The Skinny on Skin and Bone Health

Parkinson’s disease (PD), skin and bone health are closely intertwined. Researchers are exploring how they are connected to uncover information that could improve lives. Higher bone fracture risk, flaky or dry skin and too much or too little sweating can be common in Parkinson’s. Simple tips can help you tackle these and other related changes.

This article is based on a Parkinson’s Foundation Expert Briefing webinar exploring these connections presented by Nicki Niemann, MD, Muhammad Ali Parkinson Center at Barrow Neurological Institute, and Kenneth W. Lyles, MD, Duke University Medical Center. Barrow and Duke are Parkinson’s Foundation Centers of Excellence.

Parkinson’s and Skin Health

Research shows an overlap in skin health and PD. Overall cancer risk is reduced in Parkinson’s disease, but skin cancer risk — especially melanoma — increases.

In Parkinson’s, misformed alpha-synuclein protein builds up and clumps in the brain. Skin cancer biopsies of people with PD also show increased alpha-synuclein in the skin, compared to the general population. Additionally, people diagnosed with rosacea — facial flushing, redness and sometimes, bumps — are nearly two times as likely to be diagnosed with Parkinson’s.

PD and other neurological disorders also increase the risk for bullous pemphigoid (a skin condition causing itching, redness and large, fluid-filled blisters that can break and cause blood-borne infection).

Connections such as these have scientists exploring skin health as a possible biomarker (a measurable sign, such as heart rate, that can clue doctors in on your health) to help detect Parkinson’s sooner. Skin biopsy holds promise as a potential future Parkinson’s disease diagnostic tool. Earlier diagnosis can improve outcomes for people living with PD.

Skin Cancer Safeguards

Despite past misconception, levodopa, the most commonly prescribed PD medicine, does not increase risk of melanoma. However, though the association is not yet clear, some of the same shared risk factors for PD can also increase melanoma risk. These include being male, Caucasian, having red hair, fair skin and previous pesticide exposure.

Protect yourself by reducing direct sun exposure, wearing sunblock and visiting the dermatologist annually.

When it comes to spotting melanoma, the American Academy of Dermatology recommends watching for these signs:

Asymmetry –the shape of a spot or mole is unequal
Border – an irregular or scalloped edge
Color – blues, reds, browns or black; suspect spots can vary in hue
Diameter differs, too; melanomas can be the size of a pencil eraser, larger or smaller
Evolution in spot color, shape or size should also be shared with your doctor

Skin Health Strategies

Studies estimate between 20 to 60% of people with Parkinson’s may also live with seborrheic dermatitis, compared to just three to four percent of people without PD. Symptoms can include itching, scaling, oiliness, redness and burning — mainly on the scalp, but for some people, the face, chest or back, too.

Over-the-counter medicated shampoos containing salicylic acid, zinc, selenium, tar or ketoconazole can help. A dermatologist can recommend treatment for severe symptoms, such as prescription-strength shampoos, steroids or other immune suppressants.

Excessive drooling can also be common in Parkinson’s. It can cause perioral dermatitis — redness and irritation around the mouth. Anticholinergic medications and botulinum toxin A (BOTOX ®) can be used to decrease drooling.

Sweating Changes     

Sweating too much — whether on the head, neck or trunk — is more common in Parkinson’s than not sweating enough. Excess sweating can also happen on the foot soles, palms or at night. It’s often experienced even prior to a Parkinson’s diagnosis.

Sometimes changes in the autonomic nervous system, an area controlling automatic body functions such as rate of breathing, are responsible. Carbidopa-levodopa-related motor fluctuations, or “wearing off,” can increase sweating, as can other medications unrelated to PD, such as certain antidepressants. Infections, sleep apnea, endocrine conditions and cancer can intensify sweating, too.

Though not as common, decreased sweating can also pose problems for some people with Parkinson’s. This is often related to anticholinergics, including amantadine and trihexyphenidyl. Review your medication list with your doctor who can adjust prescriptions, identify other causes or offer treatments, such as:

• topical medications, including prescription antiperspirant aluminum chloride hexahydrate
• oral propranolol (Inderal®)
• anticholinergic drugs, such as glycopyrrolate
• BOTOX ® injections for localized sweating 
• electric current iontophoresis therapy

These at-home tips can help with sweating:

• Wear breathable cotton clothes and socks, and non-synthetic shoes
• Take lukewarm or cold showers
• Increase fluid intake
• Drink cold liquids
• Use antiperspirant

Skin Changes

Sometimes, PD treatments can cause skin issues. While there are few reports of true levodopa/carbidopa allergy, the 25/100 formulation can cause a rash for some people, possibly due to a yellow dye. If this side effect occurs, your doctor might switch you to formulation without yellow dye, including 10/100, 25/250, Parcopa, Stalevo or Sinemet CR.

Some Parkinson's medications can also cause leg edema (swelling due to trapped fluid). These include amantadine and dopamine agonists, such as ropinirole, pramipexole, rotigotine and apomorphine. Talk to your doctor if leg swelling occurs within a few months of starting a medication.

People using Duopa therapy, levodopa/carbidopa intestinal gel delivered by pump through a small, surgically placed hole in the stomach, can also experience skin issues, including redness, leakage around the opening or abscess. Proper pump tube care and increased healthcare provider access is essential.

Deep brain stimulation (DBS) uses surgically placed electrodes in the brain and with an implantable pulse generator to block abnormal nerve signals in the brain that cause motor symptoms. Though skin-related complications are uncommon, a small percentage of users might experience hardware-site infection, or skin erosion near components.

Parkinson’s and Bone Health

Caring for bone health when living with Parkinson’s is critical. Exercise, regular bone mineral density screenings are key.

It’s estimated that about 45 million Americans have low bone mass, putting them at risk of joining the more than 12 million people in the U.S. who live with osteoporosis (a condition where bones become thin, fragile and prone to fracture). Such skeletal problems are often associated with aging.

People with PD are at higher skeletal fracture risk than others, experiencing fractures two to three times more frequently. Hip fractures occur four times as frequently. At best, less than five percent of people with Parkinson’s who experience fractures are treated. However, addressing and treating fractures is crucial: It can take someone who lives with PD longer to recover from a fall injury or fracture, and they may experience worsening symptoms, loss of independence and cognitive decline.

Fortunately, there are many ways to reduce fracture rates in people with PD and current research is exploring further ways to minimize bone risks.

Who’s at a high risk of osteoporosis?

• People living with Parkinson’s  
• Women
• Older people
• Those with low body weight
• Those with a family history of osteoporosis
• Those with a history of fractures or low-impact fractures
• Smoking and excessive alcohol intake increase risk

Glucocorticoid therapy, medicine used to reduce inflammation, can increase bone loss and fracture risk. Other medications can too — including proton pump inhibitor therapy, anticonvulsants, aromatase inhibitors, tamoxifen, Depo-Provera and steroids. Conditions that are associated with bone loss include gastrointestinal and autoimmune diseases, genetic issues, diabetes and others.

Boosting Bone Health

What’s good for your body is also good for your bones:

• Stop smoking
• Limit alcohol
• Avoid sedating medications

Exercise can keep bones strong and strengthen muscles and in Parkinson’s, it can also improve many disease-related symptoms. Find something that makes you want to move and stay active. Physical therapy can help, too.

Maintaining optimal levels of calcium and vitamin D3 benefits bones and overall health. Because calcium in dairy foods can inhibit levodopa absorption, people with PD can find it hard to get the recommended 1200 mg daily for women over 50 and 1000 mg daily for men over 70. Calcium-fortified foods, such as juices, rice and breakfast cereals, can boost calcium levels. Chewable calcium citrate tablets can be taken without food and are easily absorbed. Doctors recommend limiting single doses to no more than 600 mg elemental calcium, splitting the dose if needed.

The body also needs adequate vitamin D to take in enough calcium. Research shows depressed vitamin D levels in people living with Parkinson’s. Vitamin D is easy to absorb if you live in a sunny place — wear sunscreen. If this isn’t possible, a nutritious diet, including fatty fish, such as salmon, liver, eggs and fortified milk or cereals, can help. Your doctor might also recommend vitamin D3 supplements.

Osteoporosis Medications  

Medicines are also available to treat bone density loss. Hormonal medications include estrogen therapy and raloxifene, a selective estrogen receptor modulator, or SERM.

Prescription therapies that stop bone breakdown, called antiresorptives, include bisphosphonates such as alendronate (Fosamax®), risedronate sodium (Actonel®), ibandronate sodium (Boniva®) and zoledronic acid (Reclast ®). Anabolic medications boost bone building, and include teriparatide, abaloparitide and romosozumab.

On The Horizon

The TOPAZ trial is currently enrolling people to test if test if a medicine called zoledronate can prevent fractures in people with PD. You can join without leaving your home. If you are eligible, a registered, Certified Mobile Research Nurse (CMRN) will come to your home to give you a short exam.

Learn more about this Parkinson’s study or call the Parkinson’s Foundation Helpline at 1-800-4PD-INFO (1-800-473-4636).