Clinical implications of aging skin: cutaneous disorders in the elderly

Medication Error When Switching from Warfarin to Rivaroxaban Leading to Spontaneous Large Ecchymosis of the Abdominal and Chest Wall

Non-vitamin K oral anticoagulant (NOAC) therapy may be inappropriate if prescription was incorrect, the patient’s physiological parameters change, or interacting concomitant medications are erroneously added. The aim of this report was to illustrate inappropriate NOAC prescription in a 78-year-old woman with non-valvular atrial fibrillation and borderline renal dysfunction who was switched from warfarin to rivaroxaban and subsequently developed bruising with hemorrhagic shock and acute on chronic renal failure. Administration of 4-factor prothrombin complex concentrate effectively reversed coagulopathy and stopped bleeding. Retrospective determination of circulating plasma levels of rivaroxaban and warfarin confirmed that excessive anticoagulation was likely due to warfarin that the patient probably continued to take although rivaroxaban was initiated. Pharmacodynamic interaction between rivaroxaban and warfarin may not only be additive but synergistic. In patients at high risk of complications, judicious prescribing and dosing of NOACs, and regular monitoring of concomitant medications and renal function are highly recommended.

In situ production of ROS in the skin by photodynamic therapy as a powerful tool in clinical dermatology

Photodynamic therapy (PDT) is a clinical modality of photochemotherapy based on the accumulation of a photosensitizer in target cells and subsequent irradiation of the tissue with light of adequate wavelength promoting reactive oxygen species (ROS) formation and cell death. PDT is used in several medical specialties as an organ-specific therapy for different entities. In this review we focus on the current dermatological procedure of PDT. In the most widely used PDT protocol in dermatology, ROS production occurs by accumulation of the endogenous photosensitizer protoporphyrin IX after treatment with the metabolic precursors 5-methylaminolevulinic acid (MAL) or 5-aminolevulinic acid (ALA). To date, current approved dermatological indications of PDT include actinic keratoses (AK), basal cell carcinoma (BCC) and in situ squamous cell carcinoma (SCC) also known as Bowen disease (BD). With regards to AKs, PDT can also treat the cancerization field carrying an oncogenic risk. In addition, an increasing number of pathologies, such as other skin cancers, infectious, inflammatory or pilosebaceous diseases are being considered as potentially treatable entities with PDT. Besides the known therapeutic properties of PDT, there is a modality used for skin rejuvenation and aesthetic purposes defined as photodynamic photorejuvenation. This technique enables the remodelling of collagen, which in turn prevents and treats photoaging stygmata. Finally we explore a new potential treatment field for PDT determined by the activation of follicular bulge stem cells caused by in situ ROS formation.

Chronic pruritus in the elderly: pathophysiology, diagnosis and management

Chronic itch in the elderly is a common problem, with a significant impact on quality of life and sleep in elderly patients. Chronic itch may be attributable to several causes, including dry skin, immunosenescence and neural degeneration. Itch may also be caused by skin diseases, such as seborrhoeic dermatitis and stasis dermatitis; systemic conditions, such as end-stage renal disease and diabetes; and psychogenic conditions, such as depression and anxiety. The use of polypharmacy may also cause itch, with or without a rash. Specifically, thiazides and calcium channel blockers have been known to cause itch in elderly patients. Management should be tailored according to the underlying dermatological or systemic aetiology of itch. Topical treatment is the mainstay of therapy, providing special emphasis on skin hydration and barrier repair. In addition, topical and oral medications that target the nervous system and reduce neuronal hypersensitization, such as gabapentin and selective antidepressants, have a role in treating patients with severe chronic itch. Furthermore, management must account for changes in metabolism and pharmacokinetics of drugs in the aging population in order to prevent the occurrence of adverse effects.

Skin diseases among elderly patients attending skin clinic at the Regional Dermatology Training Centre, Northern Tanzania: a cross-sectional study

Background

As global population of the elderly continues to rise, a critical need to provide it with health services, including dermatology, will be significant, especially in developing countries like Tanzania. To adequately meet their dermatologic needs, knowledge of local patterns of skin conditions is vital. This study was aimed to describe the spectrum of skin diseases among elderly patients attending skin clinic at the Regional Dermatology Training Centre (RDTC) in Northern Tanzania.

Methods

A descriptive hospital based cross-sectional study was conducted between January 2013 and April 2013 at RDTC and included all patients aged 55 years and above who consented to be examined. Diagnoses were clinical, diagnostic tests being done only when necessary. Ethical clearance to conduct the study was granted.

Results

A total of 142 patients, age ranges 55–99 years, median age of 67.5 years were seen. Eczemas were the leading disease group (43.7 %), with unclassified eczemas (33.9 %) predominating. Papulosquamous disorders (15.4 %) were second with psoriasis (50 %) being the leading disease. Infections (11.3 % with fungal infections the leading group representing 5.6 % of all diseases), tumours (9.8 %: Kaposi’s sarcoma 4.2 %), vascular disorders 9.1 % (lymphedema 4.9 %), autoimmune disorders 7.7 % (connective tissue diseases 4.9 %), vitiligo 4.2 %, nutritional diseases 2.1 % (pellagra 0.7 %), urticaria 0.7 % and drug reactions 0.7 %.

Conclusions

Eczemas are the most common group of disorders among elderly patients presenting at RDTC.

Synthetic lipopeptides as potential topical therapeutics in wound and skin care: in vitro studies of permeation and skin cells behaviour

Wound healing is an extraordinarily complicated process associating with the cell aging, slowing down of cell renewal mechanism and even loss of protective function to environmentally induced oxidative stress.

Clinical implications of aging

Figure summarizes the major changes of aging and some key ways these changes affect pages. Though many changes occur with aging, under normal or resting conditions, there is usually very little functionally that is diminished solely on the basis of aging. The net effects are reductions in reserve capacity and placing geriatric patients at higher risk for adverse consequences related to medications and diseases. Interactions between lifestyle factors, such as exercise, diet, and environmental exposures, have a large impact on aging and lead to great individual variability. The interplay between these environmental factors, aging, and development of chronic diseases multiply the amount of variation seen as individual's age.

Adverse events associated with deep brain stimulation for movement disorders: analysis of 510 consecutive cases

BACKGROUND

Although numerous studies have focused on the efficacy of deep brain stimulation (DBS) for movement disorders, less is known about surgical adverse events, especially over longer time intervals.

OBJECTIVE

Here, we analyze adverse events in 510 consecutive cases from a tertiary movement disorders center at up to 10 years postoperatively.

METHODS

We conducted a retrospective review of adverse events from craniotomies between January 2003 and March 2013. The adverse events were categorized into 2 broad categories--immediate perioperative and time-dependent postoperative events.

RESULTS

Across all targets, perioperative mental status change occurred in 18 (3.5%) cases, and symptomatic intracranial hemorrhage occurred in 4 (0.78%) cases. The most common hardware-related event was skin erosion in 13 (2.5%) cases. The most frequent stimulation-related event was speech disturbance in 16 (3.1%) cases. There were no significant differences among surgical targets with respect to the incidence of these events. Time-dependent postoperative events leading to the revision of a given DBS electrode for any reason occurred in 4.7% ± 1.0%, 9.3% ± 1.4%, and 12.4% ± 1.5% of electrodes at 1, 4, and 7 years postoperatively, respectively. Staged bilateral DBS was associated with approximately twice the risk of repeat surgery for electrode replacement vs unilateral surgery (P = .020).

CONCLUSION

These data provide low incidences for adverse events in a large series of DBS surgeries for movement disorders at up to 10 years follow-up. Accurate estimates of adverse events will better inform patients and caregivers about the potential risks and benefits of surgery and provide normative data for process improvement.

Age-dependent variation in cytokines, chemokines, and biologic analytes rinsed from the surface of healthy human skin

In the skin, aging is associated with overall epidermal thinning, decreased barrier function, and gradual deterioration of the epidermal immune response. However, the presence and role of cytokines, chemokines, and biologic analytes (CCBAs) in immunosenescence are not known. Here we identified age-related changes in skin properties and CCBAs from stratum corneum of healthy human subjects, providing a means to utilize CCBAs as benchmarks for aging skin health. Transepidermal water loss and a(*) (skin redness) decreased in an age-dependent manner, and were significantly lower (p < 0.05) in Groups 2 (56.6 ± 4.6 years) and 3 (72.9 ± 3.0 years) vs. Group 1 (24.3 ± 2.8 years). In skin wash fluid, 48 CCBAs were detected; seven were significantly lower (p < 0.05) in Groups 2 and 3: EGF, FGF-2, IFNα2, IL-1RA, HSA, keratin-6, and involucrin; cortisol was significantly higher (p < 0.05) in Groups 2 and 3. Our results correspond with the pro-inflammatory shift that occurs with immunosenescence and also provides basis for understanding the inflammatory changes in normal aging skin.

Skin reactions at the application site of rivastigmine patch (4.6 mg/24 h, 9.5 mg/24 h or 13.3 mg/24 h): a qualitative analysis of clinical studies in patients with Alzheimer's disease

BACKGROUND AND OBJECTIVES

Rivastigmine patch is approved for the treatment of all stages of Alzheimer's disease (AD). Application site reactions may be a concern to clinicians and we used two large clinical trial databases to investigate the incidence of skin reactions in patients receiving rivastigmine patch.

METHODS

Data from a 24-week, randomised, double-blind (DB) evaluation of 13.3 vs. 4.6 mg/24 h rivastigmine patch in severe AD (ACTION) and a 72- to 96-week study comprising an initial open-label (IOL) phase followed by a 48-week randomised, DB phase (13.3 vs. 9.5 mg/24 h rivastigmine patch) in declining patients with mild-to-moderate AD (OPTIMA) were analyzed. The incidence, frequency, severity, management and predictors of application site reactions were assessed.

RESULTS

Application site reactions were mostly mild or moderate in severity and reported by similar proportions in each treatment group (

ACTION

13.3 mg/24 h, 24.5% and 4.6 mg/24 h, 24.2%; OPTIMA: IOL 9.5 mg/24 h, 22.9%; DB 13.3 mg/24 h, 11.4% and 9.5 mg/24 h, 12.0%); none were rated serious. In both studies, <9% of patients required treatment for application site reactions. Application site reactions led to discontinuation of 1.7% and 2.5% of the 13.3 mg/24 h and 4.6 mg/24 h groups, respectively, in ACTION, 8.7% in OPTIMA IOL and 1.8% and 3.5% of the 13.3 mg/24 h and 9.5 mg/24 h groups, respectively, in OPTIMA DB.

CONCLUSIONS

Application site reactions were experienced by <25% of patients in both studies, with no notable effect of dose. No reactions qualified as serious and skin reactions were uncommon as a reason for study discontinuation.

Considerations in treating physically active older adults and aging athletes

Life spans are increasing and research is showing more and more how important exercise is to successful aging. Medical practitioners need to appreciate the physiologic and physical changes that occur with age, as well as the significant benefits of physical activity, so they not only can properly treat their older patients but also so they can promote the benefits of exercise to their sedentary older patients.

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

Background

Skin tears are traumatic injuries occurring mostly on the extremities due to shearing and friction forces that separate the epidermis and the dermis from underlying tissues. They are common and occur mostly in older adults and those taking medications that compromise skin integrity. Pretibial skin tears can develop into leg ulcers, which require lengthy, expensive treatment to heal. Traumatic injuries are the second most common type of wounds after pressure ulcers in care homes and are the commonest reason for older adults to require the attention of a community nurse. Common causes of skin tear injuries are bumping into furniture and other obstacles, using mobility aids, transfer to/from wheelchairs, getting in and out of bed and falls. No effective preventative measures currently exist but knee-length, protective socks are now available that contain impact-resistant Kevlar fibres (of the type used in stab-proof vests) and cushioning layers underneath.

Methods/design

In this pilot parallel group, randomised controlled trial, 90 people at risk of skin-tear injury will be randomised with equal allocation to receive the intervention or usual care. They will be recruited from care homes and from the community via general practices and a research volunteer database. Pilot outcomes include recruitment, eligibility, attrition, ascertainment of injuries and completion of outcome measures. Acceptability of the intervention and of study participation will be explored using semi-structured interviews. The proposed primary outcome for the future definitive trial is skin tear-free days. Secondary outcomes are skin tear severity, health status, specific skin-tears quality of life, capability and fear of falling, measured at baseline and the end of the study and in the event of a skin tear.

Discussion

The results of this study will be used to inform the development and design of a future randomised controlled trial to assess the effectiveness and cost-effectiveness of a unique and innovative approach to skin tear prevention.

Approval was granted by the NRES - Cornwall and Plymouth Research Ethics Committee (13/SW/013). Dissemination will include publication of quantitative and qualitative findings, and experience of public involvement in peer-reviewed journals.

Trial registration

Current Controlled Trials: ISRCTN96565376

Skin aging modulates percutaneous drug absorption: the impact of ultraviolet irradiation and ovariectomy

Ultraviolet (UV) exposure and menopause are known as the inducers of damage to the skin structure. The combination of these two factors accelerates the skin aging process. In this study, we aimed to evaluate the influence of UV and ovariectomy (OVX) on the permeation of drugs through the skin. The role of tight junctions (TJs) and adherens junctions (AJs) in the cutaneous absorption of extremely lipophilic permeants and macromolecules was explored. The OVX nude mouse underwent bilateral ovary removal. Both UVA and UVB were employed to irradiate the skin. The physiological and biochemical changes of the skin structure were examined with focus on transepidermal water loss (TEWL), skin color, immunohistochemistry, and mRNA levels of proteins. UVB and OVX increased TEWL, resulting in stratum corneum (SC) integrity disruption and dehydration. A hyperproliferative epidermis was produced by UVB. UVA caused a pale skin color tone due to keratinocyte apoptosis in the epidermis. E-cadherin and β-catenin showed a significant loss by both UVA and UVB. OVX downregulated the expression of filaggrin and involucrin. A further reduction was observed when UV and OVX were combined. The in vitro cutaneous absorption demonstrated that UV increased the skin permeation of tretinoin by about twofold. However, skin accumulation and flux of estradiol were not modified by photoaging. OVX basically revealed a negligible effect on altering the permeation of small permeants. OVX increased tretinoin uptake by the appendages from 1.36 to 3.52 μg/cm(2). A synergistic effect on tretinoin follicular uptake enhancement was observed for combined UV and OVX. However, the intervention of OVX to photoaged skin resulted in less macromolecule (dextran, molecular weight = 4 kDa) accumulation in the skin reservoir because of retarded partitioning into dry skin. The in vivo percutaneous absorption of lipophilic dye examined by confocal microscopy had indicated that the SC was still important to controlling topical delivery, although the role of epidermal junctions could not be simply ignored.

Increased osteopontin levels in children undergoing venom immunotherapy may serve as a marker of clinical efficacy

BACKGROUND

Venom immunotherapy (VIT) has its effect by modulating various mediators resulting in immune tolerance. The aim of this study was to measure changes in plasma osteopontin (OPN) and serum basal tryptase (sBT) levels over the course of 1 year of VIT in children with venom allergy.

METHODS

Children who suffered from a large local reaction (LLR) or a systemic reaction (SR) after insect stings were included along with control subjects. Measurements were performed before the initiation of VIT and 6 and 12 months after it had been started.

RESULTS

A total of 58 children (24 with SR, 18 with LLR and 16 control subjects) with a median age of 9.5 years (range 6.7-12.8) were enrolled. The plasma OPN levels of patients with LLR [median 1,477 ng/ml, interquartile range (IQR) 1,123-1,772] were significantly higher than patients with SR (882 ng/ml, 579-1,086; p < 0.001) and healthy control subjects (1,015 ng/ml, 815-1,203; p = 0.002). A significant increase in plasma OPN levels in children was determined after the 1-year VIT. The sBT levels of children with SR (4.1 ng/ml, 3.6-5.8) were significantly higher than children with LLR (3.1 ng/ml, 2.5-4.0) and control subjects (3.0 ng/ml, 2.9-3.8; p = 0.001). There was no significant change in the sBT levels of the patients after the 1-year VIT.

CONCLUSIONS

The results of our study showed higher baseline levels of OPN in children with LLR compared to control subjects and children with SR. In children with SR, OPN levels were increased after the 1-year VIT. Our results may suggest a possible association between OPN and successful VIT in children.

Quantitative analysis of intrinsic skin aging in dermal papillae by in vivo harmonic generation microscopy

Chronological skin aging is associated with flattening of the dermal-epidermal junction (DEJ), but to date no quantitative analysis focusing on the aging changes in the dermal papillae (DP) has been performed. The aim of the study is to determine the architectural changes and the collagen density related to chronological aging in the dermal papilla zone (DPZ) by in vivo harmonic generation microscopy (HGM) with a sub-femtoliter spatial resolution. We recruited 48 Asian subjects and obtained in vivo images on the sun-protected volar forearm. Six parameters were defined to quantify 3D morphological changes of the DPZ, which we analyzed both manually and computationally to study their correlation with age. The depth of DPZ, the average height of isolated DP, and the 3D interdigitation index decreased with age, while DP number density, DP volume, and the collagen density in DP remained constant over time. In vivo high-resolution HGM technology has uncovered chronological aging-related variations in DP, and sheds light on real-time quantitative skin fragility assessment and disease diagnostics based on collagen density and morphology.

Short-term sensory and cutaneous vascular responses to therapeutic ultrasound in the forearms of healthy volunteers

Background

Therapeutic ultrasound (US) is used for a variety of clinical pathologies and is thought to accelerate tissue repair and help with pain reduction via its thermal and nonthermal effects. The evidence on physiological effects of US on both sensory and vascular functions in humans is incomplete. Hence, the purpose of this study was to determine the short-term impact of two doses of US (3 MHz, 1:4, 0.25 W/cm², 5 min; 1 MHz, continuous, 0.8 W/cm², 3 min), on sensory and vascular responses in the healthy forearms.

Methods

Twenty healthy subjects were recruited (mean age, 29.6 ± 8.8 years) for the study. Superficial blood flow (SBF) in the distal forearms was determined using the tissue viability imaging system. Sensory perception thresholds (SPT) were determined from ring finger (C7, C8) to assess A-beta (at 2,000 Hz) and C fiber function (at 5 Hz), using a Neurometer CPT/C device. Subject’s two hands were randomly allocated to group order (AB/BA). Scores were obtained before and immediately after the application of US and control. Differences in these were analyzed using repeated measures.

Results

Both 3 MHz pulsed US and 1 MHz continuous US showed small to moderate (effect size = 0.12 to 0.68), statistically significant reductions in SBF (3 MHz, mean change = 2.8 AU and 1 MHz, mean change = 3.9 AU, p < 0.05 respectively), skin temperature (2.5°C and 1.1°C, p < 0.05), and SPT at 5 Hz (1.3 and 1 mA, p < 0.05) across time. SPT at 2,000 Hz remained unaltered by all three conditions (p > 0.05). Age and gender also had no effect on all outcome measures (p > 0.05).

Conclusion

This study demonstrated minor reductions in skin blood flow, skin temperatures, and C fiber perception thresholds immediately after 3 MHz, and 1 MHz US. The responses observed may have been due to a thermo-cooling effect of the gel or due to the direct effect of US on C fibers of median and ulnar nerves. US had a negligible effect on A-beta fibres. This would suggest that future studies looking at physiological effects of US should move towards investigating larger dosages and study the effects in patient populations.

Hypo-osmotic shock-induced subclinical inflammation of skin in a rat model of disrupted skin barrier function

Aging disrupts skin barrier function and induces xerosis accompanied by pruritus. In many cases, elderly patients complain of pruritus during skin hygiene care, a condition called aquagenic pruritus of the elderly (APE). To date, the pathophysiology and mechanism of action of APE have not been elucidated. We conducted the present study to test the hypothesis that hypo-osmotic shock of epidermal cells induces skin inflammation and elongation of C-fibers by nerve growth factor β (NGFβ) as a basic mechanism of APE. The dorsal skin of HWY rats, which are a model for disrupted skin barrier function, was treated with distilled water (hypotonic treatment [Hypo] group) or normal saline (isotonic treatment [Iso] group) by applying soaked gauze for 7 days. Untreated rats were used as a control (no-treatment [NT] group). Histochemical and immunohistochemical analyses revealed inflammatory responses in the epidermis and the dermal papillary layer in the Hypo group, while no alterations were observed in the Iso or NT groups. Induction of expression and secretion of NGFβ and elongation of C-fibers into the epidermis were found in the Hypo group. In contrast, secretion of NGFβ was significantly lower and elongation of C-fibers was not observed in the Iso group. These results suggest that hypo-osmotic shock-induced inflammatory reactions promote hypersensitivity to pruritus in skin with disrupted barrier function.

Decreased proliferative capacity of aged dermal fibroblasts in a three dimensional matrix is associated with reduced IGF1R expression and activation

Skin aging results in increased susceptibility to injury and impaired wound healing. Proliferation of fibroblasts is reduced in aged dermis, which contributes to delays in wound closure. Age-associated differences are regulated, in part, by local or systemic factors such as the IGF-1/IGF1R system. The aim of this study was to determine if expression and activation of IGF1R in aged human dermal fibroblasts, when compared to young fibroblasts, is associated with altered proliferative capacity in a 3D collagen matrix that better simulates the dermal extracellular matrix in vivo. The proliferation of young and aged human dermal fibroblasts in 3D collagen and its association with baseline levels of IGF1R expression were measured. The effect of stimulation and inhibition of Erk phosphorylation on the proliferative capacity of fibroblasts in a 3D collagen matrix was defined. Our results show that proliferation and Erk phosphorylation is reduced in aged dermal fibroblasts relative to young fibroblasts. Activation of Erk phosphorylation in aged fibroblasts is associated with a significant increase in fibroblast proliferation in 3D collagen.

Age-related dermal collagen changes during development, maturation and ageing - a morphometric and comparative study

The tissue organisation of dermal collagen is gaining importance as a contributing factor both in development and ageing, as well as in skin maturation processes. In this work we aim to study different representative parameters of this structural organisation in 45 human skin samples of assorted ages, by means of image analysis. The variation of these parameters on the basis of age was assessed using several regression models (linear, quadratic and cubic). The area occupied by collagen was significantly reduced as a function of age in the papillary dermis (R(2) = 0.437, P < 0.0001), as well as the thickness of the collagen bundles (R(2) = 0.461, P < 0.0001), following statistical models of cubic and quadratic regression, respectively. The width of the papillary dermis increased in a significant manner over a linear regression model (R(2) = 0.26, P < 0.0001). In the reticular dermis, the cubic regression indicated a significant decline (R(2) = 0.392, P = 0.002) of the area filled with collagen according to the age. Both collagen thickness and bundle orientation parameters fit a quadratic regression over the age in a significant way (R(2) = 0.433 and R(2) = 0.334, respectively, both P < 0.0001). The width of the reticular dermis followed also a significant quadratic distribution according to age (R(2) = 0.193, P = 0.011). These parameters could partially explain the lifelong functional changes taking place in the skin and propose a baseline providing a useful entry point for future investigation.

11β-Hydroxysteroid dehydrogenase 1: translational and therapeutic aspects

11β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1) interconverts the inactive glucocorticoid cortisone and its active form cortisol. It is widely expressed and, although bidirectional, in vivo it functions predominantly as an oxoreductase, generating active glucocorticoid. This allows glucocorticoid receptor activation to be regulated at a prereceptor level in a tissue-specific manner. In this review, we will discuss the enzymology and molecular biology of 11β-HSD1 and the molecular basis of cortisone reductase deficiencies. We will also address how altered 11β-HSD1 activity has been implicated in a number of disease states, and we will explore its role in the physiology and pathologies of different tissues. Finally, we will address the current status of selective 11β-HSD1 inhibitors that are in development and being tested in phase II trials for patients with the metabolic syndrome. Although the data are preliminary, therapeutic inhibition of 11β-HSD1 is also an exciting prospect for the treatment of a variety of other disorders such as osteoporosis, glaucoma, intracranial hypertension, and cognitive decline.

Mice with heterozygous deficiency of manganese superoxide dismutase (SOD2) have a skin immune system with features of "inflamm-aging"

Dendritic cells (DC) are central in regulating skin immunity. Immunosenescence is associated with a chronic inflammatory state. Little is known about the contribution of DC to "inflamm-aging". When determining langerhans cell (LC) numbers, we found a 60 % reduction of LC in aged epidermis. Reactive oxygen species(ROS) are linked with aging. The mitochondrial manganese superoxide dismutase (SOD2) is in the first line of antioxidant defense. We investigated the function of DC from SOD2 heterozygous mice (SOD2+/-) and found that at 4 months of age LC numbers are not altered, but activated LC have impaired expression of MHC-II and CD44. Immature SOD2+/- DC produced increased proinflammatory IL-6 and chemokines CXCL1 and CXCL2. Upon challenge SOD2+/- DC accumulated ROS. When activating SOD2+/- DC by LPS they less efficiently upregulated MHC-II, CD86 and CD44. Surprisingly, in vivo contact hypersensitivity (CHS) was enhanced in SOD2+/- mice although SOD2+/- DC were less potent in stimulating wt T cells. However, SOD2+/- T cells showed increased proliferation, even when stimulated with SOD2+/- DC, possibly explaining the increased CHS. Our findings suggest that SOD2 is a molecular candidate in the regulation of "inflamm-aging" conveying both immunosuppressive and proinflammatory signals through alteration of DC and T cell functions.

Unique Aspects of the Elderly Surgical Population: An Anesthesiologist's Perspective

Increasing life expectancies paired with age-related comorbidities have resulted in the continued growth of the elderly surgical population. In this group, age-associated changes and decreased physiological reserve impede the body's ability to maintain homeostasis during times of physiological stress, with a subsequent decrease in physiological reserve. This can lead to age-related physiological and cognitive dysfunction resulting in perioperative complications. Changes in the cardiovascular, pulmonary, nervous, hepatorenal, endocrine, skin, and soft tissue systems are discussed as they are connected to the perioperative experience. Alterations affect both the pharmacodynamics and pharmacokinetics of administered drugs. Elderly patients with coexisting diseases are at a greater risk for polypharmacy that can further complicate anesthetic management. Consequently, the importance of conducting a focused preoperative evaluation and identifying potential risk factors is strongly emphasized. Efforts to maintain intraoperative normothermia have been shown to be of great importance. Procedures to maintain stable body temperature throughout the perioperative period are presented. The choice of anesthetic technique, in regard to a regional versus general anesthetic approach, is debated widely in the literature. The type of anesthesia to be administered should be assessed on a case-by-case basis, with special consideration given to the health status of the patient, the type of operation being conducted, and the expertise of the anesthesiologist. Specifically addressed in this article are age-related cognitive issues such as postoperative cognitive dysfunction and postoperative delirium. Strategies are suggested for avoiding these pitfalls.

Evaluation of dermatological consultations of patients treated in intensive care unit

BACKGROUND

Skin disorders which require treatment are a common development in patients treated in intensive care units (ICUs). There are very few prospective studies about skin complications in adult ICUs.

OBJECTIVE

The aim of this study is to evaluate skin disorders in ICU-treated adult patients who were consulted for dermatological problems.

METHODS

Eighty-two of 591 patients admitted to ICUs who were consulted for dermatological problems were included in the study. The correlation between skin complications and associated comorbidities, age, gender and ICU length of stay were analyzed.

RESULTS

Ninety dermatological complications were observed. Cutaneous drug reactions were significantly more frequent in female patients than males (p = 0.020). Candidal intertrigo was more frequent in diabetic patients than in nondiabetic patients (p = 0.042).

CONCLUSION

Patients in ICUs may develop various skin disorders that need to be evaluated by dermatological consultations. Clinical features of the patients, especially gender and comorbidities, may predispose skin complications.

Characteristics of the Aging Skin

SIGNIFICANCE

Although most researches into the changes in skin with age focus on the unwelcome aesthetic aspects of the aging skin, skin deterioration with age is more than a merely cosmetic problem. Although mortality from skin disease is primarily restricted to melanoma, dermatological disorders are ubiquitous in older people with a significant impact on quality of life. The structural and functional deterioration of the skin that occurs with age has numerous clinical presentations, ranging from benign but potentially excruciating disorders like pruritus to the more threatening carcinomas and melanomas.

RECENT ADVANCES

The degenerative changes that occur in the aging skin are increasingly understood at both the molecular and cellular level, facilitating a deeper understanding of the structural and functional deterioration that these changes produce.

CRITICAL ISSUES

A loss of both function and structural stability in skin proceeds unavoidably as individuals age, which is the result of both intrinsic and extrinsic processes, which contribute simultaneously to a progressive loss of skin integrity. Intrinsic aging proceeds at a genetically determined pace, primarily caused by the buildup of damaging products of cellular metabolism as well as an increasing biological aging of the cells. Estrogen levels strongly influence skin integrity in women as well; falling levels in midlife, therefore, produce premature aging as compared with similarly aged men. Extrinsic insults from the environment add to the dermatological signs of aging.

FUTURE DIRECTIONS

A deeper understanding of the physiological basis of skin aging will facilitate progress in the treatment of the unwelcome sequelae of aging skin, both cosmetic and pathogenic.

Age-Related Tissue Stiffening: Cause and Effect

SIGNIFICANCE

Tissue elasticity is severely compromised in aging skin, lungs, and blood vessels. In the vascular and pulmonary systems, respectively, loss of mechanical function is linked to hypertension, which in turn is a risk factor for heart and renal failure, stroke, and aortic aneurysms, and to an increased risk of mortality as a result of acute lung infections.

RECENT ADVANCES

Although cellular mechanisms were thought to play an important role in mediating tissue aging, the reason for the apparent sensitivity of elastic fibers to age-related degradation remained unclear. We have recently demonstrated that compared with type I collagen, a key component of the elastic fiber system, the cysteine-rich fibrillin microfibril is highly susceptible to direct UV exposure in a cell-free environment. We hypothesized therefore that, as a consequence of both their remarkable longevity and cysteine-rich composition, many elastic fiber-associated components will be susceptible to the accumulation of damage by both direct UV radiation and reactive oxygen species-mediated oxidation.

CRITICAL ISSUES

Although elastic fiber remodeling is a common feature of aging dynamic tissues, the inaccessibility of most human tissues has hampered attempts to define the molecular causes.

CLINICAL CARE RELEVANCE

Although, currently, the localized repair of damaged elastic fibers may be effected by the topical application of retinoids and some cosmetic products, future studies may extend the application of systemic transforming growth factor β antagonists, which can prevent cardiovascular remodeling in murine Marfan syndrome, to aging humans. Acellular mechanisms may be key mediators of elastic fiber remodeling and hence age-related tissue stiffening.

Elderly adults and skin disorders: common problems for nondermatologists

Diseases of elderly adults are becoming increasingly important as life expectancy gradually rises worldwide. To promote healthy aging, it is important to understand the skin changes associated with aging. This review focuses on the special considerations for some of the more common dermatological disorders in elderly adults and examines presentation, contributing factors, and association with systemic diseases.

Efficacy of mesotherapy in facial rejuvenation: a histological and immunohistochemical evaluation

BACKGROUND

Mesotherapy, commonly known as "biorejuvenation" or "biorevitalization", is a technique used to rejuvenate the skin by means of a transdermal injection of a multivitamin solution and natural plant extracts that are thought to improve the signs of skin aging.

OBJECTIVES

This prospective study aimed to evaluate the clinical effect of mesotherapy applied to periorbital wrinkles and to quantitatively evaluate histological changes in the skin occurring in response to the same treatment.

METHODS

Six volunteers with Fitzpatrick skin types III or IV and Glogau class I-III wrinkles were subjected to a three-month course of mesotherapy injections in the periocular area (six sessions administered at two-week intervals). Standard photographs and skin biopsies were obtained from the treatment area at baseline, at the end of treatment, and at three months post-treatment. Quantitative evaluation of collagen types I, III, and VII, newly synthesized collagen, total elastin, and tropoelastin was performed using a computerized morphometric analysis.

RESULTS

The clinical evaluation of volunteers at baseline, end of treatment, and three months post-treatment revealed no significant differences. Histological and immunostaining analysis of collagen types I, III, and VII, newly synthesized collagen, total elastin, and tropoelastin showed no statistically significant changes (P > 0.05) after mesotherapy injection.

CONCLUSIONS

The present study indicates that mesotherapy for skin rejuvenation does not result in statistically significant histological changes or clinical improvement.

Multiple minimally invasive Erbium: Yttrium Aluminum Garnet laser mini-peels for skin rejuvenation: an objective assessment

BACKGROUND

As the demand for minimally invasive rejuvenation is increasing, micropeel resurfacing using Erbium:Yttrium Aluminum Garnet (Er:YAG) laser 2940 nm has been reported for the treatment of photoaged skin without ablation of the epidermis. However, little is known about the efficacy and underlying histologic changes associated with this type of treatment.

AIMS

The aims of this study are to evaluate the clinical effect and objectively quantify the histological changes in response to multiple sessions of Er:YAG laser 2940 nm mini-peels.

PATIENTS AND METHODS

Six female volunteers of Fitzpatrick skin type III-IV and Glogau's class I-III wrinkles were subjected to six microresurfacing peels at 2-week intervals using Er:YAG 2940 nm laser at subablative fluences of 2-3 J/cm(2) to treat periorbital rhytides. Quantitative evaluation of collagen types I, III, and VII, newly synthesized collagen, total elastin, and tropoelastin was performed by histochemistry and immunohistochemistry coupled with computerized morphometric analysis at base line, end of treatment, and 3 months post-treatment.

RESULTS

Compared to the base line, evaluation of volunteers revealed obvious clinical improvement in response to Er:YAG mini-peels. Collagen types I, III, and VII, as well as newly synthesized collagen, together with tropoelastin showed a statistically significant increase in response to treatment, while the mean level of total elastin was significantly decreased in response to treatment. However, this was followed by regression of improvement at 3 months post-treatment but was still better than baseline.

CONCLUSIONS

This study revealed that multiple Er:YAG mini-peels is a promising treatment option for photoaging as it reverses the signs of photoaged skin with little downtime and side effects. However, to maintain the short-term improvement achieved after treatment, continued Er:YAG 2940 nm laser mini-peels is required.

Aging in elderly: chronological versus photoaging

Background:

Skin is a window to aging changes, a biological reality. There is a dearth of studies regarding the various chronological (intrinsic) aging and photoaging (extrinsic) changes seen in Asians. This study was undertaken to detect the clinical pattern of aging skin changes and dermatoses seen in the elderly.

Materials and Methods:

This was a descriptive study conducted on 500 consecutive elderly individuals attending the Dermatology out-patient department. The severity of photoaging was graded using Glogau scale.

Results:

Most of the population had skin type IV and V. Majority (415, 83%) of our cases had chronological aging without photoaging and the remaining 85 (17%) individuals had photoaging along with chronological aging. The common skin changes due to chronological aging were thin skin, fine wrinkles, xerosis, and loss of elasticity. Photoaging changes such as dyspigmentation, freckles, thick skin, deep wrinkles, melasma, citrine skin, senile purpura, pseudostellate scar, acrokeratoelastoidosis marginalis, and lentigines were less frequent in our study. Smoking and prolonged sun exposure was the risk factors aggravating photoaging. The most common dermatosis was pruritus in 248 (49.6%) individuals, of which 149 (29.8%) had pruritus associated with xerosis. Contact dermatitis was more common in males. Fungal infections were frequently seen in females. Seborrhoeic keratosis (253, 50.6%) was the most common benign neoplasm more commonly seen in males. Cutaneous malignancies were less common in our study population.

Conclusion:

Photoaging changes were less common than chronological aging changes in skin type IV. Chronological changes were more frequent in females than males, while photoaging was more frequent in males.

Management of skin-related adverse events during locomotor training with robotic-assisted body weight supported treadmill: A case report

The purpose of this case report is to describe attempts to prevent skin-related adverse events from occurring and protect the skin once breakdown occurred in a person with chronic stroke during locomotor training. There is scant literature in how to address skin during locomotor training with the Lokomat(®), particularly when a patient presents with sensory deficits and frail skin. The patient was a 75-year-old male survivor of stroke who participated in the Lokomat(®) group of a randomized clinical pilot study comparing locomotor training with the Lokomat(®) and conventional means. He had diminished sensation to light touch and proprioception on his left leg with skin on both lower legs presenting as thin, flaky, and virtually hairless. Although much effort was put towards prevention of skin breakdown, he developed numerous skin-related adverse events during his training. However, his skin healed completely with reduced training intensity and initiation of "pre-wrapping" his lower legs with Akton(®) viscoelastic polymer sheets and elastic bandages. Significant improvements were noted in his Functional Improvement Measure(™) locomotion score and Stroke Impact Scale domains of strength, participation/role function, and total recovery, though not in his 10-m walk test velocity or 6-min walk test. The Akton(®) sheets and team approach between study team, patient, and his wife allowed simultaneous safe continuation of locomotor training with the Lokomat(®) and healing of his skin breakdown.

Geriatric dermatoses: a clinical review of skin diseases in an aging population

Geriatric dermatoses are a challenging job for the physician in terms of diagnosis, management, and followup. Since skin of the elderly population is going through a lot of changes from both an intrinsic and extrinsic point of view, it is imperative for the physician to have a better understanding of the pathophysiology of geriatric skin disorders and their specific management, which differs slightly from an adult population. This review focuses on a brief introduction to the pathophysiological aspects of skin disorders in elderly, the description of some common geriatric skin disorders and their management and the new emerging role of psychodermatological aspects of geriatric dermatoses is also discussed. At the end, ten multiple choice questions are also added to further enhance the knowledge base of the readers.

Evaluation of ultrasonography for measurement of skin thickness in Shar-Peis

OBJECTIVE

To determine whether high-frequency diagnostic ultrasonography is useful for assessment of skin thickness in Shar-Peis.

ANIMALS

10 healthy Shar-Peis and 10 healthy Beagles used as controls.

PROCEDURES

Ultrasonographic examination of the skin was performed on 4 cutaneous sites by use of a 13-MHz linear-array transducer, and the mean of 3 measurements was calculated. Ultrasonography results were compared with histologic findings of skin specimens stained with H&E, Alcian blue at a pH of 2.5, and Masson trichrome stains, with histometric measurements of skin thickness made by use of a microscope, and with measurements of skin thickness made by use of a plicometer. Ultrasonograpy results were also compared via age and sex of selected animals.

RESULTS

A clear correlation was detected between ultrasonography results and results of histologic and histometric analysis in both groups. In Shar-Peis, no correlation was found between ultrasonography results and age and sex, whereas in Beagles, a weak positive correlation was found only between skin thickness in dorsal cervical and frontal (on the rostral margins of the supraorbital processes) regions and age. A positive overall correlation was found in Shar-Peis between measurements made via ultrasonography and plicometery.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasonography was a useful tool to assess skin thickness, and in Shar-Peis, it might be considered a valid alternative to invasive methods such as histologic examination to objectively estimate the severity of hereditary cutaneous hyaluronosis.

Petechiae in hanging: a retrospective study of contributing variables

Petechiae, one of the classic signs of asphyxia, are thought to be more frequently observed in cases of hanging where part of the body is supporting the victim's weight, ie, cases of incomplete hanging. However, there is very little evidence-based medicine to support this claim. The present study is intended to evaluate the relationship between petechiae and the type of hanging (complete vs. incomplete). Furthermore, several other variables were analyzed to determine if they contribute significantly to the presence of petechiae. An 8.5-year retrospective study of 206 cases of death by hanging reviewed autopsy reports for the presence of petechiae. For each case, the following information was also compiled: gender and age, height and weight, body mass index, the type of hanging (complete or incomplete suspension), the type of ligature used (narrow or wide), and whether or not the victim had received cardiopulmonary resuscitation maneuvers. Statistical analysis revealed that the incidence was higher among incomplete hanging victims compared with cases of complete suspension and that the incidence of petechiae varied inversely with the height of the victims. The other factors were not shown to contribute significantly to the presence of petechiae.

Exercise training and the control of skin blood flow in older adults

The ability to control skin blood flow decreases with primary aging, making older adults less able to adequately thermoregulate and repair cutaneous wounds. Lifestyle factors such as physical activity, diet, and smoking might interact with the aging process to modulate "normal" age-associated changes in the cutaneous microcirculation. The main focus of this brief review is the effects of exercise training on the control of skin blood flow in older adults.

Irritant contact dermatitis: effect of age

Knowledge on age-relationship to irritant contact dermatitis (ICD) remains of interest. We searched for articles and textbooks on age-relationship to ICD and evaluated relevant data. Irritant response may be enhanced in children and decline with increasing age. In general, older skin reacts more slowly and with less intensity to irritants when compared with young skin. Such age-related changes may depend: (i) on differences in percutaneous penetration in old and young skin, and/or on (ii) differences in the microcirculatory efficiency, which serves as the route by which inflammatory cells make their way to the site of inflammation. Additionally, stratum corneum turnover time increases with age which means that an irritant remains longer on the skin; a compromised cutaneous blood vessel network with ageing may lead to a decreased inflammatory response, decreased absorption and decreased clearance. In conclusion, age-related differences of ICD are present despite some conflicting data. Investigations elucidating this interesting subject may benefit in prevention and intervention strategies.