Skin Disorders in Older Adults: Dermatoses Related to Scratching, Rubbing, and Impaired Epidermal Integrity, Part 2

ABSTRACT: Scratching, rubbing, and impairment of epidermal integrity can produce pathological changes in the skin. Patients who have neurotic excoriations respond to treatment with selective serotonin reuptake inhibitors, which alleviate pruritus independent of their antidepressant effects. Perforating folliculitis is usually associated with renal disease, but it can occur with diabetes or as an isolated finding. UV-B phototherapy can relieve associated pruritus. Chondrodermatitis nodularis chronica helicis (CNH) results from pressure to the ear. Although the diagnosis can usually be made clinically, a biopsy can help rule out basal cell carcinoma and keratoacanthoma, which can mimic CNH. The key to the treatment of intertrigo is to eliminate the friction, heat, and maceration that predispose patients to this disease.

Key words: neurotic excoriation, perforating folliculitis, chondrodermatitis nodularis chronica helicis, hyperkeratosis, intertrigo

The skin is not a passive agent. When manipulated, it reacts to maintain its function and when it cannot do so, a variety of pathological states result.

In this 2-part series, I describe the secondary changes that scratching, rubbing, and impairment of epidermal integrity can produce. The focus is on those conditions that are more commonly found in older adults.

Here I discuss neurotic excoriations, perforating folliculitis, chondrodermatitis nodularis chronica helicis (CNH), hyperkeratosis, and intertrigo. In the first Part (Skin Disorders in Older Adults: Dermatoses Related to Scratching, Rubbing, and Impaired Epidermal Integrity, Part 1), I addressed postinflammatory pigmentary alteration, amyloidosis, lichen simplex chronicus, and prurigo nodularis.

Figure 1 – These erosions and crusts are neurotic excoriations.

NEUROTIC EXCORIATIONS

Repetitive scratching or picking creates neurotic excoriations. This condition can be initiated by a minor skin lesion, such as an insect bite, folliculitis, or acne, but it can also be independent of any pathology. Because there is no significant underlying skin disease, neurotic excoriations are considered a dermatological manifestation of a psychiatric disorder. The scratching or picking is usually episodic and irregular; however, it can be constant.

Figure 2 – Geometric erosions remained after this elderly patient had scratched away the bullae of pemphigus vulgaris. These lesions resemble neurotic excoriations.

Neurotic excoriations feature clean, linear or geometric erosions, crusts, and scars that can be hypopigmented or hyperpigmented (Figure 1). The erosions and scars often have irregular borders and are usually similar in size and shape. They occur on areas that the patient can scratch, particularly the extensor surfaces of the extremities, the face, and the upper part of the back. The distribution is bilateral and symmetrical. In elderly debilitated patients, neurotic excoriations must be distinguished from primary blistering diseases, such as pemphigus vulgaris (Figure 2) and dermatitis herpetiformis, which can manifest with geometric erosions after a patient has scratched away the bullae.

In the treatment of neurotic excoriations, studies have shown that selective serotonin reuptake inhibitors consistently have the greatest antipruritic effect.^1-3 The relief of pruritus is unrelated to changes in the patient's mood and occurs more rapidly than would be expected for antidepressant effects. Because of its sedating and antipsychotic effects, doxepin( (10 to 25 mg PO at bedtime) is also useful in treating neurotic excoriations.

PERFORATING DISEASE

Figure 3 – Central keratotic white-yellow adherent crust on these papules is an easily recognizable feature of perforating disease.

Perforating folliculitis is most commonly associated with renal disease, but it can occur in association with diabetes or as an isolated finding. Trauma, such as that caused by scratching, may play a role in the development of perforating folliculitis.⁴

This disorder is characterized by hyperpigmented papules with a keratotic white-yellow adherent crust (Figures 3 and 4). Microscopic examination reveals disruption of the infundibular portion of the follicular wall, with transepidermal (transfollicular) elimination of connective tissue elements and cellular debris. The papules typically are concentrated on hair-bearing areas of the extremities and buttocks. The lesions are usually asymptomatic, although they can be pruritic, especially in persons with renal insufficiency.

Figure 4 – A larger nodule of perforating disease is evident in this patient.

Perforating folliculitis can wax and wane and persist for months or years. Spontaneous remission can occur, and remission following kidney transplant has been documented in patients in whom perforating folliculitis developed after renal failure.⁵ Treatment with UV-B phototherapy can alleviate associated pruritus and may also result in improvement in the clinical appearance of the condition. Topical corticosteroids are generally not helpful.

CHONDRODERMATITIS NODULARIS CHRONICA HELICIS

Figure 5 – Biopsy confirmed that this tender nodule on an older man's ear was chondrodermatitis nodularis chronica helicis, which can mimic skin cancer.

(Courtesy of Charles E. Crutchfield III, MD, Humberto Gallego, MD, and Eric J. Lewis, MD, PhD.)

This painful inflammatory disease of collagen( occurs mostly in middle-aged and elderly men and results from pressure to the ear. The characteristic lesions are tender papules or nodules of 3 to 20 mm in diameter; they usually have a rolled edge and central dell or erosion with keratotic material at the bottom (Figure 5). The lesions erupt and reach their maximum size quickly and then remain stable in size.

The right ear is affected more frequently than the left, and bilateral distribution occasionally occurs. Lesions develop on the most prominent projection of the ear, typically the apex of the helix. In women, the lesions are most commonly found on the antihelix.

CNH occurs in persons who sleep predominantly on one side. It can be precipitated by minor trauma, such as from tight headgear or a telephone headset, or by exposure to cold. Reduction in the local blood supply of the ear—caused, for example, by aging—prevents adequate healing. Although the diagnosis can usually be made clinically, a biopsy can help rule out basal cell carcinoma and keratoacanthoma, which can mimic CNH.

Therapy involves the elimination of pressure to the lesion. Such behavior modification is often challenging because of patient preference or habit. A pressure-relieving cushion can be made by cutting a hole in the center of a bath sponge; it can then be held in place with a headband. Special prefabricated pillows that help relieve pressure on the ear are also available.

Surgical options for the treatment of CNH include cryotherapy, wedge excision, curettage, electrocauterization, carbon dioxide laser ablation, and excision of the involved skin and cartilage. I have found curettage and electrocauterization to be effective; however, some reports suggest it may not result in a consistent cure.⁶

HYPERKERATOSIS

Figure 6 – Hyperkeratosis is one of the most common disorders that affect the foot, particularly in obese persons.

Hyperkeratosis of the foot. This is one of the most common disorders that affect the foot (Figure 6), particularly in obese persons.⁷ Mechanical forces and hereditary factors contribute to the development of hyperkeratosis. Thickening of the outermost layer of the epidermis occurs over sites that experience increased pressure or friction. Urea( 40% cream is a helpful treatment for this condition.

Corns and calluses. Helomata (corns) and tylomata (calluses) are common hyperkeratotic lesions. These papules, nodules, and plaques can erode, and ulcers can result, particularly in elderly patients.

Unlike a wart, a corn is not characterized by a change in dermoglyphics. This painful, well-demarcated callosity is found over a bony prominence of the foot or on the toe (Figure 7). Soft corns between the toes can lead to maceration and cellulitis.

Figure 7 – This painful, well-demarcated callosity occurred on the toe of a man who wore ill-fitting shoes.

A callus usually affects the sole of the foot. The ball of the foot and margins of the heel are most susceptible to the development of these broad plaques.

Changing the patient's shoes and gait to decrease unnecessary pressure and friction can ameliorate corns and calluses. If conservative treatment is ineffective, consider surgery.

INTERTRIGO

Figure 8 – Obesity predisposed this patient to intertrigo, which can occur at any site where skin surfaces rub against each other.

Impairment of the integrity of the epidermis results in intertrigo, which can occur at any site where tissue folds are apposed and the skin surfaces rub against each other. Pink to brown erythema, maceration, and erosions characterize the disorder (Figure 8). Symptoms can include burning, itching, and stinging.

Risk factors for intertrigo include the following:

Figure 9 – Candidiasis, seen here in a woman's axilla, can mimic or occur concurrently with intertrigo.

Moisture and warmth are needed for intertrigo to develop and progress. Sweat, feces, urine, vaginal secretions, or wound drainage can provide the moisture. Secondary infection may develop, most commonly with Candida but Staphylococcus aureus infection or herpes simplex can also occur.⁸

The following studies may be useful in the evaluation:

In addition, order appropriate laboratory tests if diabetes, acrodermatitis enteropathica, or necrolytic or migratory erythema secondary to a glucagonoma is suspected.

Intertrigo can be treated initially with nystatin and Polysporin (bacitracin and polymyxin B( sulfate) powders in combination. If this is ineffective, use—either alone or in combination—weak topical corticosteroid cream; drying agents, such as Domeboro (aluminum sulfate and calcium acetate() soaks or Castellani Paint Modified (carbol-fuchsin); or topical antibiotic or antifungal creams. Avoid potent corticosteroids in intertriginous areas because they may cause skin thinning, which can result in striae and even ulcers. Calcineurin inhibitors such as tacrolimus ointment and pimecrolimus( cream reduce inflammation without causing skin atrophy; however, they are very expensive and the drug packaging carries a warning about the risk of inducing skin cancer.

Barrier agents are also useful in the treatment of intertrigo. Options include: