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Advances in Geriatric Dermatology
Author:
Anne Lynn S Chang
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Springer
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2015
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This concise, easy-to-read book summarizes the current clinical evidence and basic science relating to aging and the skin, assisting the clinician in addressing skin problems in older dermatologic patients. Each chapter focuses on a particular area in which new knowledge has rapidly emerged over the past 5 years, ensuring that the book is completely up-to-date. Recent insights into aging skin from basic and translational science are first discussed, covering the underlying genetics and the potential role of topical agents and procedures in reversing the aging process. Evidence-based prescribing in older patients is then explained, and the evidence relating to treatments for psoriasis, reviewed. Further chapters in Geriatric Dermatology address non-surgical treatment options for basal cell carcinoma, the increase in and management of sexually transmitted diseases in older dermatology patients, and cutaneous signs of elder mistreatment. Case vignettes and informative illustrations assist the reader in quickly grasping the connection between an age-related process and its clinical impact. Geriatric Dermatology is written for dermatologists, research scientists with translational interest, geriatricians, and gerontologists.

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Springer International Publishing Switzerland 2015

Anne Lynn S. Chang (ed.) Advances in Geriatric Dermatology 10.1007/978-3-319-18380-0_1

Dermato-pharmacology in Older Patients

Olivia Yu-Ping Lai 1

(1)

Keck School of Medicine of the University of Southern California, Health Sciences Campus, 1975 Zonal Avenue, Los Angeles, CA 90089, USA

(2)

Department of Dermatology, University of Wisconsin-Madison, 1 South Park Street, 7th Floor, Madison, WI 53715, USA

Olivia Yu-Ping Lai

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Justin Endo Clinical Assistant Professor (Corresponding author)

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Keywords

Geriatric Pharmacology Older Prescribing Geropharmacology Aged Cutaneous Polypharmacy Skin Dermatology

Physiologic Principles of Geropharmacology

Providers who treat older adult dermatology patients may hold preconceived notionswhether positive or negativeabout the aging process and providing caring for this population. However, if one thinks of the characteristics of various older adult dermatology patients, a diversity of aging is likely to be found. The 90-year-old healthy, community-dwelling great-grandmother requesting a general skin check and refill of topical rosacea medications will be approached differently than the 70-year-old frail, institutionalized male with a non-operable basal cell carcinoma, unintentional weight loss, low performance status, poorly controlled psoriasis, and infected decubitus ulcers wishing to have aggressive therapy for all his conditions.

Aging is a heterogeneous process that results from an accumulation of both natural cellular senescence (i.e., healthy or intrinsic aging) and external factors (e.g., comorbid conditions, lifestyle, medications, environmental exposures) []. In a later section, practical correlates of these geropharmacologic principles are demonstrated through common examples.

Pharmacokinetics of Aging

Medication Absorption

The two primary routes of dermatologic medication absorption are oral and topical. In healthy older adults, gastrointestinal (GI) and transdermal absorption do not appear to be significantly decreased compared to younger patients, despite changes in GI motility and age-related epidermal atrophy, respectively []. Obviously, some older patients might have other comorbidities or surgeries that affect medication absorption. Therefore, the alterations in medication absorption should be taken into consideration when prescribing to these patients.

Volume of Distribution

The volume of distribution (Vd) is a theoretical construct that relates the amount of medication in the body (extravascular space) with respect to the medications concentration in the blood or plasma [].

Hepatic Metabolism

The liver is the primary site of metabolism of many dermatologic drugs [].

Table 1

Common dermatologic medications that might require dose adjustment, interact with other common medications, or have other potentially adverse effects in older adult patients

Medication	Renal dose adjustment	Cytochrome P450 metabolism	Pharmacokinetic notes	Example of medication interaction
Acyclovir	Y	Delirium, nephrotoxicity
H1-antagonists (particularly first generation antihistamines)	Diphenhydramine is potent CYP2D6 inhibitor []f	Hydroxyzine is very lipophilic and has prolonged half-life in older patients	Counteracts cholinesterase inhibitors (might aggravate dementia or cause delirium)	Constipation, delirium
Azathioprine	Y	Decreases warfarin levels
Benzodiazepines	Excessive sedation, falls, delirium, fractures
Cephalosporins	Cephalexin	Many cephalosporins increase warfarin levels
Cetirizine	Y
Chloroquine	Y	Unknown if older patients, especially with existing macular degeneration or renal insufficiency, are at higher risk than younger healthy adults for ocular toxicity
Cimetidine	Increases warfarin levels
Ciprofloxacin	Y	CYP1A2 inhibitorf	If taken with systemic corticosteroids, increases tendon rupture risk. Increases warfarin levels	Prolonged QTc, delirium, and tendon rupture (especially if taken with systemic corticosteroids)
Colchicine	Y
Cyclosporine	Y	Metabolized by CYP3A3/3A4f	Increases digoxin levels	Nephrotoxicity risk
Dapsone	Metabolized by CYP3A3/3A4f	May cause hemolytic anemia, which might not be tolerated in patients with cardiopulmonary disease or baseline anemiaa
Dicloxacillin	Decreases warfarin levels
Erythromycin	CYP3A4/3A5 inhibitorf	Increases warfarin levels
Famciclovir	Y	Increases warfarin levels
Fluconazole	Y	CYP2C9 inhibitorf	Increases warfarin levels
Gabapentin	Y	Taper rather than abruptly stop so as to prevent withdrawalb	Recommend initiating at 100 mg QHS with slow titration to prevent ataxia and somnolence.
Griseofulvin	Weak/moderate CYP1A2/2C9/3A4 inducerf	Decreases warfarin levels
Itraconazole	CYP3A4/3A5 inhibitorf	Increases digoxin levels
Ketoconazole	CYP3A4/3A5 inhibitorf
Loratadine	Though a second generation non-sedating antihistamine, it is considered anticholinergic by an American Geriatrics Society expert panel and should be used cautiously []	Loratadine probably has less anticholinergic effects compared to cetirizine
Macrolides	Increases warfarin levels (except for azithromycin) Increases digoxin levels
Methotrexate	Y	Caution with trimethoprim, penicillins, nonsteroidal anti-inflammatory drugs (NSAIDs)c
Metronidazole	Increases warfarin levels	May cause dysgeusia and aggravate anorexia in frail patients
Nafcillin	Decreases warfarin levels
Opioids	Many are hepatically metabolized	Delirium, falls, sedation, constipation []. Use low dose and carefully titrate. Recommend scheduled bowel regimen.
Prednisone	Weak/moderate CYP2C19/3A4 inducerf	Hypertension, hyperglycemia, osteoporosis, delirium, psychosis, heart failure exacerbation, dysrhythmias, myopathy. Peptic ulcer risk increased 15-fold with concomitant nonsteroidal anti-inflammatory drug (NSAID) (See Table 3)

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