Clinical implications of aging skin: cutaneous disorders in the elderly

Skin injury prevention and treatment in the older person: reframing our approach in the community setting

In the past, maintaining skin integrity has been synonymous with preventing and treating a single skin injury, namely pressure injury. However, there is growing recognition that this single-injury approach overlooks the multitude of skin injuries that may be sustained by older people. This article proposes that reframing the approach to skin integrity care away from the single-injury focus and towards a comprehensive and holistic paradigm is imperative. Guided by the Skin Safety Model, this article presents a case study illustrating comprehensive skin integrity assessment and care planning for an older person in the community setting. It is hoped that the information presented will guide community nurses in addressing skin injuries experienced by older adults in holistic and comprehensive way.

Long-term stability of a novel platelet-rich plasma-based topical serum for cutaneous applications

BACKGROUND

Skin alterations are usually related to chronic diseases that demand sustained and long-term dosages; hence, it is pivotal that the stability of treatments is preserved. A novel storable and endogenous topical serum (ES) based on the patient's own blood has been recently developed.

AIMS

To investigate the long-term stability of the formulation and to provide preliminary data of its biologic potential.

METHODS

Samples from six donors were obtained and either used as fresh samples or cold-stored for 6 months. Physicochemical, rheological, and biological stability of the formulation was determined.

RESULTS

Endogenous topical serum maintained unaltered its organoleptic properties, viscosity, pH, spreadability index, and sterility. The growth factor content including TGFβ-I, EGF, PDGF-AB, HGF, and Ang-I showed no decrease. In contrast, ES showed lower levels of IGF-I once stored. Dermal fibroblasts showed no change in their proliferative activity.

CONCLUSION

Endogenous topical serum showed to maintain its physicochemical and biological properties after six months of storage. ES might reduce the frequency of blood extractions and would enable patients with chronic disorders to maintain a daily use of the product in a minimally invasive way.

Care complexity individual factors associated with adverse events and in-hospital mortality

Introduction

Measuring the impact of care complexity on health outcomes, based on psychosocial, biological and environmental circumstances, is important in order to detect predictors of early deterioration of inpatients. We aimed to identify care complexity individual factors associated with selected adverse events and in-hospital mortality.

Methods

A multicenter, case-control study was carried out at eight public hospitals in Catalonia, Spain, from January 1, 2016 to December 31, 2017. All adult patients admitted to a ward or a step-down unit were evaluated. Patients were divided into the following groups based on the presence or absence of three adverse events (pressure ulcers, falls or aspiration pneumonia) and in-hospital mortality. The 28 care complexity individual factors were classified in five domains (developmental, mental-cognitive, psycho-emotional, sociocultural and comorbidity/complications). Adverse events and complexity factors were retrospectively reviewed by consulting patients’ electronic health records. Multivariate logistic analysis was performed to identify factors associated with an adverse event and in-hospital mortality.

Results

A total of 183,677 adult admissions were studied. Of these, 3,973 (2.2%) patients experienced an adverse event during hospitalization (1,673 [0.9%] pressure ulcers; 1,217 [0.7%] falls and 1,236 [0.7%] aspiration pneumonia). In-hospital mortality was recorded in 3,996 patients (2.2%). After adjustment for potential confounders, the risk factors independently associated with both adverse events and in-hospital mortality were: mental status impairments, impaired adaptation, lack of caregiver support, old age, major chronic disease, hemodynamic instability, communication disorders, urinary or fecal incontinence, vascular fragility, extreme weight, uncontrolled pain, male sex, length of stay and admission to a medical ward. High-tech hospital admission was associated with an increased risk of adverse events and a reduced risk of in-hospital mortality. The area under the ROC curve for both outcomes was > 0.75 (95% IC: 0.78–0.83).

Conclusions

Several care complexity individual factors were associated with adverse events and in-hospital mortality. Prior identification of complexity factors may have an important effect on the early detection of acute deterioration and on the prevention of poor outcomes.

Self-reported generalised pruritus among community-dwelling older adults in Malaysia

Background

The ageing skin is more susceptible to pruritic dermatoses, which are associated with adverse psychosocial effects and reduced quality of life among older adults. This cross-sectional study aimed to identify the burden of pruritus and factors associated with its presence and severity among older adults recruited to the Malaysian Elders Longitudinal Research study.

Methods

Seven hundred seventy individuals aged 55 years (lower age limit) and above were interviewed as to whether they experienced pruritus during the preceding week and the locations involved if present. The association between generalised pruritus, sleep quality, and major systemic risk factors were explored.

Results

5.97% of respondents reported generalised pruritus. Generalised pruritus was associated with poorer sleep quality, with Pittsburgh Sleep Quality Index score above 6. Mean haemoglobin level was lower in subjects with generalised pruritus (13.14 g/dL) but there was no significant difference in the frequency of generalised pruritus and severe generalized pruritus between subjects with clinically defined anaemia. Also, there were no significant associations between other major systemic risk factors and generalised pruritus in this population-based study. There was no association between generalised pruritus with depression, anxiety or stress.

Conclusion

The negative effect of pruritus on sleep quality suggests a possible deleterious effect of pruritus on health and quality of life. Further prospective research on the longer-term effects of pruritus on health status is now warranted.

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Work-related skin symptoms among Bulgarian dentists

BACKGROUND

Dentists are at high risk of developing skin symptoms due to occupational contact with irritants and/or allergens.

OBJECTIVES

To assess the point prevalence of work-related skin symptoms and associated factors in Bulgarian dentists.

METHODS

A cross-sectional study was performed using a self-report questionnaire.

RESULTS

A total of 4675 dentists filled the questionnaire (response 48.1%). The point prevalence of self-reported skin symptoms was 31.6%. According to logistic regression analysis, factors significantly associated with work-related skin symptoms included a personal history of atopic dermatitis (odds ratio [OR] 2.72, 95% confidence interval [CI]: 2.24-3.31), allergic rhinoconjunctivitis and/or asthma (OR 1.85, 95%CI: 1.56-2.19), work experience >30 years (OR 2.21, 95%CI: 1.78-2.74), personal history of contact allergy (OR 1.79, 95%CI: 1.48-2.17), female sex (OR 1.87, 95%CI: 1.59-2.19), hand washing >8 times a day (OR 1.32, 95%CI: 1.03-1.69), daily contact ≥4 hours with protective gloves (OR 2.09, 95%CI: 1.64-2.67), and use >10 pairs of gloves per day (OR 1.51, 95%CI: 1.11-2.04).

CONCLUSION

Bulgarian dentists have a high prevalence of work-related skin symptoms. History of atopic dermatitis, prolonged work experience, and protective gloves use were the strongest risk factors.

Prevalence and treatment outcomes of skin infections among elderly population: a retrospective cross-sectional study

Background: Geriatric population is increasing day by day throughout the world and there is a critical need to provide them the best health services including dermatological care due to their weakened immune system. The main objective of this study is to determine the prevalence and factors affecting the treatment outcomes of skin infections among elderly population.Methods: A 5-year retrospective cross-sectional study was conducted at the Department of Dermatology, Hospital Pulau Pinang. Patients aged ≥65 years of age with confirmed diagnosis of skin infection were included in the study.Results: A total of 455 patients were included and the most prevalent skin infections were eczema (27.6%) followed by dermatitis (13.8%), xerosis (13.8%), and bullous pemphigoid (8.8%). Cloxacillin (18%), Tetracycline (7.9%), and Unasyn (Ampicillin and Sulbactam) (5.7%) are the common antibiotics prescribed to treat skin infections. Age, alcohol consumption, polypharmacy, and presence of other co-morbidities are the most important factors that affected the treatment outcomes of skin infections among geriatrics.Conclusion: Eczema is the most prevalent skin infection among the elderly population. Age, consumption of alcohol, usage of more than five medicines simultaneously, and presence of co-morbidities are the main factors that are involved in better treatment outcomes of skin infections among study population.

Skin Biomechanics and miRNA Expression Following Chronic UVB Irradiation

Objective: Exposure to ultraviolet (UV) light from the sun is known to accelerate the skin aging process and leads to significant alterations in skin biomechanics; however, the molecular mechanisms by which chronic UVB affects biomechanical properties of the skin have not been well described. Approach: A murine model for chronic UVB exposure was used to examine changes in epidermal barrier function, skin biomechanics, and miRNA expression as a result of UVB. Results: UVB irradiation caused skin to be weaker, less elastic, stiffer, and less pliable. Notably, these changes were not reversed after a 5-week period of recovery. Following UVB exposure, dermal collagen fibrils were significantly smaller in diameter and expression of the miR-34 family was significantly increased. Innovation: To our knowledge, this is the first study to concurrently examine alterations in skin function, miRNA expression, and tissue biomechanics in response to chronic UVB exposure. Conclusion: The data suggest that UVB alters miR-34 family expression in skin, in addition to dysregulating collagen structure with subsequent reductions in strength and elasticity. miRNAs may play a pivotal role in regulating extracellular matrix deposition and skin biomechanics following chronic UVB exposure, and thus may be a possible target for therapeutic development. However, additional studies are needed to directly probe the link between UVB exposure, miRNA production, and skin biomechanics.

Comparative Study of Dermatological Diseases of the Elderly in Relation to the Rest Population

Background

According to Eurostat, the geriatric population in Greece constitutes almost 21.8% of the total population, with an increasing tendency. Skin diseases of the elderly often originate from internal medicine diseases. The aim of this study was to identify different dermatological conditions among patients over 65 years of age compared to younger patients.

Methods

The present study was conducted between May 2015 and December 2017 in public medical offices in the Municipality of Thessaloniki. A total of 8422 patients of all ages were screened and their dermatological problem was recorded. The sample was then divided into two age groups. The first group was composed of 3629 elderly patients over 65 years of age. The second group consisted of 4793 patients up to 65 years old.

Results

Pruritus was the main dermatological complaint in the elderly (14.2%) compared to the younger age group (1%), who were more interested in their mole examination (15.1%). Precancerous lesions (4%) and skin cancers (2.4%) presented more frequently in elderly patients than in people younger than 65 years old (0.7% and 0.5%, respectively).

Conclusion

There are significant differences in the frequency and etiology of dermatological diseases between the two age groups. Pruritus and non-cancerous tumors of the elderly are considered to be the main findings of geriatric dermatology.

Optimizing skin pharmacotherapy for older patients: the future is at hand but are we ready for it?

Age-related changes affect both the local pharmacotherapy of skin diseases and the transdermal administration of drugs. The development of aged skin models disregards the highly individual process of aging, facilitating general conclusions for older patients. Nevertheless, 'omics technology, high-content screening, and non-invasive imaging, as well as bioprinting, CRISPR-Cas, and, patients-on-a-chip, can retrieve personalized information for the generation of in vitro models. Herein, we suggest a strategy to optimize pharmacotherapy for older patients. The technology for relevant human cell-based models is at hand and the consideration of patient heterogeneity is required to unlock their full potential.

Biologic Treatment in Elderly Patients With Psoriasis: A Systematic Review

With our aging population, an increasing number of psoriasis patients are classified as elderly. However, psoriasis treatment in older adults can be challenging, given an increased number of comorbid conditions and immunosenescence. Biologic agents present a solution to this treatment dilemma because of their high efficacy and favorable tolerability. The objective of this systematic review was to summarize the findings of clinical trial and real-world studies exploring the safety and efficacy of biologic agents in elderly patients with moderate-to-severe psoriasis. We searched MEDLINE, Embase, the Cochrane Library, and clinical trial databases. Studies analyzing biologics for psoriasis were included if elderly patients were the main population of interest or were a separate subgroup in their analysis. Eighteen articles met inclusion criteria after screening. Across all biologic classes, efficacy for biologics between nonelderly adult patient and elderly patients was similar. Adverse events (AEs) and infections occured at a similar frequency between both groups. However, serious AEs were more common in the elderly. The available literature on the safety and efficacy of biologic agents in elderly patients supports the use of these agents in this population. However, serious AEs and discontinuation due to AEs were more common in older patients. As elderly patients have a higher burden of comorbid conditions and an increased baseline vulnerability for AE, physicians should continue to be prudent in screening before initiating biologics and monitor patients more closely as AEs tend to be more severe.

Effects of differences in wiping pressure applied by nurses during daily bed baths on skin barrier function, cleanliness, and subjective evaluations

AIM

To clarify the actual condition and examine the effects of differences in wiping pressure applied by clinical nurses during daily bed baths on skin barrier function, cleanliness, and subjective evaluations.

METHODS

For the purposes of the present quasi-experimental interventional study, "wiping pressure" was defined as the "force applied vertically to the skin surface during bed baths." Two types of bed baths, one using ordinary wiping (pressure: 23-25 mmHg) and the other using weak wiping (pressure: 12-14 mmHg), were performed on the forearms (right and left) of 30 healthy adult men and women, and the effects on transepidermal water loss, stratum corneum hydration, cleanliness, and subjective evaluations were examined.

RESULTS

The results showed no differences between ordinary and weak wiping pressure in regard to the effects on skin barrier function and cleanliness. In terms of subjective evaluations, a significant association was seen between wiping pressure and the "sensation of having dirt removed" (P = .036). Regarding "degree of pain," some participants reported that the wiping pressure felt "slightly painful" under both conditions (ordinary: 31.1%; weak: 10.7%), while some with sensitive skin reported feeling pain even during weak wiping pressure.

CONCLUSIONS

The results of the present study suggest that skin assessments should be performed before and after bed baths, and that wiping pressure should be controlled and evaluated while considering the patient's feelings.

Novel approaches for managing aged skin and nonmelanoma skin cancer

The process of aging influences every bodily organ and tissue, and those with rapid epithelial cell turnover, are particularly affected. The most visible of these, however, is the skin (including the epidermis), the largest human organ that provides a barrier to external insults, structure to the body and its movements, facilitates thermoregulation, harbors immune cells, and incorporates sensory neurons (including mechanoreceptors, nociceptors, and thermoreceptors). Skin aging has traditionally been categorized into intrinsic and extrinsic, with the latter nearly exclusively restricted to "photoaging," (i.e., aging due to exposure to solar or artificial ultraviolet radiation). However, both intrinsic and extrinsic aging share similar causes, including oxidative damage, telomere shortening, and mitochondrial senescence. Also, like other malignancies, the risk of malignant and nonmalignant lesions increases with age. Herein, we review the most recent findings in skin aging and nonmelanoma skin cancer, including addition to traditional and developing therapies.

Management of Itch in the Elderly: A Review

Chronic itch is common in the elderly patient and may be caused by a variety of known dermatologic and non-dermatologic conditions and can have a significant effect on quality of life. Age-related changes in barrier function, immunosenescence, and neuronal changes and neuropathies are common predisposing factors to chronic itch in this age group. Certain primary dermatologic conditions are more common in the elderly and can cause chronic itch. Also, co-morbid diseases particularly of the renal, hepatobiliary, or hematologic systems, psychologic conditions, or medications may contribute to chronic itch in this population. Thus, medical workup for an elderly patient with chronic itch requires special attention to the patient's medical history, current health status, and medications. Topical treatments and emollients may be recommended for elderly patients, with consideration of specific adverse effects and alternatives. Systemic medications pose a higher risk of adverse effects and many are contraindicated in the elderly for this reason. In addition, management in the elderly may be complicated by differential pharmacokinetics of medications, the presence of co-morbid health conditions, cognitive disorders, physical limitations, and polypharmacy. New and emerging treatment modalities hold promise for use in the elderly due to these special considerations.

Burden of melanoma in China, 1990-2017: Findings from the 2017 global burden of disease study

Melanoma is an aggressive form of skin cancer, and a worldwide problem with increasing incidence. Little is known about the burden of melanoma in the Chinese population. We evaluated temporal trends and geographic variation in melanoma-associated burden, to narrow an important knowledge gap concerning the consequences of this disorder across time, provinces in China. After the general analytic strategy used in the 2017 Global Burden of Disease study, we analyzed the incidence, mortality, prevalence and disability-adjusted life-years (DALYs) of melanoma, by age, sex and geography from 1990 to 2017. Levels in melanoma burden were assessed for 33 province-level administrative units between 1990 and 2017. We used joinpoint regression analysis to estimate the slope of incidence and mortality trends. The age-standardized incidence rate of melanoma was 0.9 per 100,000 in 2017, with a 110.3% rise compared to 1990. Although the age-standardized DALYs rate (per 100,000) decreased from 9.1 in 1990 to 7.6 in 2017, it showed an upward trend from 2007 to 2017. The DALYs rate increased steadily with age for females while increased and peaked at 55-59 years for males. The incidence of melanoma was higher in the clustered eastern provinces than western provinces, while the DALYs showed a pattern in opposite direction. In China, there has been a substantial increase in the burden of melanoma over the last decade, representing an ongoing challenge in Chinese population. More targeted strategies should be developed for elderly population, especially for females, to reduce the melanoma burden throughout China, particularly the western provinces.

Morphology and composition play distinct and complementary roles in the tolerance of plantar skin to mechanical load

Plantar skin on the soles of the feet has a distinct morphology and composition that is thought to enhance its tolerance to mechanical loads, although the individual contributions of morphology and composition have never been quantified. Here, we combine multiscale mechanical testing and computational models of load bearing to quantify the mechanical environment of both plantar and nonplantar skin under load. We find that morphology and composition play distinct and complementary roles in plantar skin's load tolerance. More specifically, the thick stratum corneum provides protection from stress-based injuries such as skin tears and blisters, while epidermal and dermal compositions provide protection from deformation-based injuries such as pressure ulcers. This work provides insights into the roles of skin morphology and composition more generally and will inform the design of engineered skin substitutes as well as the etiology of skin injury.

A Cross-Sectional Observational Study of Geriatric Dermatoses in a Tertiary Care Hospital of Northern India

Introduction

Geriatric dermatoses are one of the most common reasons for day-to-day consultation in the elderly. Over the past few years, understanding of the pathophysiology of skin changes in the geriatric age group has improved and has paved the way for better therapeutic options. There are only a few studies conducted in India about the geriatric dermatoses. This article reviews the various physiological and pathological changes of aging, dwelling on the role of intrinsic and extrinsic factors in the pathogenesis of aging skin thus better understanding of this emerging branch in dermatology leading to enhance resource management for elderly population.

Materials and Methods

This is a cross-sectional observational study carried out on 500 consecutive patients aged 60 years and above in Department of Dermatology of a Tertiary care hospital of Northern India after meeting the inclusion and exclusion criteria.

Results

Out of 500 patients studied with male to female ratio of 1.4, wrinkles followed by cherry angiomas were the most common physiological cutaneous manifestations, and infective dermatoses followed by allergic contact dermatitis were the most common pathological conditions seen. Few rare cases were also seen during the study such as cutis marmorata, delusion of parasitosis, and sweet syndrome in case of acute myeloid leukemia.

Conclusion

Geriatric dermatology is an emerging branch in dermatology, and an update on this, will go a long way to effectively manage these patients. A thorough knowledge of the epidemiology as well as gender distribution of dermatological diseases in geriatric population in the tertiary care hospital will help in assessing health status and health care needs related to skin for better allocation of resources, distribution of material and manpower, and help health care providers in better decision-making resulting in higher clientele satisfaction.

A novel protein-based autologous topical serum for skin regeneration

BACKGROUND

As skin ages, a functional decrement occurs. To avoid future vulnerability to dermatologic diseases, an optimal cutaneous regeneration is mandatory. Biological therapies based on blood-derived autologous proteins are gaining attention of scientists and dermatologists.

OBJECTIVES

A novel 100% autologous topical serum has been developed using plasma rich in growth factors technology. The physicochemical characterization and the biologic potential of the novel formulation have been studied.

METHODS

Rheological and mechanical properties and the biological capacity of the formulation were characterized. Human dermal fibroblast culture and 3D organotypic skin explants were used as in vitro and ex vivo cutaneous models, respectively.

RESULTS

The autologous topical serum presented an optimal spreadability index and appropriate shear thinning behavior that allowed an easy handling and rapid integration within the cutaneous tissue. The formulation has a high growth factor load with the ability to progressively penetrate into the dermal/epidermal layers of the skin. It is biocompatible and promotes cell proliferation and chemotactic activity. The autologous topical serum promotes the biosynthetic activity of cells by the stimulation of collagen and hyaluronic acid expression.

CONCLUSIONS

These findings present an in situ and easy to prepare autologous topical serum based on the patient's own blood with physicochemical and bioactive properties that may be used for skin regeneration purposes.

The effect of aging in primary human dermal fibroblasts

Skin aging is a complex process, and alterations in human skin due to aging have distinct characteristic as compared to other organs. The aging of dermal cells and the biological mechanisms involved in this process are key areas to understand skin aging. A large number of biological mechanisms, such as decreasing of protein synthesis of extracellular matrix or increasing of degradation, are known to be altered through skin aging. However, environmental influence can accelerate this characteristic phenotype. In this study, we analyzed primary human dermal fibroblasts in three different in-vitro aging models—UVB irradiation and accelerated proliferation of human dermal fibroblasts from young donors as well as from elderly donors—for the gene expression of COL1A1, COL1A2, COL3A1, COL4A1, COL7A1, MMP1, MMP2, MMP3, MMP7, MMP8, MMP9, MMP10, MMP12, MMP13, MMP14, TIMP1, TIMP2, TIMP3, TIMP4, IL1B, IL1A, IL6, IL8, IL10, PTGS2, TP53, CASP3, LMNA, SIRT1. We compared the gene expression levels with young control. Furthermore, the behavior of skin fibroblasts was also evaluated using cell growth rate. The findings reveal that the gene expression levels in skin fibroblasts was altered in the process of aging in all three in-vitro aging models, and the cell growth rate was reduced, suggesting that these methods can be employed to understand skin aging mechanisms as well as drug discovery screening method.

The Application of Thromboelastography in Understanding and Management of Ecchymosis After Total Knee Arthroplasty

BACKGROUND

Ecchymosis is a common complication after total knee arthroplasty (TKA). However, only a few studies have been conducted to determine the coagulation status of these patients. Using thromboelastography (TEG), a new technique recording the viscoelastic changes of a whole-blood sample, this study was performed to understand the ecchymosis-related coagulation status and its risk factors.

METHODS

Seventy-five patients receiving unilateral TKA were recruited in this observational study. Oral rivaroxaban was applied as prophylaxis treatment after surgery. TEG was performed 1 day before surgery and 4 days after surgery. Total blood loss and hidden blood loss were recorded and calculated. Univariate and multivariate analyses were conducted to determine risk factors.

RESULTS

Twenty-five patients (33.3%) developed ecchymosis within 2-3 days after TKA. Compared with the baseline before TKA, the α-angle (P = .032) and calculated coagulation index (CI; P = .012) were increased in non-ecchymosis group, whereas in the ecchymosis group, there was no significant difference regarding any variable of postoperative TEG evaluation. The ecchymosis group exhibited more hidden blood loss (P = .007) and total blood loss (P = .011). Value change of CI (OR = 0.666, 95% confidence interval = [0.496, 0.895], P = .007) and hidden blood loss (OR = 1.008, 95% confidence interval = [1.002, 1.013], P = .004) were recognized as the independent risk factors for postoperative ecchymosis.

CONCLUSION

In TEG evaluation, the value change of CI and hidden blood loss are independent risk factors of ecchymosis. In view of the relative hypocoagulation status, it is reasonable to stop anticoagulation therapy in patients with excessive ecchymosis. Personalized anticoagulation therapy may be helpful for managing ecchymosis after TKA.

Malnutrition is independently associated with skin tears in hospital inpatient setting-Findings of a 6-year point prevalence audit

Skin tears cause pain, increased length of stay, increased costs, and reduced quality of life. Minimal research reports the association between skin tears, and malnutrition using robust measures of nutritional status. This study aimed to articulate the association between malnutrition and skin tears in hospital inpatients using a yearly point prevalence of inpatients included in the Queensland Patient Safety Bedside Audit, malnutrition audits and skin tear audits conducted at a metropolitan tertiary hospital between 2010 and 2015. Patients were excluded if admitted to mental health wards or were <18 years. A total of 2197 inpatients were included, with a median age of 71 years. The overall prevalence of skin tears was 8.1%. Malnutrition prevalence was 33.5%. Univariate analysis demonstrated associations between age (P ˂ .001), body mass index (BMI) (P < .001) and malnutrition (P ˂ .001) but not gender (P = .319). Binomial logistic regression analysis modelling demonstrated that malnutrition diagnosed using the Subjective Global Assessment was independently associated with skin tear incidence (odds ratio, OR: 1.63; 95% confidence interval, CI: 1.13-2.36) and multiple skin tears (OR 2.48 [95% CI 1.37-4.50]). BMI was not independently associated with skin tears or multiple skin tears. This study demonstrated independent associations between malnutrition and skin tear prevalence and multiple skin tears. It also demonstrated the limitations of BMI as a nutritional assessment measure.

Care Complexity Individual Factors Associated With Hospital Readmission: A Retrospective Cohort Study

PURPOSE

To determine the frequency of care complexity individual factors documented in the nursing assessment and to identify the risk factors associated with hospital readmission within 30 days of hospital discharge.

DESIGN

Observational analysis of a retrospective cohort at a 700-bed university hospital in Barcelona, Spain. A total of 16,925 adult patient admissions to a ward or intermediate care units were evaluated from January to December 2016. Most patients were admitted due to cardiocirculatory and respiratory disorders (29.3%), musculoskeletal and nervous system disorders (21.8%), digestive and hepatobiliary conditions (17.9%), and kidney or urinary disorders (11.2%).

METHODS

Readmission was defined as rehospitalization for any reason within 30 days of discharge. Patients who required hospital readmission were compared with those who did not. The individual factors of care complexity included five domains (developmental, mental-cognitive, psycho-emotional, sociocultural, and comorbidity or complications) and were reviewed using the electronic nursing assessment records. Multivariate logistic analysis was performed to determine factors associated with readmission.

FINDINGS

A total of 1,052 patients (6.4%) were readmitted within 30 days of hospital discharge. Care complexity individual factors from the comorbidity or complications domain were found to be the most frequently e-charted (88.3%). Care complexity individual factors from developmental (33.2%), psycho-emotional (13.2%), mental-cognitive (7.2%), and sociocultural (0.7%) domains were less frequently documented. Independent factors associated with hospital readmission were old age (≥75 years), duration of first hospitalization, admission to a nonsurgical ward, major chronic disease, hemodynamic instability, immunosuppression, and relative weight of diagnosis-related group.

CONCLUSIONS

A substantial number of patients required readmission within 30 days after discharge. The most frequent care complexity individual factors recorded in the nursing assessment at index admission were related to comorbidity or complications, developmental, and psycho-emotional domains. Strategies related to transition of care that include clinical characteristics and comorbidity or complications factors should be a priority at hospital discharge and after leaving hospital, but other factors related to developmental and psycho-emotional domains could have an important effect on the use of healthcare resources.

CLINICAL RELEVANCE

Nurses should identify patients with comorbidity or complications, developmental, and psycho-emotional complexity factors during the index admission in order to be able to implement an effective discharge process of care.

Frailty and body mass index are associated with biophysical properties of the skin in community-dwelling older adults

AIM OF THE STUDY

This study aimed to investigate the association of frailty and body mass index (BMI) with biophysical properties of the skin in community-dwelling older people.

MATERIALS AND METHODS

A cross-sectional study was conducted in a suburban Japanese city. Older adults aged ≥65 years and participating in a health checkup program were recruited (n = 128). Stratum corneum hydration, clinical manifestations of dry skin, skin elasticity and condition of the dermis (as measured by ultrasonography) were evaluated on the volar forearm. Frailty phenotype and BMI were also evaluated.

RESULTS

The mean age of participants was 74.5 years, and 96.1% were women. Skin thickness was significantly decreased in frail participants compared with non-frail participants in an age-adjusted multivariate model (p = 0.009). Frail participants showed significantly lower skin elasticity values than non-frail participants in a univariate analysis (p = 0.024), but this was not significant in the multivariate model. In participants with BMI ≥25 kg/m², clinical manifestations of dry skin were significantly decreased compared with BMI <21.5 kg/m² (p = 0.002). Participants with BMI ≥25 kg/m² and with 21.5 ≤ BMI <25 kg/m² showed significantly higher skin elasticity values than participants with BMI <21.5 kg/m² (p = 0.014 and p = 0.042, respectively).

CONCLUSION

Frailty was associated with decreased skin thickness and decreased skin elasticity partially via the influence of chronological aging. Low body mass was associated with increased xerosis manifestations and decreased skin elasticity in community-dwelling older adults.

Cutaneous Drug Reactions in the Elderly

Cutaneous adverse drug reactions comprise a significant proportion of all adverse drug reactions. They may mimic other dermatologic or systemic illnesses and may cause significant morbidity or mortality. Seven morphologic groups encompass the most commonly encountered cutaneous drug reaction syndromes: exanthematous (maculopapular), dermatitic/eczematous, urticarial, pustular, blistering, purpuric, and erythrodermic. Drug reactions may have significant downstream consequences for the older individual.

Immune System Dysfunction in the Elderly

Human aging is characterized by both physical and physiological frailty that profoundly affects the immune system. In this context aging is associated with declines in adaptive and innate immunity established as immunosenescence. Immunosenescence is a new concept that reflects the age-associated restructuring changes of innate and adaptive immune functions. Thus elderly individuals usually present chronic low-level inflammation, higher infection rates and chronic diseases. A study of alterations in the immune system during aging could provide a potentially useful biomarker for the evaluation of immune senescence treatment. The immune system is the result of the interplay between innate and adaptive immunity, yet the impact of aging on this function is unclear. In this article the function of the immune system during aging is explored.

The efficacy and safety of phototherapy in geriatric patients: a retrospective study

BACKGROUND

While phototherapy is a well-established treatment for many dermatoses, data from the literature regarding its use in elderly patients are quite limited.

OBJECTIVE

In this study, we aimed to determine the phototherapy indications in geriatric patients and to evaluate the effectiveness and reliability of phototherapy in this group.

METHODS

This study included 95 patients of 65 years of age and older who were treated in our phototherapy unit between 2006 and 2015. The data for this study were collected retrospectively from patient follow-up forms in the phototherapy unit.

RESULTS

Phototherapy was administered to 28 (29.5%) patients for mycosis fungoides, 25 (26.3%) patients foplaque type psoriasis, 12 (12.6%) patients for palmoplantar psoriasis, 12 (12.6%) patients for generalized pruritus, and 18 (19%) for other dermatoses. Of the patients, 64.2% had received a narrowband UVB (NB-UVB), 21.1% oral psoralen UVA (PUVA), and 14.7% local PUVA treatment. A complete response was achieved in 76.9-85.7% of the mycosis fungoides and in 73.71-100% of the psoriasis vulgaris patients treated with NB-UVB and PUVA, respectively. All the patients with generalized pruritus were treated with NB-UVB, and 80% of these patients achieved significant improvement. The erythema rate was found to be 0.43% per session for NB-UVB treatment and 0.46% per session for PUVA treatment as a side effect.

STUDY LIMITATIONS

The limitations of our study are that it was retrospective and the remission durations of the patients are not known.

CONCLUSION

This study showed that phototherapy is effective and reliable in the elderly population with proper dose increases and close follow-up.

What is the role of mitochondrial dysfunction in skin photoaging?

Skin ageing is a complex process involving both internal and external factors, which leads to a progressive loss of cutaneous function and structure. Solar radiation is the primary environmental factor implicated in the development of skin ageing, and the term photoaging describes the distinct clinical, histological and structural features of chronically sun-exposed skin. The changes that accompany photoaging are undesirable for aesthetic reasons and can compromise the skin and make it more susceptible to a number of dermatological disorders. As a result, skin ageing is a topic that is of growing interest and concern to the general population, illustrated by the increased demand for effective interventions that can prevent or ameliorate the clinical changes associated with aged skin. In this viewpoint essay, we explore the role that mitochondria play in the process of skin photoaging. There is continuing evidence supporting the proposal that mitochondrial dysfunction and oxidative stress are important contributing factors in the development of skin photoaging. Further skin-directed mitochondrial research is warranted to fully understand the impact of mitochondrial status and function in skin health. A greater understanding of the ageing process and the regulatory mechanisms involved could lead to the development of novel preventative interventions for skin ageing.

Immunological and non-immunological mechanisms of allergic diseases in the elderly: biological and clinical characteristics

A better hygiene, a Westernized diet, air pollution, climate changes, and other factors that influence host microbiota, a key player in the induction and maintenance of immunoregulatory circuits and tolerance, are thought to be responsible for the increase of allergic diseases observed in the last years. The increase of allergic diseases in elderly is related to the presence of other factors as several comorbidities that should interfere with the development and the type of allergic reactions. A central role is played by immunosenescence responsible for modifying response to microbiota and triggering inflamm-ageing. In addition, in elderly there is a shift from Th1 responses vs. Th2, hence favouring allergic responses. Better understanding of the mechanisms of immunosenescence and its effects on allergic inflammation will most certainly lead to improved therapy.

Prevalence and determinants of seborrhoeic dermatitis in a middle-aged and elderly population: the Rotterdam Study

BACKGROUND

Seborrhoeic dermatitis is a chronic relapsing inflammatory skin disease with unclear pathophysiological mechanisms.

OBJECTIVES

To establish which lifestyle and physiological determinants are associated with seborrhoeic dermatitis.

METHODS

Seborrhoeic dermatitis was diagnosed by a trained physician during a full-body skin examination within the Rotterdam Study, a prospective population-based cohort study in middle-aged and elderly people. The current design is a comparative cross-sectional study embedded in the Rotterdam Study. Potential factors were identified from the literature and analysed in a multivariable logistic regression, including: age, sex, obesity, skin colour, stress, depression, education level, hypertension, climate, xerosis cutis, alcohol and tobacco use.

RESULTS

Of the 5498 participants, 788 participants were diagnosed with seborrhoeic dermatitis (14·3%). We found associations between seborrhoeic dermatitis and male sex [adjusted odds ratio (OR) 2·09, 95% confidence interval (CI) 1·77-2·47], darker skin (adjusted OR 0·39, 95% CI 0·22-0·69), season (summer vs. winter: adjusted OR 0·63, 95% CI 0·48-0·82) and generalized xerosis cutis (adjusted OR 1·41, 95% CI 1·11-1·80).

CONCLUSIONS

Seborrhoeic dermatitis is one of the most common inflammatory dermatoses in middle-aged and elderly individuals, especially during winter. Men, and people with a light and dry skin were most likely to have seborrhoeic dermatitis.

Causes, pathophysiology, and treatment of pruritus in the mature patient

Chronic itch is a common and debilitating health condition in the elderly. There are several common causes of itch in the mature population, such as skin xerosis, immunosenescence, and neuropathic changes. In addition, skin diseases, such as seborrheic dermatitis and stasis dermatitis, systemic conditions (end-stage renal disease and diabetes), or psychogenic derailments, such as depression, anxiety, and dementia, can all serve as triggers of pruritus. Polypharmacy, a common occurrence among the elderly population, may also serve as a cause of itch that may or may not be accompanied by dermatitis. Such medications as μ opioids and calcium channel blockers have been found to have a connection with pruritus in the advanced aging population. Determining the exact trigger for pruritus in the elderly may be especially challenging, because itch can be idiopathic in many cases. The role of treatments should not only take into account elimination of various underlying cutaneous, systemic, or psychogenic conditions associated with itch but also focus on the skin changes that are characteristic of the aging process. Development of such treatment options can be guided by elucidation of the mechanisms underlying the pathophysiology of itch in the geriatric population.

Pilot parallel randomised controlled trial of protective socks against usual care to reduce skin tears in high risk people: 'STOPCUTS'

BACKGROUND

Skin tears are common in older adults and those taking steroids and warfarin. They are traumatic, often blunt injuries caused by oblique knocks to the extremities. The epidermis may separate from the dermis or both layers from underlying tissues leaving a skin flap or total loss of tissue, which is painful and prone to infection. 'Dermatuff™' knee-length socks containing Kevlar fibres (used in stab-proof vests and motorcyclists' clothing) aim to prevent skin tears. The acceptability of the socks and the feasibility of a randomised controlled trial (RCT) had not been explored.

METHODS

In this pilot parallel group RCT, 90 people at risk of skin-tear injury from Devon care homes and primary care were randomised to receive the socks or treatment as usual (TAU). The pilot aimed to estimate parameters to inform the design of a substantive trial and record professionals' views and participants' acceptability of the intervention and of study participation.

RESULTS

Participants were randomised from July 2013 and followed up until February 2015. Community participants were easier to recruit than care homes residents but were 10 years younger on average and more active. To recruit 90 participants, 395 had to be approached overall as 77% were excluded or declined. Seventy-nine participants (88%) completed the trial and 27/44 (61%) wore the socks for 16 weeks. There were 31 skin tear injuries affecting 18 (20%) of the 90 participants. The TAU group received more injuries, more repeated episodes, and larger tears with greater severity. Common daily diary reasons for not wearing the socks included perceived warmth in hot weather or not being available (holiday, in hospital, bed rest). Resource use data were obtainable and indicated that sock wearing gave a reduction in treatment costs whilst well-completed questionnaires showed improvements in secondary outcomes.

CONCLUSIONS

This pilot trial has successfully informed the design and conduct of a future definitive cost-effectiveness RCT. It would need to be conducted in primary care with 880 active at-risk, elderly patients (440 per arm). Skin tear incidence and quality of life (from EQ5D5L) over a 4-month period would be the primary and secondary outcomes respectively.

TRIAL REGISTRATION

ISRCTN, ISRCTN96565376.

Blistering diseases in the mature patient

Autoimmune blistering diseases (AIBD) are a group of chronic diseases affecting the skin and mucous membranes, with different presentation, clinical course, histologic and immunopathologic findings, and different therapeutic approach. Blisters develop as a result of autoantibodies directed against distinct adhesion structures within desmosomes or within the basement membrane zone. The most common AIBD that develops in the elderly is bullous pemphigoid (previously also named "pemphigoid senilis"), but mature patients can also present with other AIBD as mucous membrane pemphigoid, epidermolysis bullosa acquisita, paraneoplastic pemphigus, pemphigus vulgaris, pemphigus foliaceus, linear IgA dermatosis, and dermatitis herpetiformis. There are no differences in treatment approach to mature patients with AIBD, but due to more common comorbidities, systemic therapy should be given with more caution and control, and due to distorted skin integrity in the aged skin, the safety concerns are increased with the long-term use of any topical medication.

Skin barrier and dry skin in the mature patient

Dry skin is the most common clinical manifestation of dermatologic diseases, and it presents with itching, redness, and desquamation-signs and clinical manifestations that are not only physically uncomfortable but also affect patients psychologically. The water content in the stratum corneum is largely dependent on the composition and amount of the intercellular lipids, which regulate the loss of water from the skin, and on the levels of hygroscopic substances of the natural moisturizing factors, which are responsible for retention of water in the stratum corneum. Prevention of water loss and penetration of potentially toxic substances and microorganisms into the body are the most important functions of the skin, which acts as a natural frontier between the inner organism and the environment. Skin barrier defects occur in several skin diseases, but the influence of aging on the skin barrier function is largely unknown and conflicting results have been reported. In this review, the structure and function of the barrier in relation to the aging process are discussed.

Cutaneous infections in the mature patient

Dermatologists must be familiar with the peculiarities of the micro-organisms that may affect the elderly, in order to optimize the diagnosis and treatment of infections, which may affect their skin, especially because the world population is rapidly aging. It is estimated that there will be 434 million individuals over 80 years of age in 2050. Since the elderly population is rapidly increasing and their infections are usually more severe and different from those observed in younger adults, it leads to a statistical increase of the rates regarding hospitalization and mortality caused by infectious diseases among people over 85 years. Other health issues may be involved in the older population. These include nutritional alterations, as malnutrition or obesity, which can aggravate the infections. Also the usual signs and symptoms of infection are subtle or uncharacteristic in elderly patients, and frequently, they are unable to report their symptoms, which can delay the diagnosis. Among the many infections that may affect the elderly we reviewed the most frequent and those that are different in this age group, as herpes zoster, cytomegalovirus, herpes simplex, bacterial skin infections, erysipelas, celullitis, impetigo, folliculitis, furunculosis and carbunculosis, secondary infections, intertrigo (body folds), fungal infection, and scabies.

Fabrication of Tamarindus indica seeds extract loaded-cream for photo-aged skin: Visioscan® studies

INTRODUCTION

Intracellular and extracellular oxidative stress triggered by free radicals promotes skin aging, which is designated by atypical pigmentation and wrinkles. The consumption of antioxidants is an efficacious measure to avert symptoms involved in skin aging.

AIM

The current research was commenced to explore the anti-aging potential of antioxidants present in Tamarindus indica seeds extract.

MATERIAL AND METHODS

Tamarindus indica seeds extract was obtained by concentrating the ethanolic extract of seeds. The antioxidant activities of the extract were measured by nitric oxide radical scavenging assay, 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical scavenging assay, hydroxyl radical scavenging assay and superoxide radical scavenging assay. Formulation comprising 4% of the concentrated extract of seeds was formulated by loading it in the internal aqueous phase of water-in-oil (W/O) cosmetic emulsion. The base, used as control, consisted of the same emulsion but without loading Tamarindus indica seeds extract. The cosmetic emulsions were applied to the cheeks of 11 healthy male volunteers for duration of 12 weeks. Both base and formulation were assessed for their antioxidant effects on different skin parameters i.e. skin moisture contents, elasticity and surface evaluation of living skin (SELS).

RESULTS

The formulation showed statistically significant (p ≤ 0.05) and the base showed insignificant (p > 0.05) effects on skin elasticity and skin moisture contents. There is a significant decline in SELS, skin scaliness (SEsc), skin wrinkles (SEw), skin smoothness (SEsm), and skin roughness (SEr) parameters after application of the formulation.

CONCLUSIONS

Topical application of the cosmetic emulsion entrapped with Tamarindus indica seeds extract containing various antioxidants exerts potential skin antiaging effects.

Aging-related changes in the diversity of women's skin microbiomes associated with oral bacteria

Skin aging is associated with changes in cutaneous physiology including interactions with a skin microbial community. A striking alteration and diversification in the skin microbiome with aging was observed between two different age groups of 37 healthy Japanese women, i.e. younger adults of 21–37 years old and older adults of 60–76 years old, using bacterial 16S rRNA gene sequencing. The analyses revealed that the alpha diversity/species richness was significantly higher in the older than the younger group for the cheek and forehead microbiomes, while the beta diversity in the overall structure significantly differed particularly for the forearm and scalp microbiomes between the two age groups. Taxonomic profiling showed a striking reduction in the relative abundance of the majority skin genus Propionibacterium in the cheek, forearm and forehead microbiomes of the older adults, and identified 38 species including many oral bacteria that significantly differentiated the two age groups with a skin site dependency. Furthermore, we found chronological age-related and unrelated skin clinical parameters that correlate with the observed changes in the skin microbiome diversity. Thus, our data suggested that the diversification of skin microbiomes in adult women was largely affected by chronological and physiological skin aging in association with oral bacteria.

Transient receptor potential vanilloid 4-expressing macrophages and keratinocytes contribute differentially to allergic and nonallergic chronic itch

BACKGROUND

Chronic itch is a highly debilitating symptom that underlies many medical disorders with no universally effective treatments. Although unique neuronal signaling cascades in the sensory ganglia and spinal cord have been shown to critically promote the pathogenesis of chronic itch, the role of skin-associated cells remains poorly understood.

OBJECTIVE

We sought to examine the cutaneous mechanisms underlying transient receptor potential vanilloid 4 (TRPV4)-mediated allergic and nonallergic chronic itch.

METHODS

Expression of TRPV4 in chronic itch and healthy control skin preparations was examined by using real-time RT-PCR. Trpv4^eGFP mice were used to study the expression and function of TRPV4 in the skin by means of immunofluorescence staining, flow cytometry, calcium imaging, and patch-clamp recordings. Genetic and pharmacologic approaches were used to examine the role and underlying mechanisms of TRPV4 in mouse models of dry skin-associated chronic itch and spontaneous scratching associated with squaric acid dibutylester-induced allergic contact dermatitis.

RESULTS

TRPV4 is selectively expressed by dermal macrophages and epidermal keratinocytes in mice. Lineage-specific deletion of TRPV4 in macrophages and keratinocytes reduces allergic and nonallergic chronic itch in mice, respectively. Importantly, TRPV4 expression is significantly increased in skin biopsy specimens from patients with chronic idiopathic pruritus in comparison with skin from healthy control subjects. Moreover, TRPV4-dependent chronic itch requires 5-hydroxytryptamine (5-HT) signaling secondary to activation of distinct 5-HT receptors in mice with allergic and those with nonallergic chronic itch conditions.

CONCLUSION

Our study reveals previously unrecognized mechanisms by which TRPV4-expressing epithelial and immune cells in the skin critically and dynamically mediate chronic itch and unravels novel targets for therapeutics in the setting of chronic itch.

The global burden of melanoma: results from the Global Burden of Disease Study 2015

BACKGROUND

Despite recent improvements in prevention, diagnosis and treatment, vast differences in melanoma burden still exist between populations. Comparative data can highlight these differences and lead to focused efforts to reduce the burden of melanoma.

OBJECTIVES

To assess global, regional and national melanoma incidence, mortality and disability-adjusted life year (DALY) estimates from the Global Burden of Disease Study 2015.

METHODS

Vital registration system and cancer registry data were used for melanoma mortality modelling. Incidence and prevalence were estimated using separately modelled mortality-to-incidence ratios. Total prevalence was divided into four disease phases and multiplied by disability weights to generate years lived with disability (YLDs). Deaths in each age group were multiplied by the reference life expectancy to generate years of life lost (YLLs). YLDs and YLLs were added to estimate DALYs.

RESULTS

The five world regions with the greatest melanoma incidence, DALY and mortality rates were Australasia, North America, Eastern Europe, Western Europe and Central Europe. With the exception of regions in sub-Saharan Africa, DALY and mortality rates were greater in men than in women. DALY rate by age was highest in those aged 75-79 years, 70-74 years and ≥ 80 years.

CONCLUSIONS

The greatest burden from melanoma falls on Australasian, North American, European, elderly and male populations, which is consistent with previous investigations. These substantial disparities in melanoma burden worldwide highlight the need for aggressive prevention efforts. The Global Burden of Disease Study results can help shape melanoma research and public policy.

Aloe sterol supplementation improves skin elasticity in Japanese men with sunlight-exposed skin: a 12-week double-blind, randomized controlled trial

Background/objective

Recently, it was confirmed that the daily oral intake of plant sterols of Aloe vera gel (Aloe sterol) significantly increases the skin barrier function, moisture, and elasticity in photoprotected skin. This study aimed to investigate whether Aloe sterol intake affected skin conditions following sunlight exposure in Japanese men.

Methods

We performed a 12-week, randomized, double-blind, placebo-controlled study to evaluate the effects of oral Aloe sterol supplementation on skin conditions in 48 apparently healthy men (age range: 30–59 years; average: 45 years). The subjects were instructed to expose the measurement position of the arms to the sunlight outdoors every day for 12 weeks. The skin parameters were measured at 0 (baseline), 4, 8, and 12 weeks.

Results

Depending on the time for the revelation of the sunlight, the b* value and melanin index increased and the skin moisture decreased. After taking an Aloe sterol tablet daily for 12 weeks, the skin elasticity index (R2, R5, and R7) levels were significantly higher than the baseline value. There were no differences between the groups in these skin elasticity values. In the subgroup analysis of subjects aged <46 years, the change in the R5 and R7 was significantly higher in the Aloe group than in the placebo group at 8 weeks (P=0.0412 and P=0.0410, respectively). There was a difference in the quantity of sun exposure between each subject, and an additional clinical study that standardizes the amount of ultraviolet rays is warranted. No Aloe sterol intake-dependent harmful phenomenon was observed during the intake period.

Conclusion

Aloe sterol ingestion increased skin elasticity in the photodamaged skin of men aged <46 years.