Geriatric Skin Changes

Geriatric Changes

• Benign skin lesions often occur in geriatric patients, which may cause confusion when screening for skin cancer.

Normal Skin Aging

• Solar lentigos (liver spots/age spots) are tan or brown irregular macules on sun-exposed skin, resulting from melanin overproduction.
• Senile purpura involves hemorrhages in the papillary dermis, appearing as red to purple macules, often on sun-exposed skin where vessels are brittle. It can be extensive in patients on anticoagulant medications and may leave a permanent bronze discoloration.
• Seborrheic keratoses are tan, brown, black, or gray waxy or wart-like papules and plaques with a stuck-on appearance that are benign and can be removed for cosmetic reasons using cryotherapy curettage or shave excision. A sudden eruption of many seborrheic keratoses that rapidly grow and increase in number may indicate an internal issue.

Pre-cancerous Lesions

• Actinic keratosis is caused by UV ray exposure, with elderly, fair-skinned, and sun-sensitive individuals at higher risk. These lesions are rough, scaly patches on areas of maximum sun exposure like the face, scalp, neck, ears, and forearms, often felt before seen with a sandpaper texture.
• Actinic keratosis is common for multiple lesions to occur in the same area. Diagnosis is based on presentation, and a biopsy is reserved for lesions suspicious of SCC or those unresponsive to treatment. If left untreated, 20% can develop into squamous cell carcinoma.
• Refer to a dermatologist for diagnosis and treatment of actinic keratosis. Medical treatment aims for total eradication with minimal surrounding tissue damage.
• Lesions may regress, stay the same, or progress into SCC.
• 5-Fluorouracil (5-FU) topical cream is commonly prescribed as 5% BID for one month, causing erythematous and uncomfortable ulcerations with crust formation. Lesions heal within 2 weeks of treatment completion.
• Imiquimod topical cream is applied 2-3 times a week for up to 4 months (usually just one month).

Follow-Up, Patient Education, and Prevention

• Patients with a history of skin cancer should have yearly whole-body skin examinations after treatment.
• Sun exposure should be avoided by wearing protective clothing.
• Sunscreen should be used with an SPF of at least 15 if sun exposure is longer than 15 minutes.
• Sunscreen should be reapplied every 2 hours or after swimming.
• Patients should stay indoors during peak sun hours, 10 AM to 2 PM.
• Seek medical attention for non-healing sores lasting longer than 4-6 weeks.
• Knowledge of the ABCDEs of melanoma is important.

Types of Skin Cancers

• Nonmelanoma includes basal cell carcinoma and squamous cell carcinoma.
• Basal cell carcinoma originates in the basal cell layer of the skin, accounting for about 80% of nonmalignant skin cancers.
• Squamous cell carcinoma arises from keratinocytes of the epidermis, accounting for 20% of all skin cancers and can develop from untreated actinic keratoses.
• Malignant melanoma arises from malignant degeneration of cells in the melanocytic system, accounting for only 4% of skin cancers but 65% of skin cancer-related deaths.
• Melanoma deaths are declining in whites under 50 but increasing in whites over 50.

Risk Factors for Skin Cancer

• UV rays, thermal burns, and radiation exposure increase the risk of skin cancer.
• Fair skin, blonde or red hair, and light blue or green eyes are risk factors.
• Tanning devices: using tanning devices may increase the risk of SCC by 2.5-fold and BCC by 1.5-fold; the risk increases with younger age at the first exposure.
• Improper/infrequent use of sunscreen.
• Blistering sunburn in adolescence.
• Intense, episodic sun exposure.
• Family history of skin cancer.
• Very high risk: skin cancer history of 10x+ general population.
• Current immunosuppressive therapy after organ transplant.
• Personal history of skin cancer.
• Two or more first-degree relatives with melanoma.
• 100 nevi or 5+ atypical nevi.
• 250+ treatments with psoralen plus ultraviolet therapy for psoriasis.

Nonmelanomas: Basal Cell Ca vs. Squamous Cell

• Basal cell carcinoma has a weaker association with UV exposure, with exposure in childhood and adolescence being more important. Tumor location is mostly on the head and neck (25-30% on the nose), with no correlation to areas of maximum sun exposure and up to 20% of tumors occurring in patients 50 years or younger.
• Squamous cell carcinoma has a strong association with ultraviolet exposure and cumulative exposure, important to tumor location is most common on the back of the hands and forearms and on the head and neck that receive maximum sun exposure. It is uncommon in patients younger than 50 years and strongly associated with fair skin, blue eyes, red or light-colored hair, and the inability to tan, as well as untreated actinic keratoses.

Clinical Presentation and Physical Exam - Basal Cell Carcinoma

• The most common sites for basal cell carcinoma are the head and neck.
• Appears as a pearly domed nodule with overlying telangiectatic vessels.
• Can also present as a plaque or a papule.
• Advanced tumors may have central ulceration and crusting.

Clinical Presentation and Physical Exam - Squamous Cell Carcinoma

• Squamous cell carcinoma typically appears on sun-exposed areas.
• The lower lip is a common site, especially in smokers.
• Indistinct margins with a firm, scaly, irregular surface that bleeds easily.
• May be red, tan, brown, or pearly gray in color.
• May have crusting, ulcerations, erosion, or scaliness.
• The metastatic rate is 3-10%, depending on tumor location, underlying medical conditions, cell differentiation, and size.

Clinical Presentation and Physical Exam - Melanoma

• Malignant melanoma is typically diagnosed in the early 40s.
• Patients often develop hypo or hyperpigmentation, bleeding, scaling, texture, or size change of an existing mole or lesion.
• Caucasians: commonly found on the back and anterior lower legs.
• Blacks: nails, hands, and feet.
• Melanomas can manifest as a new mole or a change in an existing one.
• The ABCDE characteristics are important in clinical presentation.
• A five-year survival rate is inversely proportional to the depth of the melanoma at the time of diagnosis.

Diagnostic Criteria of Melanoma

• Asymmetry (A): If you draw a line through the middle of the mole, the halves of a melanoma won't match in size.
• Border (B): The edges of an early melanoma tend to be uneven, crusty, or notched.
• Color (C): Healthy moles are uniform in color. A variety of colors, especially white and/or blue, is bad.
• Diameter (D): Melanomas are usually larger in diameter than a pencil eraser, although they can be smaller.
• Evolving (E): When a mole changes in size, shape, or color, or begins to bleed or scab, this points to danger.

Diagnostic Criteria of Melanoma

• Weighted 7-Point System: 3 major features (2 points each) including change in size, change in color, and change in shape of the lesion.
• Four minor features (1 point each) include the presence of inflammation, bleeding or crusting, sensation, and diameter >6mm.
• An ugly duckling sign, where a mole looks different from surrounding ones, is also an indicator.

Screening for Skin Cancer

• The U.S. Preventive Services Task Force concluded that current evidence is insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults.
• Healthcare providers must be cognizant of skin lesions with malignant characteristics while performing physical exams for other reasons.
• Annual skin exams should be performed by a dermatologist or primary care provider for patients with a history of skin cancer.
• The American Cancer Society has no specific guidelines but recommends that patients perform skin self-exams monthly.

Diagnostic Exams for Skin Cancer

• Suspected nonmelanoma can be examined by tissue sampling shave technique if the lesion is raised or 2-4mm, or punch biopsy of the most abnormal-appearing skin. A complete excision can be performed for smaller tumors.
• Suspected melanoma is examined by full-thickness technique with total removal. If the cells are positive for malignant melanoma, a wider excision should be performed.
• All diagnostic exams should be performed by an experienced practitioner, so it is required to refer to dermatology for all suspicious lesions.

Management of Skin Cancer

• Skin cancer is managed by dermatology.
• Basal cell carcinoma management includes electrodesiccation and curettage (scraping and burning).
• Squamous cell carcinoma management involves total excision.
• Malignant melanoma management is based on the stage of cancer.
• Stage 0 (in situ) shows no growth beyond the epidermis. Surgical intervention typically offers a 100% cure rate through excision of the lesion and surrounding skin.
• Mohs surgery is the layer-by-layer removal of skin, where each layer is examined microscopically for cancer cells. The surgeon continues to remove layers until there is no evidence of cancer.