An Overview of Common Skin & Wound Challenges Encountered In Parkinson’s Disease:By Dr. De Leon

Parkinson’s affects our insides and outsides and although commonly labeled as a movement disorder it has many more non -motor manifestations which can wreak havoc in our daily life’s . Some are cumbersome and embarrassing while others can be downright difficult to bear and live with.

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. 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.

Addendum: Eltamd UV Clear SPF 46, 48-Gram 1.7 oz.

2 possible treatments are:

Elta MD sunblock- can find at amazon

Over the counter Cerave skin cleanser & lotion helps with eczema

 

Sources:

http://www.parkinsonsvic.org.au/parkinsons-and-you/skin-scalp-and-sweating/

http://www.o-wm.com/article/skin-and-wound-issues-patients-parkinson%E2%80%99s-disease-overview-common-disorders

Excessive Sweating In Parkinson’s Patients: by Dr. De Leon

While I was still in practice, patients often would complain of having increase sweating particularly at night. Patients would often say to me; “I have a very hard time sleeping at night because of the sweats… and even Harder time staying dry!” I often concentrated more on the ‘lack of sleep’ and did not fully grasp the significance or discomfort, for that matter, of the “sweating” which was the real culprit. The issue of “sweating” somehow did not seem to be such a big problem in the grand scheme of ALL the other Parkinson’s symptoms.

But in reality, “excessive sweating” can be a real problem and if significant enough it can truly put a big damper on someone’s lifestyle; this in light of the fact that PD is already an extremely public disease for most of us. Unfortunately, sometimes in society we are judged whether we like it or not, primarily on first impressions which usually are as superficial as an appearance. Now, imagine the pressure, us PD patients’ feel, at times, when we go about in public being stiff, unable to smile with tremors and involuntary movements (dyskenisias) which only serve to fuel our inner anxiety causing a rise in our temperatures making us perspire even more adding to the embarrassment of being seen in public. Worst, although sweat typically does not smell…sweat caused by stress or anxiety does!

This overall scenario would make anyone of us want to hide under a rock or never leave our homes. However, there are a few steps we can take so that at least we can minimize our perspiration and reduce any chance for any offensive odor which might make us more self aware.
First of all, normal sweating helps to keep the body temperature in check like in hot weather or during high temperatures such as fever, or during exercise. Excessive sweating (hyperhidrosis)  means that you sweat more than normal even when you are not particularly hot, anxious or exercising. People with Parkinson’s suffer a number of changes in the skin one of which is increased perspiration. These changes can either result in under secretion (hypohidrosis) or over secretion presenting usually in the form of night sweats after starting on dopamine medications especially levodopa is very common.  But, because sweat is a way for our bodies to regulate our internal temperature any changes can be potentially harmful plus can cause severe emotional distress to an individual homeostasis and their lifestyle. For now, we are concentrating in the increase of sweat production.

So, why does this happen and what can we do to decrease the excessive sweating that may be contributing to  our  reluctance to go out in public or interfere with our  intimacy and sex life?

It is important to remember that all Parkinson’s people experience changes to their skin…skin is full of dopamine!

Over time Parkinson’s individuals lose sweating capabilities in the extremities like the hands and feet therefore increasing over the entire body as a compensatory mechanism! This process only worsens as the disease progresses. Plus, Parkinson’s medications also can cause generalized sweating or hyperhidrosis. Other causes of increased sweating are thyroid disease, anxiety disorder, cancers, and other hormonal problems to name a few as well as medications.

Anticholinergic medications can block sweat causing a dangerous rise in body temperatures especially in hot weather; hence it may be important to reconsider their use if you are an elderly patient or cut down on dose during the summer /hot months. This is because older people have a harder time regulating temperature especially during summer months if they live in very hot climates. Levodopa usually causes severe drenching especially during “off” states; but can also increase sweating at other times like night time. Therefore it is important to talk to your physician to adjust medication because if you are experiencing such severe sweating during the “off” state which usually means other motor and non-motor symptoms are uncontrolled during this time as well.

         What can you do?

  • Have medicines adjusted by tour physician /especially levodopa
  • Take lukewarm showers/baths
  • Drink extra fluids particularly water, even Gatorade and pedia-lyte (which comes in popsicles- best for hot weather)-stay hydrated
  • Wear light cotton clothes
  • If sweating is severe talk to doctor about medications like propranolol

 In order to avoid body odor due to excessive sweating:

1. Make sure you use antibacterial soap when bathing

2. Towel off completely

3. Use “industrial strength” antiperspirants/ deodorants – work best if you apply at night before bed time not after showering or will wash off; it takes 6 to 8 hours for antiperspirants to enter sweat ducts and properly clog pores plus body is cooler at night. But do reapply at least once during the day.

4.  Keep clothes clean and use garments which do not lock in sweat or bacteria, like cotton. Cut out or decrease offensive foods and drinks-like onion, garlic, alcohol, and spicy foods which tend to increase temperature of the body and wear breathable shoes and clothes.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com