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Symptoms from skin disease Itch Pain (burning / soreness) Dryness Scale Spots Redness Pigmentary changes Hair cha

Symptoms from skin disease Itch Pain (burning / soreness) Dryness Scale Spots Redness Pigmentary changes Hair changes Sweat changes. Stimulation of different nerves  different sensations: -Fine myelinated nerves  localised sensation of pricking

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Symptoms from skin disease Itch Pain (burning / soreness) Dryness Scale Spots Redness Pigmentary changes Hair cha

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  1. Symptoms from skin disease Itch Pain (burning / soreness) Dryness Scale Spots Redness Pigmentary changes Hair changes Sweat changes

  2. Stimulation of different nerves  different sensations: -Fine myelinated nerves  localised sensation of pricking -Non-myelinated C fibres  sensation of burning

  3. Causes in the Elderly • 20% about have a dermatosis • 30% have an underlying metabolic cause • Approximately 50% idiopathic i.e. half!

  4. Causes of itchy elderly skin • Primary rashes, i.e. as above • Pruritus: • Metabolic disorder • Result of mental state • Medicament related • Unknown cause

  5. Primary Rashes • Eczemas -commonest • Others in approximate order of frequency: • Psoriasis -not usually itchy, despite name • Urticarias • Fungal -not usually itchy • Scabies • Lichen Planus • Bullous disorders • Lichen sclerosis • Lymphoma

  6. History • Past history of skin disease • Medication including OTC drugs? • Any complementary / alternative therapies? • What are you using on the skin? • How do you wash & how often? • Does anyone else in the house also itch?

  7. Specific History of the Itch • When did the itch start? • Where does it itch? • When does it itch? -all day / at night / only when warm? • Does anything make it worse? -heat / bathing?

  8. Scabies No one else in the home is complaining of itch She only moved in 2 months ago Grand-daughter visits & has bad ‘hand eczema’

  9. Metabolic Causes In the elderly 30% can have a metabolic cause • Iron Deficiency • Thyroid problems • Cholestasis • Renal failure • Polycythaemia • Lymphoma • Paraneoplastic

  10. Examination • General examination • Dry skin • Rash or just excoriations • ‘Butterfly’ sign • Weight loss • Signs of burrows – scabies • Mouth • Nails • Genitalia

  11. Investigations • LFT • U+E • Glucose • FBC • Serum electrophoresis • ESR • Calcium • Ferritin • TSH • CXR • Urinary dipstix

  12. Secondary features of itch Excoriations Papular / nodular lichenification Shiny Nails Secondary infection Hyperpigmentation Healing scars ‘Butterfly’ sign

  13. Management of pruritus -moisturisers & topical antipruriticsetc -sedating antihistamine at night -iron supplements

  14. Drugs causing pruritus Opiates Aspirin ACE Inhibitors Carbamazepine Gold Tricyclic Antidepressants Cimetidine Diuretics may cause skin dryness

  15. Management Correct low humidity Avoid synthetic fabrics (cotton better than wool) Pare nails down Avoid excessive bathing and hot baths Soap substitute Moisturisers (consider those with NMF –urea) ‘Gate out’ itch with 1% menthol in a moisturiser

  16. Aqueous Cream • Never meant as a leave on cream • Is a wash product only but best avoided altogether • Not even a good moisturiser • Can exacerbate eczema • Sting many people -contains sodium lauryl sulphate -also Epaderm cream / Cetraben / Hydromol)

  17. Moisturiser FTU Face 15-30g 100mls Both Hands 25-50g 200mls Scalp 50-100g 200mls Both Arms or legs 100-200g 200mls Trunk 400g 500mls Groins and genitalia 15-25g 100mls Whole body 605 - 805g 1300mls This is BD use for an adult for 1 week

  18. Management 2 Topical steroids if skin inflamed -be bold! Balneum plus cream / E45 itch relief Occlusive bandages Antihistamines if dermographism / urticarial Systemic sedative antihistamines at night -care Review history & signs / Ix Review medication (including OTC) Consider cognitive effect -esp disturbed sleep Avoid polypharmacy

  19. Summary In generalised pruritus with itch / scratch damage, complete sparing of the areas not accessible to the patients hands suggest that the rash is due to scratching rather than a primary dermatosis Most widespread pruritus is due to a dermatosis rather than to systemic disease

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