GERIATRIC SKIN DISEASES

As we age, it is natural for the human body to undergo changes, and this includes the natural aging of the skin. These changes are the result of both biological and environmental factors. The skin undergoes two processes of aging: intrinsic (chronological) and extrinsic. Intrinsic or natural aging is brought about by physiological metabolic changes, and is inevitable. Extrinsic aging refers to the changes in the skin due to its interaction with the environment. This includes photoaging (aging due to constant sun exposure), environmental pollution, smoking, and other external factors. The elderly population (often defined as those aged > 65 years) experiences age-related changes in skin structure and function, and are more susceptible to a wide variety of dermatological conditions.

Changes in Elderly Skin

• Dryness and roughness due to thinning of the epidermis and decrease in barrier function
• Delayed healing due to decrease in cell turnover and reduced capacity for repair following insult
• Uneven pigmentation
• Wrinkles and skin laxity due to decrease in collagen and elastic fibers, and reduced subcutaneous fat
• Decreased sensory perceptions
• Impaired thermoregulation
• Less sweat production due to regression of apocrine glands
• Less sebum production
• Hair turns white/gray in color
• Reduced nail growth

Common Geriatric Dermatoses

1. Pressure ulcers (Decubitus ulcers)

Pressure or decubitus ulcers usually occur over bony areas of the body. It is common in critical care patients, quadriplegics, and diabetics, and it frequently appears on patients who are immobile or who are on wheelchairs for extended periods of time. Prolonged immobility can result in skin and tissue damage, as the underlying tissue is unable to get enough oxygen supply (ischemia). Treatment depends on the stage of the ulcer, so it is better to consult with your doctor for proper staging and management. Prevention techniques include increasing mobility, proper repositioning of bedridden patients, and careful skin care.

2. Xerosis

Dry skin (xerosis) is one of the most common skin conditions in the elderly population. It is also usually seen in patients with Chronic Kidney Disease, liver problems, and autoimmune conditions. In the elderly, the skin’s ability to retain moisture lessens, hence leading to dry skin. Dry skin can lead to pruritus (itch), constant scratching, and can considerably decrease the quality of life. The mainstay of treatment includes the application of moisturizers to aid and protect the skin barrier. It also helps to increase water intake, avoid hot showers, and refrain from overusing soaps that can remove the natural oils in the skin and increase dryness.

3. Asteatotic dermatitis

Asteatotic dermatitis presents as dry, cracked, and fissured skin commonly found on the extremities. It often appears during cold weather. Those with eczema should limit bath time to 5-10 minutes, and should apply emollients on damp skin within 3 minutes after showering. Your dermatologist may also prescribe topical corticosteroids and topical calcineurin inhibitors if warranted.

4. Pruritus

As previously mentioned, pruritus or itch is often caused by xerosis. In the elderly, pruritus may also be caused by systemic disorders (co-morbidities), age-related changes in the skin and nerves, and polypharmacy. The underlying cause should be determined, as this dictates what treatment or management is best to use. Some agents that are utilized for pruritus include topical corticosteroids, emollients, and antihistamines.

5. Stasis dermatitis

Stasis dermatitis happens when there is poor circulation of blood on the lower legs. They can appear as red patches or plaques commonly located on the medial malleolus. Lesions can be dry, weepy, scaly, or thick. It can also be associated with the presence of varicose veins. Patients with stasis dermatitis should use compression stockings, exercise their calf muscles by walking, and elevate their feet when sitting or lying down. If left unattended, these lesions can become exacerbated and form ulcers. Topical corticosteroids can be applied, and antiseptics or antibacterial agents may be given if a bacterial infection is present.

6. Solar lentigines

Solar lentigines are small hyperpigmented lesions that can be found on sun-exposed areas such as the face, neck, and arms. These lesions generally do not require any form of treatment, but it is advisable to consult with a dermatologist if there are any irregularities in shape, color, or size in order to rule out melanoma. Using sunscreen, as well as other photoprotective practices like seeking shade and wearing a wide-brimmed hat can help prevent solar lentigines.

7. Infections

Infections in the elderly can be bacterial, viral, or fungal in nature. The most common infectious skin conditions include the following:

• Cellulitis – a bacterial infection of the subcutaneous fat that mostly affects the lower legs in the elderly population. Lesions appear as red patches, plaques, or even ulcers, which can be tender and warm-to-touch. Treatment includes the use of topical and systemic antibiotics.
• Herpes zoster (Shingles) – a viral infection due to the reactivation of the chickenpox virus. Lesions appear as painful, grouped, red vesicles following a unilateral and dermatomal pattern. Antivirals may be given as treatment, as well as wet to dry dressings and calamine lotion. Non-steroidal anti-inflammatory drugs may also be given to address the pain.
• Onychomycosis – a fungal infection affecting the nails, most commonly the toenails. There can be some yellowish discoloration, thickening of the nail bed, and eventual separation of the nail plate from the nail bed. Oral antifungals are given to treat onychomycosis.

​8. Scabies infestation

Scabies is common in the elderly population, especially those living in nursing homes. It is caused by the scabies mite (Sarcoptes scabiei), and can be easily transmitted from person to person. Lesions appear as small red dots affecting the wrists, armpits, finger webs, areola, periumbilical area, genitals, and buttocks. Lesions are usually itchy at night. Topical scabicides such as permethrin should be given as treatment.

9. Drug eruptions

Most of the elderly population have multiple comorbidities and are taking a variety of medications. Drug eruptions usually begin suddenly and can affect any part of the body. Lesions are also varied, but they mostly appear as widespread, red spots or patches which may be flat or raised. These lesions can be accompanied by other symptoms such as fever and fatigue. A visit to the dermatologist is needed for proper treatment.

10. Benign and Malignant Neoplasms

​There is an increased frequency of benign and malignant neoplasms in the elderly population. These include the following:

• Seborrheic keratosis - a benign condition that usually presents as warty, brown to black lesions on the face, trunk, and extremities. These are removed via electrosurgery, cryosurgery, or curettage.
• Skin tags - a benign condition that appears as outpouchings of skin commonly found in the neck and axillary folds (armpits). Skin tags are associated with other medical conditions such as diabetes and obesity. Larger lesions are excised, whereas smaller lesions are treated with electrodessication.
• Melanoma - occurs in the elderly population and is mostly due to constant sun exposure. Lesions appear similar to brownish or black moles, but with irregular borders and color changes. It is better to have a dermatologist look at these lesions, so that proper treatment may be given.
• Basal cell carcinoma - is the most common malignant tumor which often looks like a bump with rolled edges and blood vessels near the surface of the skin. This is also caused by chronic sun exposure and is most often seen on the face. There are many ways of treating basal cell carcinoma; therefore, it is recommended to visit your dermatologist for appropriate diagnosis and management.

Take-Home Messages

The ultimate goal for elderly skin is to keep it healthy, hydrated, and to prevent the development of skin problems, which can also cause mental and emotional stress. Sun protection is still the most important preventive measure, as well as the use of hypoallergenic, mild products on the skin. If there are any skin problems, it is best to consult with a dermatologist so that early intervention techniques may be given. It is quite difficult to manage skin problems in the elderly because of the many changes in their skin structure. Ultimately, prevention is more effective than treatment.

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References:

• Blume-Peytavi, U., Kottner, J., Sterry, W., Hodin, M. W., Griffiths, T. W., Watson, R. E. B., Hay, R. J., & Griffiths, C. E. M. (2016). Age-Associated Skin Conditions and Diseases: Current Perspectives and Future Options. The Gerontologist, Suppl 2, S230–S242. https://doi.org/10.1093/geront/gnw003
• Hahnel, E., Lichterfeld, A., Blume-Peytavi, U., & Kottner, J. (2017). The epidemiology of skin conditions in the aged: A systematic review. Journal of Tissue Viability, 1, 20–28. https://doi.org/10.1016/j.jtv.2016.04.001
• Jafferany, M., Huynh, T. V., Silverman, M. A., & Zaidi, Z. (2012). Geriatric dermatoses: a clinical review of skin diseases in an aging population. International Journal of Dermatology, 5, 509–522. https://doi.org/10.1111/j.1365-4632.2011.05311.x
• Reszke, R., Pełka, D., Walasek, A., Machaj, Z., & Reich, A. (2015). Skin disorders in elderly subjects. International Journal of Dermatology, 9, e332–e338. https://doi.org/10.1111/ijd.12832

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