gastrointestinal tract in about 70% of the people and is a normal organism on mucus membranes. Things that trigger infection: any local tissue damage that causes disturbance of the skin or alteration of the pH or removal of competing organisms through use of antibiotics. Any time we increase the amount of glucose, saliva, sweat, or urine this will prevent bacteria from inhibiting yeast growth and, lastly, any warm, moist environment such as found in this intertrigonal area provides an excellent media. Sometimes we will get oral thrush when on systemic or inhaled corticosteroids or antibiotics.

9. CANDIDIASIS Diagnosis: KOH preparation reveals spores and pseudohyphae
Treatment:
Keep skin dry
Improve hygiene
Use topical or oral anticandidal agents (1% clotrimazole lotion, nystatin, ketoconazole)
The diagnosis is made via a KOH prep which reveals spores and pseudohyphae. The treatment is drying the skin, improving hygiene and using topical or oral anticandidal agents.

10. What’s wrong with the nails?
What’s wrong with these little beauties?

11. Answer: Onychomycosis
often yellow, thickened, and friable, with yellow-brown debris under the nail plate.
Causes: dermatophytes, yeasts, and nondermatophytic molds
Often preceded by or concomitant with tinea pedis
Diagnose by KOH preparation or fungal culture
Onychomycosis: Often yellow, thickened and friable. The causes is dermatophytes, yeasts and some nondermatophytic molds, often preceded by concomitant tinea pedis. Again, the KOH can help us diagnose or fungal culture.

12. TREATMENT OF ONYCHOMYCOSIS
For cosmetic concerns, comorbidities (diabetes), or pain
Topical agents not usually effective
Oral griseofulvin: poor absorption, side effects, and drug interactions limit adherence and efficiency
Oral terbinafine: only orally active fungicidal agent, may interact with tricyclic antidepressants
Oral fluconazole: safe and useful for candida, well tolerated
Oral itraconazole: potential for drug interactions (cytochrome P-45O)
Treatment may take 3 to 4 months
Relapse rate is high
Most of the time you treat this for cosmetic concern, occasionally pain, occasionally comorbidities of diabetes. Topical agents don’t work. Oral griseofulvin has poor absorption, side effects and drug interactions and is really limited. Oral terbinafine at 250 mg a day for 3 months is 70-80% effective. Oral fluconazole is safe, well tolerated and more useful for candida. About mg q week for 6-12 weeks is 30-40% effective. Lastly, oral itraconazole has some drug interaction, especially in the P-450 system. Its dosing is 200 mg a day for 3 months or 200 mg twice a day for 1 week a month for 4 months. This reaches up to 84% effective.

13. What’s this?

14. Prodrome: pain, burn, itch, dull ache
Answer: HERPES ZOSTER
Prodrome: pain, burn, itch, dull ache
Grouped clusters of vesicles and pustules on an erythematous base involving a dermatome.
More than 2/3 of cases occur in persons aged 50 or older
Incidence is 20 to 50 times higher among immunosuppressed patients
Ddx: -Herpes simplex;
-Dermatitis herpetiformis
-Allergic contact dermatitis
This is Herpes zoster or shingles. It has a prodrome with a burn, itch, pain, dull ache. Then you will see the eruption of clusters of vesicles and pustules on an erythematous base. More than two thirds of cases occur over age 50. These grouped vesicles will become crusted in about 5-10 days. The thoracic distribution is the most common. Occasionally trigeminal or cervical regions are involved in about 20% of the cases. If you see more than 25 vesicles be concerned that disseminated zoster may be eminent. The differential includes herpes simplex, but this is more common if the lesions are recurrent and in the same location. Dermatitis herpetiformis lesions are more symmetrical, more generalized and are nondermatomal distribution. Lastly, allergic contact dermatitis usually has a distribution nondermatomal and associate with an suspicious contact and pruritis is a common symptom rather than pain.

15. HERPES ZOSTER
Most important reason for varicella zoster virus (VZV) reactivation is senescence of the cellular immune response to VZV with increasing age
Reactivation also associated with HIV, malignancy, use of immunosuppressive drugs
Aging seems to predispose us to this by allowing reactivation of varicella zoster virus with cellular immunity senescence. Of course, it can also reactivate with HIV, malignancy and other immunosuppressive drugs.

16. COMPLICATIONS OF ZOSTER
Involvement of ophthalmic branch of trigeminal nerve
Requires careful ophthalmic monitoring
Hutchinson’s sign: vesicles on the tip of the nose represents involvement of nasociliary branch
Ramsay-Hunt syndrome (involvement of facial or auditory nerves)
Presents as herpes zoster of external ear or tympanic membrane
Leads to facial palsy with or without tinnitus, vertigo, and deafness
Pain can precede, co-exist, or persist after rash
Post-herpetic neuralgia: pain that persists or appears after rash has healed > 30 days after onset of rash
Occurs in 70% of those ≥ 70
Prevention and education more effective than treatment
Inc
The ophthalmic branch of the trigeminal nerve requires careful monitoring often by an ophthalmologist. Hutchinson’s sign: vesicles on the tip of the nose represent a high risk for eye involvement. Ramsay-Hunt: involvement of the facial or auditory nerves; presents as herpes zoster of external ear or tympanic membrane. It can lead to facial palsy, vertigo and deafness. But probably the most feared is Post-Herpetic Neuralgia - it is defined as pain that persists after the rash has been healed for 30 day or more. It is very common in the elderly. Prevention and education are more effective than treatment. Educating your patient early about the sequelae of this disease helps them sometimes to accept it when it occurs.

17. DIAGNOSIS OF HERPES ZOSTER
Tzanck smear from base of vesicle shows multinucleated giant cells and epithelial cells containing intranuclear inclusion bodies
Smear can be sent for direct fluorescent antibody staining
Definitive diagnosis by viral culture
The diagnosis: staining of the fluid of the vesicles. These smears can be sent for direct fluorescent antibody staining. Viral culture can be used, but most of the time the distribution and the presentation are enough for the diagnosis.

18. TREATMENT OF HERPES ZOSTER
If intact immunity, herpes zoster is usually self-limited
Treatment should start within 72 hours of rash
Acyclovir 800 mg, 5x / day for 7 to 10 days
Valacyclovir ( Valtrex) 500 mg tid X 10 days
Famciclovir (Famvir) 500 mg tid x 7 days
Early treatment: 1)halts progression of disease, ) increases rate of clearance of virus from vesicles, 3) decreases incidence of visceral and cutaneous dissemination, 4) decreases ocular complications when eye is involved, may decrease pain and incidence of post-herpetic neuralgia
Wet compresses(Burrow’s)/topical antibiotics can treat secondary bacterial infection
If our immunity is intact, it alone can limit the herpes zoster. Treatment should start within 72 hours. Why? It can halt progression of the disease, increase viral clearance from the vesicles, decrease incidence of visceral and cutaneous dissemination, reduce risk of ocular complications and probably the most important, reduce incidence of post-herpetic neuralgia. Listed here are a variety of medications and treatment regimes. Wet compresses can soothe the lesions; topical antibiotics can treat the secondary bacterial infection.

19. TREATMENT OF POST-HERPETIC NEURALGIA
No definitive therapy
Antidepressants, anticonvulsants Narcotics, epidural injection of local anesthetics, capsaicin, acupuncture
Corticosteroids may decrease acute neuropathic pain and reduce pain medicine requirements
If one goes on to develop Post-Herpetic Neuralgia there is no specific therapy. Some choices available are antidepressants that have some neuropathic pain reduction, although nortriptyline and amitriptyline are poorly tolerated in elderly. More commonly used are the anticonvulsants such as gabapentin and lamotrigine. Narcotics and epidural injections have been used. Capsaicin cream, if applied, should not be to open lesions and should be applied at least 3 times a day of a 0.025%. Acupuncture has also been used. Corticosteroids have been used to reduce acute neuropathic pain with initial does of prednisone 1 mg per kg for 1 week followed by a taper of over 3 weeks should be performed close to the onset of the disease.

20. What’s this? 77 yo male homeless with diffuse pruritus, erythematous rash with scabs.
What do you see on this 77-year-old homeless male with diffuse pruritic, erythematous rash with scabs? This is a gimme.

21. Signs: erythematous, crusted papules, and linear burrows
Answer; SCABIES
Symptoms include severe pruritus (esp. of hands, axillae, genitalia, and peri-umbilical region),
Signs: erythematous, crusted papules, and linear burrows
Infestation of mite Sarcoptes scabiei
Common in institutionalized older persons; epidemics occur in long-term-care facilities
Eradication can be difficult
Spread by person-to-person contact
Ddx; - Lichen simplex chronicus
-Atopic dermatitis
-Flea or insect bites
-Pruritus of systemic disease
Scabies. Symptoms include pruritus that can be quite severe, erythematous crusted papules can be seen with linear burrows. This is common in institutionalized individuals. Epidemics, which are very difficult to control, can occur in long-term care facilities. It is spread from person to person through linen, clothing, towels. The female can survive for at least 3 days off the human host. The fertilized female that excavates and burrows in the skin puts in about eggs then the larvae emerge after 3-7 days and mature and travel on the skin’s surface. Once you have had these little critters for 1-2 months you start to get sensitivity to the organism or the fecal pellets and then you start itching. With re-infection symptoms occur within 24 hours and the pruritus is much more intense. The differential includes lichen simplex chronicus. Here it’s differentiated by no burrows. The distribution is not typically on the wrist or the finger webs. Atopic dermatitis – the distributions of lesions occur on the antecubital or popliteal areas instead. Flea and insect bites will have many papules in a fixed area. Lastly, pruritus of system disease is usually associated with more of a macular papular eruption of generalized xerosis.

22. SCABIES
Diagnosis: scraping of suspected lesion (mite excreta, eggs or mite may be seen)
Treatment often initiated when clinical suspicion of infestation is strong
Treatment:
Topical permethrin 5% or lindane ( Kwell) 15 cream
Re-treat in 1 week if itching and lesions persist
Launder bed linens and clothing in hot water
May use topical corticosteroids for pruritus
Pruritus may persist for weeks to months
How do you diagnosis this? Sometimes it’s difficult. Scraping of the lesions might show you some mites, eggs or excretions. Any time you suspect it, begin treatment because once it is infested it is very difficult to root out. Contact should be treated at the same time in entire families. Permethrin or lindane can be used. Re-treat in 1 week if itching and lesions persist. Clothing and bedding used over the past week should be laundered. . Topical steroids such as 0.1% triamcinolone can reduce the pruritus, but just know that the pruritus may last for weeks or months.

23. The End of “Skin Show” Module Four
Thank you for Your kind Attention !!
Ed Vandenberg MD CMD
Section of Geriatrics
UNMC
Omaha NE
Web: geriatrics.unmc.edu
This completes our fourth and last module on geriatric dermatology, you should complete this review with a question and answer. To access the the question, close out of this window, advance to question 2, answer the question and review the answer. We thank you for your patience and persistence with the skin modules.
Question 497

24. post-test
A 74-year-old man with diabetes mellitus and hypertension has onychomycosis of most nails on each foot confirmed by potassium hydroxide (KOH) staining and fungal culture of nail scrapings. In addition to having cosmetic concerns, the patient finds that the crumbling, thickened nails are causing discomfort and difficulty in his routine foot care. His current medications are glyburide 10 mg twice daily and enalapril 5 mg daily.
What is the most appropriate therapy for this patient?

25. What is the most appropriate therapy for this patient?
Griseofulvin 500 mg daily
B. Ketoconazole 200 mg daily
C. Itraconazole 200 mg daily
D. Terbinafine 250 mg daily
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY

26. Answer:D. Terbinafine 250 mg daily
The most appropriate treatment for this patient is terbinafine, a fungicidal agent especially useful for onychomycosis. Terbinafine is an orally active allylamine derivative with a high potency against dermatophytes. It is well absorbed from the gastrointestinal tract and metabolized in the liver. Its effect is cytochrome P-450-independent. Terbinafine is generally well tolerated, with occasional gastrointestinal side effects and the rare serious skin reaction. The treatment is with one tablet daily for 6 weeks for fingernail infections and for 3 months for toenail infections. Recurrence rates are below 10%.

27. Itraconazole is also effective against dermatophytes and is likewise readily absorbed from the gastrointestinal tract. Daily doses of 200 mg of itraconazole for 6 to 8 weeks for fingernails and 3 to 4 months for toenail mycoses have cure rates of 80% to 90%. Recurrence rates are below 10%. Itraconazole does affect drugs metabolized by the cytochrome P-450 3A system and can cause severe hypoglycemia in patients who are taking oral hypoglycemic agents, as is the case with this patient, for whom terbinafine would thus be a better choice.

28. Ketoconazole, the first orally active broad-spectrum antimycotic drug, has been abandoned for this indication because of idiosyncratic hepatic side effects. Griseofulvin is a safe systemic treatment for onychomycosis but has very low cure rates, about 50% to 60% for fingernails and 20% for toenails. Recurrence rates with use of griseofulvin approach 100%. end