Skin cancers are the most common cancers in Australia, and general practice is the most common place for the diagnosis and management of these tumours. Skin cancers increase in frequency as individuals age.
Thorough skin examination is the mainstay of early prevention and detection of skin cancers, at intervals dependent on the individual’s sun-exposure history and previous skin cancers. This reduces morbidity and complications associated with treatment. Dermatoscopy, if available, is helpful in diagnosing pigmented and vascular aberration.
Skin cancer management must be individualised to the patient, and the patient must appropriately consent if diagnostic or therapeutic procedures are to be undertaken. In all age groups, surgical treatment is the mainstay for cure; however, standard guidelines for treatment may not be appropriate for older patients. Treatment does need to be tailored to the patient’s age, general health and wishes (non-curative treatment may be considered).
Keratinocyte cancers (ie squamous and basal cell carcinomas) are the most common indicators of significant sun damage and possible precursor (solar keratosis).10 Treatment for these premalignant and malignant conditions is common in general practice, and the Cancer Council’s National Health and Medical Research Council (NHMRC)-approved Basal cell carcinoma, squamous cell carcinoma (and related lesions) – A guide to clinical management in Australia is a good reference.
Melanoma is recognised with increasing age,11 and the current treatment protocols are available through the Cancer Council’s Clinical practice guidelines for the diagnosis and management of melanoma. Older individuals are especially at risk of in situ and thin melanoma in sun-damaged fields.
Melanoma treatment has progressed markedly in the past 10 years, and many patients are using biological therapeutics to produce lasting longevity in previously rapidly fatal illness states. However, these biologic agents do cause significant skin drying and hyperkeratosis, so good emollient use must be encouraged.
Wounds and ulcers
The skin of older people is less resilient and more prone to damage as they age. Shearing force in non-elastic skin results in tears and abrasions occurring much more commonly. Skin tears are commonplace in older people given that other intercurrent illnesses may affect balance and proprioception (eg Parkinson’s disease, diabetes, cerebrovascular accident), leading to increased accidental trauma.
Repair of tears should use the patient’s own skin flap as a ‘graft’, where practicable. After cleaning the area, where possible, the patient’s skin flap should be laid back in place and needs to be held in contact with the wound bed with a firm dressing for several days. Deeper wounds must be assessed on their merits, and treatment is dependent on depth, cause, location on wound, venous and arterial competence, infection risk and general nutritional status.12,13,14,15
Decubitus or pressure ulcers need alertness for prevention in residents living in RACFs. Good nutritional status should be the aim, and good nursing care is paramount by:
- frequent repositioning of the patient
- pressure alleviation techniques (eg air cushions, beds)
- appropriate dressings with elimination of infection.
Always consider the need for biopsy of the wound edge and wound swab for microbiology if the wound or ulcer is clinically infected, using the Levine technique (refer to Appendix 2).14,16 Cutaneous cancer may present as non-healing ulcers and should be considered in these circumstances.
Barrier creams and ointments associated with reduction in causative factors are effective in the prevention of wounds and ulcers.
Varicose or stasis changes and eczema associated with varicose veins may lead to ulceration through various mechanisms, including increased tissue pressure, fluid build-up and itch-scratch reactions with resulting trauma. The use of pressure stockings and elevation of limbs can be effective in control, prevention and assisting in healing, with varying levels of evidence for different patient groups.17
Loss of skin barrier function
Dry skin is common in older people. Skin dehydration and impaired barriers cause the symptom of itch, and can bring out dermatitis and eczemas in those who are susceptible to these conditions.
Increased allergen penetration to the dermis results in flares of contact allergies (eg nickel), but also exacerbates previous atopic or seborrhoeic eczema. These flares can require intensive treatment, and emollients are paramount and need to be applied frequently (up to every three hours in severe cases). Steroid creams and ointments need to be considered.14
Dry skin can trigger the ‘itch-and-scratch’ cycle, which predisposes to skin excoriation, abrasion and bacterial infections. Infestations with mites (eg scabies) are also possible, and specific investigation is needed to distinguish these infestations.
It is important to be aware of the public health implications of these potentially infectious conditions to carers, family members and/or other aged-care residents.
Allergic reactions and the skin
As with any age, systemic allergies may present with skin manifestations in older people. The risks of skin allergic manifestations increases in older patients on multiple drug therapies.
Drug allergies present with a broad range of skin manifestations ranging from non-specific morbilliform erythema or urticaria to the more severe erythema multiforme, Stevens–Johnson syndrome or toxic epidermal necrolysis.18
Systemic illness and the skin
Diabetes, liver disease, thyroid disease, connective tissue disorders, and autoimmune and vasculitic illnesses may all present with skin manifestations. Deficiency states (eg iron, zinc, vitamin C or B-group vitamins) and general malnutrition may present initially with skin signs.
Recognition of certain conditions (eg dermatomyositis, bullous pemphigoid) with their peak incidence in older people can lead to prompt diagnoses and effective treatment.
Paraneoplastic skin syndromes and their manifestations should also be considered in older people.
Necrobiosis lipoidica and acanthosis nigricans are not uncommon in those who have diabetes, and should be recognised. Difficult to control flexural or mucocutaneous candidiasis should raise the question of diabetes and zoster, and especially if severe or extensive, may indicate immune impairment.
Drug therapy in older people
Older people who are on multiple medications and those with chronic illness (especially renal impairment) are at increased risk of interactions with medication-induced and drug-induced skin reactions.
Some associations are obvious (eg urticaria with aspirin) or severe reactions (eg Stevens–Johnson syndrome to sulphur-based medications or allopurinol). For others, the cause is less obvious, such as a morbilliform hypersensitivity rash in a patient on multiple medications, where it can be difficult to identify the trigger. Careful history taking may assist in the definition of these reactions.
Some medications also cause problems with the skin because of their modes of action. For example, diuretics and statins may dry the skin; chemotherapy and immunosuppressants, because of reduced immune surveillance, increase skin cancer and infections.