A Look at Geriatric Skin Conditions and How to Treat Them

The skin is the body’s largest organ and as we age it becomes more susceptible to dryness, disorders, and disease. This susceptibility increases within a confined environment like a nursing home — it’s estimated up to 30-40-percent of patients in a nursing home at any given time has a fungal infection.

One of the most worrisome things that can present on the skin would be a staph or strep infection, but there are many different skin disorders that can develop in elderly patients and not all of them require treatment.

Here are some of the most common skin conditions you’ll find in the geriatric community, along with their recommended course of treatment.

Staph and Strep Infections

• Topical antibiotics like Mupirocin (Bactroban) are commonly used to treat staph and strep infections.
• Once the infection begins to invade the surrounding tissue or become systemic, systemic antibiotics are appropriate — choose Augmentin, Bactrim, Ciprofloxicin, or Tetracycline depending on what the particular organism is, as determined by a tissue culture (swab cultures may only get the biofilm and not the organism creating the infection).

Pseudomonas

• Topically, these are treated with Triple Antibiotic Solution or Gentamicin.
• If systemic, treat with Ciprofloxicin.

Anaerobes

• The best treatment is to create an aerobic environment by opening the abscess, exposing the anaerobes to air.
• The antibiotic to use with anaerobes would be Metronidazole PLUS Metrogel topically for two weeks.

Viral Infections

• Herpes infections of one type or another are very prevalent in older patients. These can be treated with antivirals, Acyclovir being one and Famvir being another. Keep the area covered and apply topical silver to prevent secondary bacterial infection.
• Cryotherapy can used for warts and molluscum.

Parasitic Infections

• Scabies is one of the most common parasitic infections. It can be treated with Elimite 5-percent after bathing, with a repeat treatment after seven days. If multiple patients in multiple rooms are affected, a more practical course is to treat with Ivermectin, a weight based dosage.
• Lice can be treated with Permethrin 1% (Nix), with a repeat treatment in seven days.

Allergic Reactions

• For local allergic reactions, first remove the cause– detergents, medication, mites, whatever the case may be– and then treat with topical steroids for seven to fourteen days.
• Systemic allergic reactions are often caused by medications, so be sure to check any new orders the patient may have started. If using oral steroids as treatment, the dose should taper over time. Antihistamines can be used for itching.

Neoplastic Disorders

• For a Basal or Squamous Cell Carcinoma, use a shave or punch biopsy for diagnosis and refer out if positive.
• Actinic Keretosis are considered to be pre-cancerous. A punch/shave biopsy or cryotherapy should be considered, based on the patient’s or family’s wishes.
• For a melanoma, opt for a punch biopsy over a shave biopsy. These cases can then be referred to a dermatologist for further evaluation.

Pruritic Conditions

• Pruritis Nodularis is a result of chronic scratching. Treat the itch; steroids under occlusion may help.
• Lichen Simplex Chronicus are well defined plaques that occur with many chronic pruritic conditions, and require a higher potency steroid under cordarone tape. Symptomatic relief can be achieved through emollients, menthol or camphor.
• Psychogenic Pruritis is very difficult to diagnose and can come in two forms, excoriation (linear scratches only where the patient can reach) and parasitosis (the patient believes there are bugs under the skin which they then try to dig out). To keep skin as emulsified as possible, apply emollients and use a soapless cleanser like Eucerin.
• Xerosis is very common in the elderly. Moisturize the entire body, excluding the skin folds– if common moisturizers fail, try Lac-Hydrin.

Seborrheic Kertosis

• Seborrheic Kertosis is a common, but benign, skin growth. Unless it’s in a traumatic area and getting caught on clothing, it can be left alone.
• If treatment is necessary, cryo or shaving is appropriate.

Fungal Infections

• Candidiasis is a yeast infection that occurs in occluded areas: under dressings, in skin folds, and on the backs of bedbound patients. It differs from contact dermatitis in that it invades the skin folds. Candidiasis can be treated with Clotrimazole or nystatin cream and prevented with miconazole powder. In recurrent cases, you may consider bowel eradication using nystatin pastilles.
• Seborrheic Dermatitis occurs as a result of the yeast Malassezia furfur. Red and scaly in appearance, it can be found in hairy areas– the head, neck, and chest. Recommended treatments include Ketoconazole (nizorale) 2-percent shampoo or Selenium Sulfide 2.5-percent (Selsun Blue).

Tinea Infections

• Tinea Pedis usually presents along the moccasin distribution of the foot. If it begins to crack, particularly in diabetic patients, this can be a portal for a bacterial entrance. Initially you can use Clotrimazole; if ineffective, you may step up to an oral Lamasil. Miconazole powder can be used daily after bathing to prevent reoccurrence.
• Tinea Unguium is a nail infection and doesn’t require necessarily treatment unless it’s an invasive problem. Tinea Manum is a hand infection; Tinea Capitis is an infection on the head. All three can be treated with Lamisil.
• Trichomycosis, or dermatophytosis of the hair follicle, can be treated with Lamisil as well.
• Tinea Cruris (jock itch) and Tinea Pedis (athlete’s foot) can be treated with Fluconazole.
• Tinea Versicolor is a yeast infection on the back that can be more evident after sun exposure, as the affected areas do not tan. It can be treated with Clotrimazole or Selenium Sulfide as well as Lamisil.
• Tinea Corporis is more commonly known as ringworm, and is treated with Clotrimazole.

Some skin disorders may indicate underlying health problems or issues with positioning. Once patient symptoms have been alleviated, possible causes should be investigated to prevent reoccurrence.