Foy White-Chu, MD, Geriatric Fellow, Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Madhuri Reddy, MD, MSc, Department of Medicine, Director of the Chronic Wound Healing Program, Hebrew Rehabilitation Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA; Director, Wound Healing Clinic, Lahey Clinic, Burlington, MA, USA.

The skin of older adults undergoes intrinsic aging and is susceptible to multiple ailments. Both comorbidities and environmental issues increase the risk for particular skin diseases among older adults who live in long-term care facilities. This article looks at four common skin conditions frequently found among older adults living in long-term care facilities, and reviews methods of treatment and prevention.
Key words: skin, wound, skin tear, scabies, incontinence dermatitis.

The focus of this issue is on our largest and most visible organ, the skin. In this era of preventive medicine, it seems easy to tell our patients how to prevent skin problems: just stay out of the sun! However, the importance of sun exposure and vitamin D levels is becoming more and more apparent. Epidemiological evidence showing inverse relationships between multiple sclerosis and sun exposure has been available for years, and more recent evidence suggests that sun exposure may protect against juvenile (type I) diabetes mellitus. In adult populations, vitamin D may be important in preventing various neoplasias, and among older adults, it is protective against falls. It seems that once again, the more I learn the less I seem to know for sure. In any event, this month’s issue will provide lots of opportunity for useful learning. Our CME article this month is on “Common Skin Conditions among Older Adults in Long-Term Care” by Dr. Foy White-Chu and Dr. Madhuri Reddy. We have an article on “Older Adults and Burns” by Dr. Joel Fish and Dr. Kristen Davidge, and then in recognition of how much we value our looks, we have an article on “Facial Rejuvenation in the Aging Population” by Dr. Jeffrey Fialkov. As well, our cancer column this month is on a cutaneous malignancy, namely “Malignant Melanoma among Older Adults” by Drs. Wey Leong, Alexandra Easson and Michael Reedijk.

As well, we have our usual collection of articles on other important topics concerning older adults. “The Role of Peripheral Arterial Disease in the Pathogenesis of Diabetic Foot Disease: When to Refer for Vascular Surger” is by Dr. Robert Hinchcliffe and Dr. William Jeffcoate and provides practical advice to the primary care physician. Our Dementia column this month looks at “Dementia Related to Alcohol and Other Drugs” and is by Dr. Kiran Rabheru. Decubitus ulcers are a major health care problem among older adults, with multiple factors involved in their etiology and pathogenesis. A major factor is discussed in the article “The Role of Nutrition in the Prevention and Management of Pressure Ulcers” by Zena Moore and Dr. Seamus Cowman. As our population of patients with end-stage renal disease ages, the population undergoing transplantation is also aging. Combined with the prolonged survival that many patients currently experience after transplantation, we are seeing many more older renal transplant recipients. Some of the issues these patients present with are discussed in the article “Primary Care Issues in Renal Transplant Recipients” by Dr. Jeffery Schiff.

Enjoy this issue,
Barry Goldlist

G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.

Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.

G.A.E. Wong, MBChB, MRCP (UK); N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions (ADR) are a common problem affecting ambulatory and hospitalized patients. Older patients may be more predisposed to ADR due to inappropriate prescribing of medications, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathology and use of drugs with a narrow therapeutic margin. In this first of two articles, a practical approach to the assessment and diagnosis of patients with suspected drug-induced rashes will be described. A subsequent article will discuss the management of patients with cutaneous ADR.
Key words: adverse drug reaction, skin, rash, cutaneous, diagnosis, assessment.

The weekend prior to my writing this editorial, skin was featured prominently in the Sunday New York Times magazine. However, the articles were more like a commentary on society than a treatise on skin care. One article concentrated on plastic surgeons and how their major interventions were now nonsurgical and focused on skin. Botox (botulinum toxin) injections, collagen injections and dermabrasion procedures were reported as being more commonly performed by plastic surgeons than their previous mainstays: breast augmentation and liposuction. One surgeon commented on how advances in science had improved the field of cosmetic surgery, such that face-lifts, in particular, were no longer required. Several seemed inordinately proud of the recent publication (as yet unverified) that stem cells could be isolated from fat cells harvested by liposuction. The second article talked about the New York dermatologist who helped popularize Botox injections. It mentioned her indulgent life style, by extension making her procedure seem indulgent as well.

However, skin is not just a cosmetic organ. As our largest organ, it is vital to our health, and serious diseases of the skin are not uncommon. The elderly are particularly prone to these diseases and accurate diagnosis and management are important. Dr. Lester discusses Bullous Pemphigoid, a serious blistering disease that is almost exclusively seen in the elderly. Recent studies have expanded the treatment options for this condition. Skin cancer is also more common in the elderly, at least partially because of longer exposure to the sun. Dr. John Adam of Ottawa discusses this topic in detail. Dr. Scott Murray tackles the ubiquitous, but challenging, problem of dry skin in the elderly. Skin manifestations of systemic illness are also very common in the elderly, and the dynamic duo of Dr. Gary Sibbald and Dr. Madhuri Reddy address the topics of pressure ulcers and diabetic foot ulcers.

Also in this issue is an article by Cynthia Westerhout and Eric Boersma, from the Department of Cardiology at the University Hospital Rotterdam and the University of Alberta on glycoprotein IIb/IIIa in percutaneous coronary intervention. This is one of those areas where basic science investigations (in this case, on platelet function) rapidly led to important therapeutic advances.

When I saw Dr. Chris MacKnight's article on acetylcholinesterase inhibitors in the treatment of Dementia with Lewy Bodies, I thought of a chart review I had just completed on a patient (not mine) who had died in hospital. When looking at the entire chart, it was obvious that the patient's confusion with fluctuating course, Parkinsonism and falls were likely secondary to this disorder, but the diagnosis was not made. There is now solid evidence that this disorder is common and can be diagnosed reasonably accurately (e.g. data from Bristol, UK). Unfortunately, there is also evidence that in most places the diagnosis is not made accurately (neither specific nor sensitive). As therapy for this disorder evolves, accurate diagnosis will be vital to ensure that our patients benefit.

Finally, Dr. Rory Fisher, Director of the Regional Geriatric Program of Metropolitan Toronto, has contributed an excellent article on the role of specialized geriatric services in acute hospitals.

In response to last year's readership survey, the next issue will focus on Nutrition in the elderly. We'll also announce the prize winners from this year's survey. Remember to look for your name!

Enjoy this issue.

Michelle Durkin, BSc

The most common form of cancer today is skin cancer. Approximately half of all new cancers diagnosed are one of three defined types: basal cell carcinoma (BCC) , squamous cell carcinoma (SCC), or malignant melanoma (MM). Although the age of diagnosis is decreasing, most skin cancers do not appear until after the age of fifty, making this disease a serious threat to the elderly population. Fortunately it is also a disease which is successfully treated if detected early.

Epidemiology
The incidence of nonmelanoma (BCC and SCC) and MM skin cancers has increased so significantly over the past few decades it may have reached epidemic proportions, particularly in the United States and Canada. It has been projected by the National Cancer Institute along with the Center for Disease Control that in 1999 alone, skin cancer (all types combined) will claim the lives of nearly 9,200 people in the United States. Besides increasing annual incidence, more women are getting skin cancer and people are getting skin cancer at younger ages.

Individual types of skin cancer follow different morbidity and mortality distributions. About 80% of skin cancers are BCC, 16% SCC, and 4% MM. The mortality rate for nonmelanoma skin cancer is decreasing and that of melanoma is increasing.

Rhonda L. Witte, BSc

Skin--we clean it, shave it, cream it and tan it, all with a common goal--to preserve our youthful image. Not only does it help our general appearance, but it also feeds our self-image, making us "feel" younger. In a society where younger parallels attractiveness, we find ourselves constantly in search of new remedies to prevent our skin from aging . On the other hand, aging is a sign of wisdom and the more signs we have, the better we look. Can't we just age without looking older? And is what we consider to be aging of the skin really due to the aging process itself?

Cutaneous aging is a result of both intrinsic and extrinsic events. Intrinsic aging, also referred to as chronological aging, occurs independently of environmental influences. The changes seen with intrinsic aging occur in sun-protected areas. It is this characteristic that sets it apart from extrinsic aging which occurs as a result of environmental effects on the skin, the most important of which is exposure to sunlight.^1,2 The term "photoaging" refers to the age-related cutaneous changes resulting from exposure to sunlight and accounts for the majority of changes generally associated with appearance.