Skin Disorders

Prurigo nodularis is also a result of continual rubbing, scratching and picking and can be a result of stress. The nodules that characterize prurigo nodularis are erythematous and generally dispersed with keratotic nodules on the extremities. Treatment includes the topical application of triamcinolone acetonide or another corticosteroid or even a stronger steroid such as betamethasone. Alternative treatments include corticosteroid tape.

Similar treatments are applied for excoriated papules in post-inflammatory scarring at different points of healing. These neurotic excoriations may be found in patients whose condition does not fall into a normal pattern and who use their skin as a tool on which to release stress. Psychotherapeutic treatment plans are recommended by Truensgaard.3, 7 This can include strengthening the relationship between the patient and doctor, introducing alternative tactics to avoid scratching, identifying and reducing causes of stress and identifying triggers.

Delusion of parasitosis is a symptom of psychosis in which the patient complains of the feeling of parasites crawling on them when there is no evidence to support this as being true. Related factors include nutritional deficiency, arteriosclerosis, toxins and drug addiction. Depressive patients are usually treated with fluoxetine or doxepin, alprazolam or hydroxyzine for anxiety and pimozide or haloperidol for delusions. Alternative treatments may be used alongside anti-psychotics. Zyprexa may also be used.3, 6, 7

Fungal infections are also commonplace in the elderly community. These can include candidiasis, tinea pedis, tinea cruris and onychomycosis. Candida thrives in warm, moist environments where there is skin-to-skin contact and is a dispersed, bright red eruption with leaking pustules. When examined through a microscope, one can observe spores and pseudohyphae. Candidiasis is often associated with diabetes and oral antibiotic therapies. Treatment usually involves cold compress application with Burrow’s solution, topical application of antifungal creams such as econazole or miconazole and, after the eruption is cleared, absorbent powder.3

Tinea pedis, also known as ‘athlete’s foot’, infects the foot, appearing as erythematous dermatitis with a scaly and macerated presentation and, in some cases, ulceration and fissures. It can also appear alongside a secondary bacterial infection. Tinea pedis can be prevented with topical applications of benzoyl peroxide post-bathing and the wearing of shower shoes. It is treated with an imidazole such as clotrimazole, econazole or ketoconazole or an allylamine. Resistant infections may be treated with oral itraconazole, fluconazole or terbinafine.3, 8, 9

Tinea cruris, also known as ‘jock itch’, affects the groin region, in an erythematous, scaly, itchy eruption and is most commonly seen in males. Reduction of moisture is integral to the treatment of the condition and an antifungal cream is usually applied topically as treatment. Severe infection may be treated with oral antifungals. A betamethasone dipropionate–clotrimazole mixture may also be applied topically to areas of inflammation for limited periods of time.3, 9

Almost half of patients exceeding 70 years of age suffer from onychomycosis, usually caused by tinea unguium, Candida or moulds. Symptoms include pain, ulcerations within the nail bed and secondary bacterial infection. The most frequently seen form of onychomycosis, distal and lateral subungual onychomycosis (DLSO), often appears first as just a white spot on a nail that then darkens, causing the nail to become thick and crack. Treatment usually involves debridement, systemic treatment, topical treatment, benzoyl peroxide washes and improvement of hygiene.3, 10

As malnourishment and malnutrition, disease and trauma, among other things, cause changes and weakness in the skin’s makeup, skin infections become a common occurrence in the elderly. Likewise, some forms of dermatitis and insect bites and stings can reduce the skin’s natural resistance and thereby allow entrance to infections such as Staphylococcus and Streptococcus. These strains can cause impetigo in bullous or non-bullous form and, although it is often self-limiting, treatment should still be applied owing to the risk of complications such as post-streptococcal glomerulonephritis.3, 11

The bullous form of impetigo is a result of the site of the infection producing epidermolytic toxins and is defined by bullae containing cloudy or clear fluid that can burst and leave a hyperpigmented rim surrounding the lesions and honey-coloured crusted exudates. The non-bullous form of impetigo presents as pustules that can rupture, leaving a red, swollen base and a yellowish crust. This comprises 10% of impetigo and is of some resemblance to the reaction to poison ivy.3, 12

There may be some ‘honey crusting’ inside the bulla. Usually before impetigo, Staphylococcus aureus invades the nose and affects the areas around the nose and mouth and also on the limbs. Group A beta-haemolytic streptococci (GAS) occur on the intact skin and after abrasion, cut or other trauma, they enter the wound and cause infection. Treatment is usually with oral antibiotics such as cephalexin, dicloxacillin or cloxacillin or a 5 day course of azithromycin at 500 mg for the first day and half that amount on subsequent days. Mupirocin is also applied topically three times per day for the lesions.3, 11, 12

Parasitic diseases such as scabies and pediculosis are common in the elderly. Head, body and pubic lice, accompanied by pruritic papules, can be transmitted through direct contact with the infected person. Diagnosis is often carried out through examination and finding of nits. Lice are initially treated with permethrin and combing of nits. In persistent cases, treatment with malathion lotion or lindane may be given.

Scabies is characterized by burrows alongside papules and vesicles. It is diagnosed through the analysis of skin scrapings and finding of ova, mites or faeces. Scabies is often found in the male genitalia or female areolas of the nipples and can also be seen on the scalp. In keratotic scabies, thousands of mites infest the skin, a considerably larger number than the average 3–50 mites. Treatment involves oral ivermectin in 12 mg doses, one week apart, and thorough cleaning of fomites.3, 13, 14

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