What you need to know about common skin problems in older adults.

Skin ageing is a multifaceted process impacted by both intrinsic and extrinsic factors. Drier and less elastic skin with declining sebum levels in older age makes ageing skin more vulnerable to various skin conditions, including infections, inflammatory dermatoses, and cancers. Skin problems are common among older adults due to the effects of ageing, polypharmacy and multimorbidity impacting not only physical health but wellbeing and quality of life. In the UK, older adults in geriatric medicine wards may present with various skin conditions. Hospitalised older individuals may have undiagnosed skin problems unrelated to their admission, making hospitalisation an opportunity to manage unmet needs. Asteatotic eczema, incontinence associated dermatitis, seborrhoeic dermatitis, chronic venous insufficiency, and cellulitis are common disorders clinicians encounter in the geriatric medicine wards. This article outlines the importance of performing comprehensive skin assessments to help diagnose and commence management for these common conditions.

A novel cause of erythromelalgia due to pseudoephedrine.

Objective: Erythromelalgia is a rare, highly debilitating disorder characterised by severe episodes of discomfort, erythema, and desquamation of the extremities. Its causes include genetic factors, medications, and several underlying medical conditions. This paper describes a novel cause of erythromelalgia through a case report and literature review. Case description: A 47-year-old Caucasian man presented with a two-year history of intermittent pain, redness and desquamation of the hands. He experienced several such episodes, each lasting 3-4 weeks. A skin biopsy confirmed the diagnosis of erythromelalgia. After several recurrences, he admitted to the intermittent use of pseudoephedrine as a nasal decongestant, which coincided with the episodes of erythromelalgia. Complete resolution of symptoms was reported on cessation of this medication. Conclusion: Pseudoephedrine has been reported to cause a wide range of cutaneous reactions but has not been known to precipitate erythromelalgia. Recognition of this rare side effect may offer early diagnosis and reduced morbidity.

Reply to: Erosive balanitis caused by Staphylococcus haemolyticus in a healthy, circumcised adult male.

In this short letter of correspondence, we provide our specialist interpretation of what has been described in a previously published case report. We argue that this case describes a patient with chronic, undertreated male genital lichen sclerosus. If left unchecked, as in this case, lichen sclerosus can cause permanent architectural changes and damage to the affected tissues, and can thus predisposes to secondary infections, including bacterial, such as with Staphylococcus haemolyticus.

Nailbed HPV-related Bowen's disease in a man living with HIV.

Human papillomavirus (HPV) is a common sexually transmitted infection with wide-ranging clinical manifestations. High-risk anogenital HPV genotypes have also been reported to cause extragenital disease. We describe the case of a 69-year-old male patient living with HIV who was diagnosed with HPV-16 associated Bowen's Disease (BD) of the right middle finger nailbed, despite good virologic control and immune reconstitution. The lesion was managed surgically with adjunctive post-exposure HPV vaccination. This case adds to the growing body of evidence of extra-genital HPV disease attributable to anogenital genotypes in people living with HIV.

Primary penile melanoma and genital lichen sclerosus.

Background: There is a well-established association between squamous cell cancer and genital lichen sclerosus (GLSc). Although there have been several reported cases of vulval melanoma (MM) associated with LSc, particularly in the paediatric population, fewer cases of male genital (M) GLSc and penile (Pe)MM have been published. Objectives: The aim of this study was to explore further the relationship between PeMM and MGLSc by reviewing all the cases managed by our multidisciplinary service over a finite period. Methods: All patients known to our tertiary urology and male genital dermatology service with a diagnosis of PeMM and where histology was available for review were identified over an 11-year period (2011-2022). The histology was reviewed by two independent, mutually 'blinded' histopathologists. Photographs and clinical notes, where available, were retrospectively reviewed by two independent dermatologists for signs or symptoms of LSc. Results: Eleven patients with PeMM were identified for review. Histopathological examination found evidence of LSc in nine patients, and review of clinical photos corroborated the presence of LSc in three. Overall, features of LSc were present in nine out of eleven cases (82%). Conclusion: The presence of LSc in 9 out of 11 cases of PeMM is suggestive of a causative relationship between LSc and PeMM. This may be due to chronic melanocytic distress created by chronic inflammation secondary to LSc.

Genital lichen sclerosus and melanoma; a systematic review.

Background: Lichen sclerosus (LSc) is a chronic, inflammatory, destructive skin disease with a predilection for the genitalia (GLSc). An association with vulval (Vu) and penile (Pe) squamous carcinoma (SCC) is now well established but melanoma (MM) has only rarely been reported complicating GLSc. Methods: We have performed a systematic literature review of GLSc in patients with genital melanoma (GMM). Only articles that mentioned both GMM and LSc affecting either the penis or vulva were included. Results: Twelve studies with a total of 20 patients were included. Our review shows that an association of GLSc with GMM has been more frequently reported in women and female children than men viz, 17 cases compared with three. It is notable that five of the cases (27.8%) concerned female children aged under twelve. Discussion: These data suggest a rare association between GLSc and GMM. If proven, there arise intriguing questions about pathogenesis and consequences for counselling of patients and follow-up.

The association between penile cancer and HIV infection: A literature review.

Penile cancer is a rare malignancy which HIV infection appears to increase the risk of. The magnitude of this risk and the pathogenesis remain unclear. A comprehensive review of the literature was undertaken using conventional search strategies. Twenty-four publications were identified by this methodology, of which nine were case reports and 15 were observational studies. These studies were highly heterogeneous, with varying study designs, populations, and objectives. The risk of penile cancer within HIV-positive individuals is significantly greater than in those without HIV (RR = 3 .7 to 5.8, 3 studies; SIR = 3.8 to 11.1, 4 studies). HIV is also shown to influence disease characteristics, with a four-fold increased risk of death from penile cancer. Moreover, progression from intraepithelial neoplasia occurs earlier in HIV, six years sooner than in HIV-negative men. HIV-positive men have a higher prevalence of HPV infection. Ethnicity is also shown to modulate the relationship between HIV and penile carcinoma, with a higher risk of cancer in Hispanic, compared with Caucasian, HIV-positive men. This review has collated data from diverse sources to improve understanding of the relationship between HIV and penile cancer. This relationship has been quantitatively and qualitatively characterised and highlights areas deserving further enquiry.

Male genital lichen sclerosus, microincontinence and occlusion: mapping the disease across the prepuce.

BACKGROUND: Male genital lichen sclerosus (MGLSc) can lead to significant sexual dysfunction and urological morbidity, and is also a risk factor for premalignant disease (penile intraepithelial neoplasia and penile cancer), particularly squamous cell carcinoma. Although the precise aetiopathogenesis of MGLSc remains controversial, accumulated evidence indicates that it is related to chronic, intermittent, occluded exposure to urine. AIM: To perform spatial mapping of MGLSc across the human prepuce and assess how this supports the urinary occlusion hypothesis. METHODS: Preputial samples were collected from 10 patients with clinically diagnosed MGLSc undergoing circumcision. The samples were then divided into a grid pattern and 10 punch biopsies were obtained from each section to determine the extent and distribution of the disease process across each prepuce. RESULTS: All 10 patients reported having urinary microincontinence, and all were histologically confirmed as having MGLSc. The most proximal aspect of the prepuce was found to be universally affected by MGLSc in all patients, whereas the most distal part was overwhelmingly shown to be the least affected area. Of the 63 MGLSc-affected regions, 62 were in direct physical contiguity with one another. The histological extent of the disease was not found to be congruent with either the severity of the symptoms reported by the patients or the clinical examination. CONCLUSION: In uncircumcised men with urinary microincontinence, after the prepuce has been replaced post micturition, small amounts of urine can pool between the juxtaposed epithelial surfaces. The proximal aspect of the prepuce is subjected to the maximum amount of occlusion and maximal contact with accumulated urine, whereas the distal prepuce is subjected to the least. Our findings suggest that accentuated contact between urine and susceptible penile epithelium due to occlusion can lead to MGLSc. Furthermore, contiguity data suggest that once established, it is possible that MGLSc advances across tissues by physical contact. This is the first study examining the changes in the preputial landscape in patients with LSc and contributes to our understanding of disease aetiology and progression.

Extragenital lichen sclerosus arising in tattooed skin.

Lichen sclerosus (LSc) is a chronic inflammatory condition commonly affecting the anogenital area, with extragenital involvement seen in less than 1%-20% of cases. Concomitant extragenital and genital LSc is extremely rare in male patients. The Koebner phenomenon is a recognised feature of LSc; here we present a rare case of extragenital LSc occurring in tattooed skin.

Factors that predict complex reconstructions in facial skin cancer surgery.

There is a paucity of high-quality evidence and guidelines on the prediction of skin defect reconstruction, and the type of repair rests on the operating surgeon's experience and skill. Mismatches between planning and execution can have negative consequences on resources, staff, and patient counseling. To investigate the factors that predict complex reconstruction in facial skin cancer surgery, we performed a retrospective study collecting information on the several parameters that may affect the method of reconstruction. A total of 325 cases were included. Only the factors tumor size (Z = 2.54; P < .05) and predicted repair plan (Z = 2.73; P < .01) were found to be significant predictors of complex repairs. When broken down by site and size, only the nose, scalp, and temple demonstrated a significant correlation between tumor size and the need for complex repairs. Clinical judgment at the time of initial examination is by far the greatest predictor of complex repairs. This occurs even when clinicians have heterogeneous surgical skills, and most are not technically versed in complex repairs. Increasing tumor size was also found to be an independent risk factor albeit only at certain body sites such as the temple, scalp, and nose.

Is there an association between isotretinoin therapy and adverse mood changes? A prospective study in a cohort of acne patients.

Background: Treatment with isotretinoin has been associated with adverse mood changes. However, even though a number of studies support this association, others refute it, and a concrete causal link has yet to be proven. Acne itself is associated with depressive symptoms, thus making studies on the topic difficult to design and interpret. Objectives and methods: Using validated tools, we performed a prospective study in order to assess the effects of treatment with isotretinoin on the mood of patients with acne vulgaris. Results: Fifty-six patients were included with a mean age of 21 years. At baseline, questionnaire scores for all measured parameters were indicative of lower mood than published norms. During and after treatment, values of either stable or improving mood were displayed across all questionnaires. Three patients developed significantly deteriorating moods, two of whom also experienced severe physical adverse effects. Conclusion: The relationship between isotretinoin and depression is the most debated aspect of isotretinoin therapy. Our results link isotretinoin to an overall improvement in psychological wellbeing, even in patients suffering with stable mental illness. However, we also found that a small minority of patients are susceptible to severe mood deterioration, particularly in conjunction with severe physical side effects.

The use of energy devices in the treatment of striae: a systematic literature review.

BACKGROUND: Striae distensae are caused by rapid stretching of the skin. They are often secondary to obesity or pregnancy and can lead to significant cosmetic disfigurement. AIM: To determine the efficacy, indications, and side effects of commonly used energy devices in the treatment of striae. METHODS: A comprehensive literature search was performed using the PubMed and Medline databases. RESULTS: A total of 41 relevant articles were identified. Radiofrequency (RF) was the commonest employed modality (11 studies), followed by the CO2, and pulsed dye lasers (10 and 5 studies, respectively). The best results against striae alba were seen with a combination of RF, platelet-rich plasma and ultrasound (either excellent or very good results in 71.9%), followed by intense pulsed light in isolation (very good results in 40%). The response of SR was assessed by fewer studies. The best outcomes were seen after treatment with either the Nd:YAG (excellent results in 40% and good in 40%) or Er:Glass lasers (excellent results in 10% and good in 20%). CONCLUSIONS: The therapeutic measures for striae are multiple and no current treatment offers consistent and complete resolution. However, energy devices are a safe and potentially effective modality in the treatment of striae.