This article is based on a presentation given by Dr Sarita Singh, Consultant Dermatologist and Research Lead for Dermatology, Chelsea and Westminster hospital, at the GM Conference Ageing and Healthcare Today, held in Edinburgh.
The World Health Organization predicts that the global population of people aged over 60 years will reach two billion in 2050. There will be an inevitable associated increase in the burden of dermatological disease.
Ageing is associated with structural and functional changes in the skin. It can cause thinning of the epidermis and dermis, fragmentation of collagen and elastic fibres and decreased cell healing and DNA repair. There is also a decrease in melanocytes and reduced function of sebaceous glands as well as a decrease in skin lipids, vascularity and supporting structures.
The impact of skin disease on an older patient can be both physical and psychological. The physical impact includes pain, itching and sleep disturbance. Some dermatological conditions are associated with disease affecting other systems, for example psoriasis and psoriatic arthropathy.
Psychological impact includes loss of confidence, depression and anxiety, problems with interpersonal relationships and restriction of leisure activities. The impact on other family members, especially carers should not be underestimated.
Studies have shown that the most common skin diagnoses in the elderly are pruritus, eczematous dermatoses, infections and skin malignancies.1
This article will discuss investigations to perform and management plans. It will also highlight how to recognise lesions suspicious for skin cancer and also when to refer to a dermatologist.
Pruritus is defined as an unpleasant sensation of the skin that provokes the urge to scratch. Four categories of itch include localised itch with or without rash and generalised itch with or without rash.
Xerosis is the medical name for dry skin and by the age of 70 years nearly all adults are affected. Xerosis is the most common cause of generalised pruritus without rash in the elderly population.
A host of drugs can cause pruritus including antihypertensives, antibiotics, diuretics and psychotropic agents. Some medications induce itch by multiple mechanisms, either by provoking a primary inflammatory eruption or directly activating nerves. The mechanisms by which many drugs cause itch are unknown.
In generalised pruritus without rash, underlying systemic disease accounts for up to 50% of cases. This can range from diabetes and thyroid disease to renal failure and lymphoma. Appropriate investigations to elucidate the underlying cause include full blood count, ferritin, renal and liver function, thyroid function, glucose and chest x-ray.
Chronic pruritus represents one of the most significant challenges and is compounded by problems faced by many older people. This includes insomnia (as this increases time available for scratching), boredom and loneliness, bereavement, financial difficulties, chronic health issues and polypharmacy.
Eczematous dermatoses in the elderly include:
- Asteatotic eczema
- Seborrhoeic dermatitis—up to 31% of elderly patients
- Allergic contact dermatitis—up to 11% of elderly patients (decades of potential sensitisation)
- Incontinence associated dermatitis
- Often multifactorial causes eg. venous eczema and allergic contact dermatitis.
Seborrhoeic dermatitis occurs in disproportionate numbers in Parkinson’s disease and central nervous system disorders. Up to 81% of patients with chronic venous ulcers will also have allergic contact dermatitis to topical medications and dressings.
Incontinence associated dermatitis affects up to 50% of all incontinent patients and elderly patients are most often affected. This is when excessive moisture from urine and/or stools leads to overhydration and chemical irritation of the epidermis. Physical irritation (eg. cleansing) contributes to the destruction of epidermis and dermis. In addition, secondary bacterial infection is common.
Investigations for dermatitis include swabs for microbiology and skin scrape for mycology (especially unilateral distribution). An HIV test in extensive or refractory seborrhoeic dermatitis should be considered.
Patients should be referred for patch testing if allergic contact dermatitis is suspected. Referral should also be made when acute or chronic eczema is not responding or aggravated by treatment or there is an unusual distribution/pattern. Venous eczema and eyelid eczema should be seen by a specialist. A skin biopsy should be conducted for suspected eczematous drug eruptions.
Emollients combined with humectants (eg. urea) are the best strategy for treating xerosis in older patients. For preventing skin injuries the use of soap substitutes and non-detergent cleansers can reduce the incidence of skin tears and incontinence associated dermatitis.
Skin protecting effects might be enhanced when barrier products are additionally applied. In a study, the occlusive agent dimethicone was most often reported for incontinence associated dermatitis and skin-tear prevention.2
Recommended management for both pruritus and eczematous dermatoses is therefore emollients (preferably ointment containing urea) and soap substitutes. Bathing in tepid water for 10 minutes enables the stratum corneum to absorb water and the patient should moisturise immediately after.
For active eczematous areas, a mild/moderate potency topical steroid should be used on the face once daily for two weeks then 1-2 times weekly as maintenance. Whereas a moderate potency topical steroid can be used on the body once daily for two weeks then 1-2 times weekly as maintenance.
Secondary bacterial infections should be treated with appropriate antibiotics. Patients should be referred for patch testing and compression for venous eczema if appropriate.
Second and third line treatments include phototherapy and systemic treatments such as methotrexate, mycophenolate and ciclosporin.
Management of seborrhoeic dermatitis includes 2% ketoconazole shampoo to the scalp (and skin) twice weekly for four weeks, then once weekly as maintenance. A de-scaling shampoo, containing coconut oil or salicylic acid and a topical steroid can also be applied to the scalp (preferably mousse, lotion or shampoo) once daily for two weeks then twice weekly as maintenance.
In addition, a mild topical steroid that contains an antifungal agent can be used. Itraconazole 200mg od for 14 days can also be considered for refractory cases.
Common skin infections in the elderly include candidiasis, dermatophytosis, bacterial and viral infections. Investigations for fungal infections should include samples for mycology (skin scrapings, hair shafts, nail clippings) for direct microscopy (with potassium hydroxide) and culture (culture results take about six weeks). There should also be a swab for microbiology.
Localised infections should be treated with topical imidazoles (eg. clotrimazole) or allylamines (eg. terbinafine). Widespread, hair or nail disease should be treated with terbinafine, griseofulvin or pulsed itraconazole. Liver function should be monitored.
Management of intertrigo includes 2% ketoconazole shampoo to wash skin for four weeks, then once weekly as maintenance. An antifungal powder is effective as prevention and in severe cases itraconazole 200mg od for 14 days can be used. Consider flexural drug eruption if not resolving.
In scabies, the causative organism is Sarcoptes scabiei and transmission is by direct contact/close handling so care homes can be a big problem.
The commonest sites are interdigital spaces such as wrists, genitals, elbows, feet, buttocks and axillae. Investigations should include skin scraping of burrows placed on a slide in mineral oil for direct microscopy.
A wound swab should also be taken to exclude secondary bacterial infection.
Treatment is with permethrin or oral ivermectin. Secondary bacterial infections also need to be treated with an appropriate antibiotic.
Surgical excision is the only curative treatment for melanoma. Risk factors are fair skin, freckles, blue or green eyes, red or blonde hair, increased number of moles (>100), immunosuppression, family history, sunbeds and UVR exposure with a history of severe sunburn in early life.
Other red flags in patients are the sudden appearance of new moles—80% of melanomas occur de novo rather than within pre-existing moles and changes in an existing mole eg. growing rapidly, changing shape or colour, itching or bleeding.
The ABCDE and the “ugly duckling” methods can be used to differentiate a suspect lesion from an ordinary mole. ABCDE stands for Asymmetry, Border, Colour and Diameter and Evolution. An ugly duckling is when a lesion appears different to the rest on a person’s skin.
Acral melanoma is melanoma arising on the soles or palms and within the nail unit. It can be difficult to recognise so delays occur in diagnosis. A history of trauma should not exclude the possibility of a melanoma as evidence suggests many cases of melanoma are brought to the attention of the patient by co-incidental trauma and injury. They can occur in all ethnic groups and skin types.
Squamous cell carcinoma can present as a thickened red scaly spot that may bleed, or a nonhealing lesion, and it is often painful. It develops on chronically sun-exposed sites such as the face, hands, forearms. High risk squamous cell carcinomas occur on ears and lips and anything over 2cm has a higher risk of metastasising.
Basal cell carcinoma is the most common and least dangerous form of skin cancer. It is a red or pale pearly lump or scaly dry area and is usually a non-healing lesion.
In summary, ageing is associated with structural and functional changes in the skin that render it more susceptible to skin disease. Xerosis is the most common disorder in aged skin. Elderly patients are also more prone to skin infections and skin malignancy incidence is increasing.
There should be a full dermatological examination in admitted elderly patients looking for undiagnosed dermatoses, infections, skin cancers and manifestations of underlying systemic diseases. In affected patients, emollients and soap substitutes should be prescribed as standard and as basic treatment for pruritus, prevention of xerosis and skin injury. An appropriate topical formulation will aid compliance.
A maintenance regime in inflammatory dermatoses following an initial course of topical steroid also helps to break the itch/scratch cycle and reduce frequency of flares.
Key recommendations are to consider allergic contact dermatitis in refractory disease and dermatitis with an unusual distribution or patients with atopic dermatitis; to consider secondary bacterial infection in refractory disease; to look out for skin malignancies and refer promptly to a dermatologist and consider malignancy as a cause of non-healing lesions.
GM editorial team
Conflict of interest: none declared.