Dermatoporosis, a prevalent skin condition affecting the elderly: current situation and potential treatments

Deep Dissecting Hematoma Requiring Surgical Removal During Veno-Venous Extracorporeal Membrane Oxygenation Management: A Case Report

Deep dissecting hematoma (DDH) is a disease in which minor trauma leads to the formation of an extensive hematoma. If left untreated, this can result in significant skin necrosis. Therefore, early treatment following a precise diagnosis is essential. However, the complexity of the disease may require differentiating it from soft tissue infections. A 58-year-old man with severe coronavirus disease 2019 (COVID-19) pneumonia developed skin complications such as purpura and blisters on his right upper extremity while undergoing veno-venous extracorporeal membrane oxygenation (VV-ECMO). We initially suspected a soft tissue infection or venous perfusion defect caused by the VV-ECMO cannula; however, these conditions were not observed. After making an exploratory incision, we diagnosed the patient with DDH and performed hematoma removal and skin grafting. The initial symptoms of DDH include erythema, swelling, and pain. It is important to differentiate DDH from soft tissue infections, especially necrotizing fasciitis, which is a more urgent condition. Because a surgical incision is necessary for the diagnosis and treatment of DDH, we do not hesitate to perform an exploratory incision to prevent skin necrosis, thereby contributing to early healing.

Skin Ageing: A Progressive, Multi-Factorial Condition Demanding an Integrated, Multilayer-Targeted Remedy

Of the human organs, skin is the most visible one that displays the manifestations of ageing. It has a very intricate microanatomical structure and performs several key physiological functions. The pathophysiology of cutaneous ageing is characterized by deterioration of structural stability and functional integrity, implying a continuous reduction in maximal function and reserve capacity, as a result of the accumulating damage due to both intrinsic and extrinsic factors. Elimination of unfavorable expressions associated with facial and cutaneous ageing is the key patient demand in aesthetic dermatology. Even though the progress has been made in nonsurgical therapies like fillers and lasers, non-invasive interventions by using skin care products designed for rejuvenation at an early stage are the most popular and accessible solution among people. In this review, we have scrutinized the ageing-associated cutaneous changes at molecular, cellular and tissue levels. To optimize the ageing process towards a healthy skin, we propose an integrated, multilayer-targeted intervention, which involves both topical application of anti-ageing formulations from outside and oral supplementation from inside. Additionally, several promising naturally derived ingredients are reviewed from an anti-aging perspective. Most of them possess various bioactivities and may contribute to the development of the mentioned anti-ageing remedy.

Efficacy of microneedle radiofrequency therapy in the treatment of senile purpura: A prospective study

BACKGROUND

Radiofrequency (RF) devices have been used for skin rejuvenation and treating skin laxity. It may also be effective for senile purpura (SP) based on its action of promoting neocollagenesis with minimal epidermal damage. This study aimed to evaluate the efficacy and safety of microneedle RF for treating SP of the forearms in elderly.

MATERIAL AND METHODS

In this prospective study, 23 patients who underwent a single session of microneedle RF device (GENIUS, Lutronic Co., Korea) therapy for SP were enrolled. Histopathological features were assessed 1 week before and 8 weeks after therapy. The total amount of collagen and elastic fibers were measured using the computer vision method, and epidermal thickness and the number of blood vessels were analyzed using ImageJ. The clinical improvements were evaluated by blinded evaluators and the patients using investigator global assessment (IGA) and patient global assessment (PGA), respectively. Data regarding the number of purpuric lesions and the size of the largest lesion were collected via a telephone survey.

RESULTS

The total amount of collagen and elastic fibers, and mean epidermal thickness tended to improve after RF treatments, although they did not reach statistical significance. The locally estimated scatterplot smoothing curve showed decreasing tendency in both size and number of purpuras as weeks progressed. PGA showed very satisfied in 65% of patients and IGA showed 39% near-total improvement and 43% marked improvement. There were no serious adverse events.

CONCLUSIONS

Microneedle RF therapy induces remodeling of dermal circumstances with minimal epidermal impairment. It may be a promising therapeutic option for SP.

Skin Graft Donor Site Healing among Elderly Patients with Dermatoporosis - A Case Series

We reviewed donor site wound healing among morbid ≥65-year-old patients after split-thickness skin graft (STSG) harvesting. Patients were treated for a pretibial laceration or hematoma in Kymenlaakso Central Hospital, Finland, between 2015 and 2019. Twelve morbid patients with a mean Charlson Comorbidity Index of 7.1 (range 4-12) and a mean age of 80.6 years (range 69-91) were studied. Nine patients were female. Eight had a chronic cutaneous fragility syndrome, eg, dermatoporosis. All donor site areas were located on the thigh and were less than 2% TBSA. One donor site infection occurred. STSG integration on the pretibial wound bed was successful with all patients, and none of the patients needed further operative treatment. Graft thickness varied between 0.010 to 0.014 inches. STSG donor sites healed within the normal range of 21 days in 50% of patients. Among two patients, healing took 25 days, and among four, 37 to 97 days. All donor sites healed via local wound care without the need for regrafting. 4Our study indicates that harvesting STSG from elderly and morbid patients with poor skin condition is safe and does not result in significant complications. Prolonged donor site healing can occur, which can be managed with regular local wound care.

Pretibial hematomas – a real-world single centre study

We analyzed treatment, outcome, and risk factors for skin necrosis of 60 patients aged ≥65 years treated for a pretibial hematoma in the province of Kymenlaakso, Finland, between 2015 and 2019. Reviewing patients’ medical records revealed two cohorts with distinct trajectories in outcome. By comparing the cohorts, we were able to discover factors associated with the prognosis for generating skin necrosis and the need for operative treatment.

Thirty-five (58.3%) patients healed without any management, and 25 (41.7%) patients were treated with hematoma evacuation, mostly for having generated skin necrosis (72%). Among operatively treated patients’ descriptions, such as “parchment skin” and “poor skin quality” were observed frequently (80%) in the medical records. This pathology, dermatoporosis, was statistically significant (p<0.0001) among patients with a complicated outcome of a pretibial hematoma. In addition to dermatoporosis, patients with hematoma evacuation were more fragile having a higher Charlson comorbidity index (p = 0.005), a greater need for a walking aid (p = 0.0002), and overall compromised independency (p = 0.033). Hospitalization and rehabilitation were prolonged in the operatively treated cohort, 6.4 days vs. 2 days, respectively.

We recorded a delay in the diagnosis and hematoma evacuation (mean 6, range 0–51 days). In addition, six (10%) patients were misdiagnosed for having erysipelas or deep vein thrombosis indicating that pretibial hematomas are not recognized. Skin quality should be documented, and prompt surgical hematoma evacuation should be executed in fragile patients with dermatoporosis. This could prevent skin necrosis and the further need of wound care or surgical care, long hospitalization, and rehabilitation periods.

Vitamin D and Vitamin D Analogs as Adjuncts to Field Therapy Treatments for Actinic Keratoses: Current Research and Future Approaches

Actinic keratoses (AK), also known as solar keratoses, are precancerous hyperkeratotic papules caused by long-term exposure to ultraviolet radiation. Management of AK prior to progression to cutaneous malignancy represents an important window of intervention. This is important on a population level, given the high incidence, morbidity, financial costs, and the low but measurable risk of mortality from cutaneous neoplasia. Treatments for AK have been refined for many years with significant progress over the past decade. Those recent advancements lead to questions about current treatment paradigms and the role of harnessing the immune system in field therapies. Recent studies suggest a key interplay between vitamin D and cancer immunity; in particular, the systemic and/or topical vitamin D analogs can augment field therapies used for severe actinic damage. In this review, we will examine the literature supporting the use of vitamin D-directed therapies to improve field therapy approaches. An enhanced understanding of these recent concepts with a focus on mechanisms is important in the optimized management of AK. These mechanisms will be critical in guiding whether selected populations, including those with immunosuppression, heritable cancer syndromes, and other risk factors for skin cancer, can benefit from these new concepts with vitamin D analogs and whether the approaches will be as effective in these populations as in immunocompetent patients.

Deep dissecting haematoma in patients with dermatoporosis: implications for home nursing

Dermatoporosis is a chronic cutaneous insufficiency/fragility syndrome with a high prevalence in older adults. Dermatoporotic skin becomes thin and fragile and tends to tear. It may lead to deep dissecting haematomas (DDHs) as a final stage of dermatoporosis, which is a clinical emergency. Management can be challenging, as patients with lower-limb haematomas are frequently older and affected by multiple comorbidities, or are probably on medications that negatively influence wound healing. This article describes the essential role of nurses in prevention, early recognition and wound management of DDHs in patients with dermatoporosis.

Dermatological Toxicities of Bruton's Tyrosine Kinase Inhibitors

The development of Bruton's tyrosine kinase (BTK) inhibitors represents a major breakthrough in the treatment of chronic lymphocytic leukemia and other B cell malignancies. The first-generation inhibitor ibrutinib works by covalent irreversible binding to BTK, a non-receptor tyrosine kinase of the TEC (transient erythroblastopenia of childhood) family that plays a critical role in the B-cell receptor signaling pathway. It also induces an 'off-target' inhibition of a range of other kinases including (but not limited to) epidermal growth factor receptor (EGFR), SRC, and other kinases of the TEC family (interleukin-2-inducible T-cell kinase [ITK], Tec, BMX). Dermatological toxicities are among the most common toxicities of ibrutinib, but remain of mild to moderate intensity in most cases and are readily manageable. Their incidence is highest during the first year of treatment and declines over time. In addition, it has been postulated that ibrutinib-related dermatologic adverse events are mediated by the direct binding to both BTK and other 'off-target' kinases. Bruising, ecchymoses, and petechiae represent the most characteristic dermatologic adverse events. Nail and hair changes are also common, as skin infections (opportunistic infections including herpes simplex and herpes zoster virus reactivations, and Staphylococcus aureus superinfection), folliculitis, and other types of rashes. Panniculitis, aphthous-like ulcerations with stomatitis, neutrophilic dermatosis, peripheral edema, and skin cracking can also occur. Next-generation BTK inhibitors, acalabrutinib and zanubrutinib, have been designed to optimize BTK inhibition and minimize off-target inhibition of alternative kinases (Tec, ITK, EGFR, SRC-family kinases). These drugs have been recently FDA-approved for relapsed or refractory mantle cell lymphoma. Although the overall incidence of their toxicities is expected to be more limited, acalubrutinib and zanubrutinib are associated with a range of dermatologic toxic effects that appear to be similar to those previously described with ibrutinib, including bruising and ecchymoses, panniculitis, human herpesvirus infections, cellulitis, and skin rash. In particular, both drugs induce skin bleeding events in more than 30% of patients treated. However, the available dermatological data are still rather limited and will have to be consolidated prospectively. This review article analyses the wide spectrum of dermatological toxicities that can be encountered with first- and second-generation BTK inhibitors. Finally, recommendations for appropriate treatment as well as a synthesis algorithm for management are also proposed.

The external phenotype of aging

Aging is widely studied as a physiological process. Segmental aging can also occur prematurely in Mendelian disorders, and these can act this way as excellent sources of information, specifically for the underlying mechanisms. Adequate recognition of such aging characteristics in Mendelian disorders needs a well-defined phenotype of aging. Here the external phenotype of aging is described that can be recognized in the consulting room without major additional studies. Existing definitions of the signs and symptoms in Elements of Morphology or Human Phenotype Ontology are added or a new definition is suggested if none is available.

[Cross-sectional study on skin tears in fragile, aging skin: nursing deficits in a common problem in Germany]

Cross-sectional study on skin tears in fragile, aging skin: nursing deficits in a common problem in Germany Abstract. Background: Skin tears are internationally classified as a common phenomenon in elderly people. Methods of prevention, early detection, classification, and specific treatment of skin tears are internationally established. Up to now skin tears have received little attention in Germany, and the present state of studies is insufficient. Aim: The aim of this study was to reveal for the first time the nurses' perspective in Germany concerning skin tears. Methods: A cross-sectional design was conducted in an online survey to ask general and geriatric nurses about frequency, classification systems, terminology, risk factors, prevention, and treatment methods concerning skin tears. Results: With 137 completely answered questionnaires, persons from various nursing disciplines and regions were reached. The incidence of skin tears was rated by 83.2 % of the respondents as common or very common, whereas 37 different terms for skin tears had been used. Numerous risk factors and methods of prevention were named; however, classification systems are hardly known. Knowledge about dressings is partially inadequate. Conclusions: An explicit and standard terminology for the phenomenon "skin tear" as well as the utilization of international classification systems are urgently needed in Germany. Evidence-based treatment and prevention should become standard in Germany. Beginning in nursing school and nursing college, specific education and counselling must be established for nurses as well as for patients and their caregivers.