An Overview of Common Skin & Wound Challenges Encountered In Parkinson’s Disease:By Dr. De Leon
Since dopamine, the major neurotransmitter involved in PD abounds outside of the brain it is expected and of no big surprise to see problem areas arise outside of the nervous system, particularly when it comes to control of the autonomic nervous system which regulates temperature, pain, glandular secretions, and controls all involuntary functions of our bodies like bladder emptying, sexual function, and peristalsis (bowel movement).
Many people outside the neurological community may not be aware of the severity and impact of having an autonomic system which has gone haywire. Thus, presenting some of the greatest management problems to date due to lack of disease modifying treatments. The autonomic dysfunction in PD can be manifested in a number of ways presenting with various signs and symptoms involving the skin and appendages such as our hair and nails. For instance, when I first began to have symptoms of Parkinson I noticed a change both in my skin and nails which at first I assumed were due to my thyroid cancer. However, as my thyroid problems got treated and under control, I still experienced dry patches of Skin in the most unusual places- behind my ears, fortunately no one could see but I knew it was there.
Try as I might to moisturize, wash with shampoos containing Zinc and selenium, the patches remained stuck unable to be peeled away. To my amazement and surprise when I recently switched to Rytary I noticed that the patch of dry scaly skin had disappeared completely from one side and significantly diminished on the other. Such insignificant small victories that can make someone happy. But, much to my dismay about a week ago I began noticing a large scaly patch smack in the middle of my forehead – resembling a sunburn that is peeling away, I rather go back to the patches no one could see. Of course I have already discussed elsewhere the increase sweating, I like others have experienced. So I began thinking about all the changes that we experience with Parkinson’s some visible while others not so much and decided that a visit into skin changes( alterations) caused by PD, it’s medications, as well as those caused inadvertently by drug delivery methods and immobility merited my attention and a bit of discussion. Skin alterations are not commonly recognized by those outside of neurology field as I mentioned earlier yet; it appears that autonomic dysfunction affecting the eccrine sweat glands are involved early on in the disease process when compared to controls. There appears to be decrease innervation of blood vessels and to erector Pilli muscles (important in regulating temperature).
Common skin conditions:
- Sialorrhea– increased drooling
- Hyperhidrosis– increased sweating
- Malignant skin lesions– most common is increased melanoma but other skin cancers can occur.
- Seborrhea-greasy skin with limp oily hair
Seborrhea dermatitis – accumulation of sebum (oil) is the cause of seborrhea usually seen in hair, and in the forehead as well as in folds of the nose. When this becomes chronic it leads to dermatitis (inflammation of the skin- red, itchy, flaky). Skin and hair need to be washed routinely and use anti dandruff shampoos; however once dermatitis sets you may need to consult a dermatologist to treat with topical steroids. This dermatitis can affect the eyes as well causing small patches that get into the eyes and eyelashes. Inner parts of eyebrows eyelids and ears can be affected as well as chest area, under skin folds like in groin, breast and axilla. Solution to face and scalp seborrhea is to let the dandruff shampoo run over your eyes closed and wash away gently.
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| Seborrhea is more pronounced when disease is most active |
Ways to prevent & Treat Seborrhea Dermatitis:
- Wash face and skin with warm water using a mild soap (e.g. unscented glycerin soap) and rinse with cold water
- Avoid cosmetic products which contain alcohol
- Increase hair washing especially using a dandruff shampoo containing selenium (selenium sulphide), zinc, or shampoos containing 5% tea tree oil, and olive oil shampoos
- For males who made be bald- use mild soap or sorbolene cream in scalp
- If you have severe crusts or scales in your scalp try rubbing a mineral or olive oil several hours prior to washing hair
- Medicated eardrops to treat ear canal flakiness
- May need a short term steroid based cream or ointment if itching and redness is severe. (a home remedy I often tried on my patients before steroids is application of Crisco lard on scaly patches- just don’t go sit out in sun or get near fire)
Drug Therapy & Skin Changes:
Melanoma – increased risk in PD population with all dopamine and dopamine agonist especially with levodopa. Constant vigilance is of the utmost importance. See elsewhere in my blogs as to risks and diagnosis of these.
Skin sensitivity– this is something that is important to note as well since all of us with PD appear to have hypersensitivity to the sun specially when taking Mao-inhibitors like Azilect. Make sure that you protect your skin, wear cool clothes and hats and stay in the shade if possible do not go out in extreme heat particularly if you are elderly because as we age we tend to have increased skin sensitivity and fragility.
Drug side effects–
Amantadine– an oral anti flu medication used for Parkinson’s treatment particularly for tremors. However, this medication can cause skin changes known as Livedo reticularis (purple stria) in the lower extremities, it can affect the trunk as well as arms but less commonly seen. This rash is asymptomatic and usually comes up anywhere from a month to 4 years later on average. The good news is that this discoloration of skin resolves completely with cessation of drug intake
Apomorphine– is a dopamine agonist used for treatment of acute and intermittent ‘off ‘episodes with long standing drug therapy treatment for PD. This medication can be given IV infusion or by subcutaneous injections these can lead to skin necrosis (dying out skin ulcers) at site of injection; also can occur years after use. Make sure always clean area before and after and have a nurse from pharmaceutical company train you on how to use properly to decrease potential for side effects.
Transdermal drug delivery– Neupro patch, Exelon patch, Selegeline patch. These reactions can range from mild irritation to severe inflammation, pain, whelping, itchiness, and burning. One way to decrease this sensitivity is washing area thoroughly before use and drying it well; also rotate sites recommending using same site no less frequent than every 3-4 days.
Steven Johnson reaction/syndrome– serious idiopathic life threatening skin rash which can be lethal fortunately extremely rare. It is usually to a medication or an infection- begins with flu-like symptoms followed by a painful red or purplish rash that spreads and blisters. Go to ER ASAP if have this…but in all honesty not seen this with PD.
Pressure sores- As, PD advances many of us become immobilized forced to sit in wheel chair or in bed 24 hours a day. This along with the already decreased mobility of disease and increased rigidity along with moisture of chronic sweating and of urine incontinence can lead to pressure ulcers particularly in the heels and buttock areas due to pressure, shear, moisture and friction of skin and blood vessels. Need air mattresses, heel booties, constant supervision and turning by a caregiver, changing sheets and clothing, dressing in cool garments, maintaining room temperature cool and if going to maintain in disposable undergarments need to change every 2 hours at the most and wipe are clean from sweat and dirt, bathe in bed frequently (daily). If urine incontinent consider placing a catheter less risk of infection. This is what I did for my grandmother and never developed any sores or ulcers because these can get supra-infected with ordinary common organisms easily like staph infections. At the first sign of skin break down begin treatment with medicated gauzes and talk to nurses and doctors caring for patient ASAP to avoid progression, hospitalization or death.
Fungal infections-Risk of fungal infections increase in patients with PD who are incontinent of urine. These infections look like rashes in the perineal area and groin. They are moist, itchy, red and looks like satellite as infection spreads outward, sometimes they are white like babies ‘cotton-mouth/thrush’ this risk may increase with diagnosis of diabetes ( which we as Pd patients are at higher risk). Treatment consists of anti-fungal medication topically like mycostatin ointment. One way to prevent is as I said above maintaining dry are but also apply 1-2 times a week some Desitin (or other baby rash ointment with zinc) to groin area to help with moisture and decrease this type of infection.
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