Cutaneous signs of internal malignancy. A pictorial essay

The skin is a window of internal malignancies and other diseases. The cutaneous signs of internal malignancy can be divided into four major groups: (1) hypersensitivity or toxic reactions, (2) infections, (3) metabolic disorders, and (4) tumors. A diagnosis of the many signs of systemic malignancy is made by inspection, history taking, and skin biopsy. Hypersensitivity reactions or nonspecific cutaneous changes in middle-aged or elderly patients should arouse suspicion of internal malignancy. Likewise, sudden onset of a cutaneous tumor in an elderly patient should alert the attentive observer to the possibility of cancer.     

Subacute cutaneous lupus erythematosus: a decade's perspective

Based upon the rather large worldwide experience that has been published recently, it would appear that the concept of subacute cutaneous LE as presented in our original reports starting 10 years ago is still a viable one. However, we must now also consider the possibility that these patients will occasionally develop other types of autoimmune disorders such as rheumatoid arthritis and Sj?gren's syndrome and, on occasion, have their skin disease triggered by drugs such as hydrochlorothiazide. However, the majority of these patients will have recurrent skin disease activity and musculoskeletal symptoms as the major manifestations of their illness. Although most of these patients do have a relatively mild disease course, a small percentage seem to be at risk for developing potentially life-threatening complications of systemic LE. The future challenge in this area lies in identifying prognostic features that may correlate with this more aggressive disease course so that this subgroup of patients can be more efficiently managed. Our preliminary studies have suggested several candidates for further study: the papulosquamous/psoriasiform subacute cutaneous LE lesional subtype; development of acute cutaneous LE; resistance to antimalarials alone; leukopenia; high titer ANA; and the presence of circulating double-stranded DNA antibodies. Another possibility may include the rate of systemic disease onset. Discoid LE patients who have not developed clinically significant SLE manifestations within the first 2 years of the appearance of their skin lesions have a very low risk for suffering from severe SLE complications later in their disease course. The same question might be asked of subacute cutaneous LE. In addition, some subacute cutaneous LE patients have a single episode of disease activity followed by long-term, if not permanent, remission. More needs to be learned about this more benign pattern of illness in the hope of identifying favorable prognostic signs. Our impressions regarding subacute cutaneous LE disease outcome have mostly come from retrospective or point-prevalence types of clinical analyses; more prospective examinations of large groups of patients will be required to better address the issue of prognosis in subacute cutaneous LE. The data published to date suggest that this is a relatively homogeneous group of patients immunogenetically: they frequently have circulating anti-Ro auto-antibodies and often possess the HLA-DR3 phenotype. Much circumstantial evidence indicates that this particular genetically determined autoimmune response might be directly participating in pathogenesis of this form of LE-specific skin injury.(ABSTRACT TRUNCATED AT 400 WORDS)     

Zinc in the elderly

Zinc levels in plasma and leucocytes of elderly patients with and without cutaneous ulcers and in hospital were compared with those of a group of healthy elderly living at home and of a younger group. The groups in hospital had lower levels of plasma and leucocyte zinc than the control groups, but these were not associated with cutaneous ulcers. The zinc intake of the patients in hospital was well below the recommended daily allowance. Tissue zinc levels were found to be low in elderly patients in hospital, probably due to poor intake, but their contribution to the formation of skin ulcers was unproven.     

Cutaneous paraneoplastic syndromes

Paraneoplastic syndromes are caused by hormones or other substances produced by cancer cells and may be the first sign of cancer. A wide range of paraneoplastic syndromes, including endocrine, neurologic, and cutaneous disorders, occurs in patients with cancer. More than 30 cutaneous paraneoplastic syndromes have been identified; this article reviews some of the more common syndromes--acanthosis nigricans, Paget's Disease, acquired ichthyosis, telangiectasia, hypertrichosis lanuginosa acquisita, erythroderma, Bazex's Syndrome, and necrotizing migratory erythema. When these syndromes are diagnosed during the course of a malignancy, professional caregivers may misinterpret them as indicative of metastatic disease or other disorders and patients may be misdiagnosed and not receive optimal treatment. Paraneoplastic syndromes also compromise quality of life by often causing skin impairment and discomfort. Therefore, nurses must be aware of the signs and symptoms of these cutaneous disorders and know how to care for patients with paraneoplastic syndromes.     

Aging: laboratory testing and theories.

OBJECTIVE: To review theories of aging and the changes in laboratory test results that occur because of physical changes in the normal elderly patient. DATA SOURCES: Books on aging, laboratory test interpretation, and nutrition as well as published articles on aging, vitamins, and nutrition. STUDY SELECTION: Elderly people. DATA EXTRACTION: Survey of the literature. DATA SYNTHESIS: Aging theories may present possible aspects of the effects of aging on health in the elderly. Normal aging may lead to physical changes that alter laboratory test results without causing disease. Treatment of these "abnormal" results in the elderly may be detrimental to their health. CONCLUSION: As the elderly population increases, laboratorians will encounter an increasing number of elderly patients. Discriminating between truly abnormal test results and those caused by aging will require laboratory reevaluation of adult reference ranges.     

Dysplastic epidermal change in immunosuppressed patients with renal transplants

The prevalence of non-melanoma skin cancer has been studied in a group of 85 patients who have undergone renal transplantation. We also investigated the relationship between the development of neoplastic lesions and the duration of immunosuppression, previous sun exposure and infection with human papilloma virus. The overall prevalence of neoplastic and pre-neoplastic epidermal lesions in the group was 25 per cent, higher than that previously reported in studies from the United Kingdom. In patients who had survived for more than 80 months after transplantation the prevalence of these lesions was 38 per cent. There was no apparent relationship between sun exposure or skin type and the development of cutaneous neoplasia, despite the fact that the majority of lesions were found on sun-exposed sites. Exposure to ultraviolet radiation (UVR) is probably important as an initiator or co-factor rather than as a precipitant. In both sexes, high sun exposure was associated with the presence of viral warts. In females, there was a strong association between the presence of viral warts and the occurrence of neoplastic lesions elsewhere, giving support to the hypothesis that ultraviolet radiation may be acting as a co-factor in virally-mediated oncogenesis. Epidermal cell kinetic studies in 39 patients using in-vitro exposure to 3H thymidine and autoradiographic techniques showed no difference between the patients with neoplastic lesions and unaffected patients, and is not therefore a useful method of identifying an 'at risk' group.     

Peripheral nerve dysfunction in scleroderma.

Peripheral neuropathy in patients with scleroderma is thought to be rare. We have undertaken a quantitative assessment of peripheral nerve function in 29 patients with either limited cutaneous scleroderma or progressive systemic sclerosis. Tactile thresholds were raised in the fingers in 28 per cent of patients and in the foot in 50 per cent. Two-point discrimination was abnormal in 10 patients, thermal thresholds were abnormal in five and vibration thresholds were abnormal in one. Nerve conduction studies showed abnormalities in six patients, five of whom had clinical signs of a mild peripheral neuropathy: the mean duration of disease in these six patients was 10 years longer than that in the remainder of the patients. There was electrophysiological evidence of a subclinical carpal tunnel syndrome in two patients. The sympathetic skin response was recorded in 16 patients who had not been subjected to sympathectomy for Raynaud's phenomenon, and was abnormal in four. These results indicate that peripheral nerve dysfunction in scleroderma, though mild, is not as uncommon as previously thought. The abnormal cutaneous sensory thresholds may be partly due to altered viscoelastic properties of the skin, but abnormal responses in the lower limbs to tests of tactile sensitivity, the clinical findings and the disturbances of nerve conduction argue in favour of an additional neuropathic process in some patients. Low grade distal nerve trunk ischaemia may be responsible.     

Zinc in the Elderly

Zinc levels in plasma and leucocytes of elderly patients withand without cutaneous ulcers and in hospital were compared withthose of a group of healthy elderly living at home and of ayounger group. The groups in hospital had lower levels of plasmaand leucocyte zinc than the control groups, but these were notassociated with cutaneous ulcers. The zinc intake of the patientsin hospital was well below the recommended daily allowance. Tissue zinc levels were found to be low in elderly patientsin hospital, probably due to poor intake, but their contributionto the formation of skin ulcers was unproven.     

Sun-induced disorders

Photosensitivity diseases frequently occur as a result of sun exposure in individuals with inherited and acquired disorders. Several of these disorders may manifest acute cutaneous manifestations that bring the patient to the emergency room. The more common disorders that may be seen in this setting include sunburn, lupus erythematosus, porphyria, photosensitivity dermatitis, and polymorphous light eruption. The diagnosis can frequently be suspected on the basis of a careful history and physical examination. Specialized diagnostic procedures available to the dermatologist may assist in making the correct diagnosis. Effective treatment is available for many of these disorders.     

Dysplastic Epidermal Change in Immunosuppressed Patients with Renal Transplants

The prevalence of non-melanoma skin cancer has been studiedin a group of 85 patients who have undergone renal transplantation.We also investigated the relationship between the developmentof neoplastic lesions and the duration of immunosuppression,previous sun exposure and infection with human papilloma virus.The overall prevalence of neoplastic and pre-neoplastic epidermallesions in the group was 25 per cent, higher than that previouslyreported in studies from the United Kingdom. In patients whohad survived for more than 80 months after transplantation theprevalence of these lesions was 38 per cent. There was no apparentrelationship between sun exposure or skin type and the developmentof cutaneous neoplasia, despite the fact that the majority oflesions were found on sun-exposed sites. Exposure to ultravioletradiation (UVR) is probably important as an initiator or co-factorrather than as a precipitant. In both sexes, high sun exposurewas associated with the presence of viral warts. In females,there was a strong association between the presence of viralwarts and the occurrence of neoplastic lesions else where, givingsupport to the hypothesis that ultraviolet radiation may beacting as a co-factor in virally-mediated oncogenesis. Epidermal cell kinetic studies in 39 patients using in-vitroexposure to ³H thymidine and autoradiographic techniques showedno difference between the patients with neoplastic lesions andunaffected patients, and is not therefore a useful method ofidentifying an ‘at risk’ group.     

Dry skin in older adults

Dry skin is a common problem in the older individual due to physiological changes of the aging process as well as chronic health conditions. Dry skin can worsen if management is inappropriate or lacking. Nursing management of dry skin in the elderly is comprehensive including applying topical products to replenish lipids and reduce water loss, maintaining or increasing fluid intake, limiting sun exposure, and reducing symptoms of chronic illnesses.     

Sun Protection for Preventing Basal Cell and Squamous Cell Skin Cancers

Review question: What is the most effective form of sun protection (including sunscreens) to prevent basal cell carcinoma and cutaneous squamous cell carcinoma of the skin?     

Common skin disorders in the elderly

Skin diseases commonly seen in the elderly are more often than not the effects of sun damage or vascular disease. The effects of a lifetime of even casual sun exposure can be dramatic. Chronically sun-exposed skin becomes thin, loses collagen, and has disrupted elastin and decreased glycosaminoglycans. The result is skin that breaks easily, bruises, sags, irritates easily, and itches. The spots and bumps that patients associate with age are all sun-induced. Consider how lesionless a 60-year-old's buttock is compared to the extensor forearm. The reason that bruising attributed to anticoagulation seems to occur exclusively on the extensor forearm and not the volar aspect of the arm is that sun-induced elastin degradation is greatest on the extensor forearm. Even trivial trauma will cause unsupported capillaries to shear and bleed whether the patient is anticoagulated or not. This article reviews the primary skin disorders associated with the elderly and some of the management approaches that the primary care physician can use.     

Common skin disorders in the elderly

Skin diseases commonly seen in the elderly are more often than not the effects of sun damage or vascular disease. The effects of a lifetime of even casual sun exposure can be dramatic. Chronically sun-exposed skin becomes thin, loses collagen, and has disrupted elastin and decreased glycosaminoglycans. The result is skin that breaks easily, bruises, sags, irritates easily, and itches. The spots and bumps that patients associate with age are all sun-induced. Consider how lesionless a 60 year-old's buttock is compared to the extensor forearm. The reason that bruising attributed to anticoagulation seems to occur exclusively on the extensor forearm and not the volar aspect of the arm is that sun-induced elastin degradation is greatest on the extensor forearm. Even trivial trauma will cause unsupported capillaries to shear and bleed whether the patient is anticoaguaated or not. This article reviews the primary skin disorders associated with the elderly and some of the management approaches that the primary care physician can use.     

Clinical indicators of dehydration severity in elderly patients.

STUDY OBJECTIVE: To determine which of the signs and symptoms of dehydration obtainable from patient history and physical examination in the emergency department are most useful in assessing the severity of dehydration in elderly patients. DESIGN: Prospective, correlational study. SETTING: Two university teaching hospitals. Patients: Fifty-five patients aged 60 or older presenting to the emergency department with suspected dehydration were studied. MEASUREMENTS AND MAIN RESULTS: In the emergency department, patients were evaluated by a standardized history and physical examination that included assessment of 38 signs and symptoms commonly attributed to dehydration. The relationships between the presence and intensity of these putative dehydration indicators and an independent rating of dehydration severity based on a comprehensive review of the medical record were evaluated. Also evaluated were the relationships between these dehydration indicators and patient age. Indicators that correlated best with dehydration severity but were unrelated to patient age included: tongue dryness (P less than 0.001), longitudinal tongue furrows (P less than 0.001), dryness of the mucous membranes of the mouth (P less than 0.001), upper body muscle weakness (P less than 0.001), confusion (P less than 0.001), speech difficulty (P less than 0.01), and sunkenness of eyes (P less than 0.01). Other indicators had only weak associations with dehydration severity or were also related to age. Patient thirst was unrelated to dehydration severity. CONCLUSIONS: A set of signs and symptoms related to dehydration severity in elderly patients has been identified. These indicators may be more useful for evaluation of dehydration severity in the emergency department than other commonly used indicators.     

Rehabilitation considerations of prosthetic fittings for Kaposi's sarcoma amputees

Purpose: We report on cutaneous limb manifestations of Kaposi's sarcoma and the secondary infection of these lesions that necessitated five lower-limb amputations. Method: The cases are briefly described and prosthetic adaptations in respect to pressure, traction and sweating on the skin are considered. Results: All four patients ambulated initially; one lady died, the double amputee stopped walking owing to the excessive physical demand, and two patients ambulate freely. Conclusion: Special considerations to the cutaneous/prosthesis interface are necessary in order to provide these patients with optimal ambulatory ability.     

Rehabilitation considerations of prosthetic fittings for Kaposi's sarcoma amputees

Purpose : We report on cutaneous limb manifestations of Kaposi's sarcoma and the secondary infection of these lesions that necessitated five lower-limb amputations. Method : The cases are briefly described and prosthetic adaptations in respect to pressure, traction and sweating on the skin are considered. Results : All four patients ambulated initially; one lady died, the double amputee stopped walking owing to the excessive physical demand, and two patients ambulate freely. Conclusion : Special considerations to the cutaneous/prosthesis interface are necessary in order to provide these patients with optimal ambulatory ability.     

Behavioural first aid for elderly cats and dog

ABSTRACT:

Ageing is part of life and, as veterinary care improves, we can expect to see increasing numbers of elderly pets being presented at veterinary practices. Care of the geriatric pet has become a major part of the veterinary nurse's role, with many practices running nurse-led geriatric clinics. Despite this, owners remain reticent to present the older pet – concerned that any visit to the practice may be the last – leading to many elderly pets living in discomfort and depleted welfare. As in so many cases, behavioural changes can be the first signs of physical problems and the veterinary nurse plays a vital role in identifying the elderly dog that requires support.     

An audit of rectal examination on general/geriatric wards in a district general hospital

A study of 187 in-patients on designated medical/geriatric wards revealed that rectal examination was performed as part of physical examination in only 25% of patients. In the elderly (118 patients) it was performed in 36%. A prospective analysis of 100 elderly patients, in whom digital rectal examination was performed, revealed that 46 patients had significant findings. In only 33 of these were there any gastrointestinal or genitourinary symptoms or signs. As a result of these findings it is recommended that digital rectal examination be considered mandatory in the elderly admitted into hospital.