More than just skin deep: considerations when managing ageing skin

Skin problems abound in the older generations and though not contributing vast numbers to mortality figures, prove a morbidity burden on those in their later years. Skin goes through a number of physiological changes over time, influenced by both intrinsic and extrinsic factors. These factors promote the numerous skin pathologies that increase in number in older people, which ultimately guides patient management.

As individuals go through life they have different concerns and expectations regarding their physical health. With a wish to ‘stay young and beautiful’ it can be the skill in dermatological consultation to mediate expectations of the outcome.

Significant comorbidities, poly-pharmacy and dexterity issues provide a need for consideration not only to implications of diagnosis and treatment but also to the day to day requirements in managing chronic skin conditions.

Management of ageing skin

When planning management of ageing skin it is imperative to understand the natural consequences of age to skin. Skin has many more functions alongside its main role in acting as a barrier between the internal and external environment.¹ As skin ages, the vasculature progressively atrophies with capillaries and small vessels regressing and becoming disordered.²

This results in less effective thermoregulation. The supporting dermis also deteriorates, with collagen and elastin fibres becoming sparse. There is a loss of superficial pain sensation, which increases the risk of injury from external insults.² Generation of an inflammatory response is often blunted, with an increase in skin pH the susceptibility for infection increases.²³

Alongside this the repair capacity of the skin diminishes over time, resulting in slower healing as cellular proliferation rates drop significantly. A parallel erosion of normal immune function produces higher levels of autoimmune skin disorders.¹

With these changes in skin protective mechanisms, the incidence of malignancy inevitably multiplies. Patients presenting via the two-week-wait referral route will often complain of multiple lesions of concern. Management of these patients needs a careful multidisciplinary approach. It is even more paramount in these cases to make use of clinical photography to document and track skin change.

Increasing age should not be the only reason for undertaking a full skin review in consultation (as this is a fundamental part of all dermatological examinations); however, a higher index of suspicion and a closely discerning eye needs to be engaged.

Eyesight may be a limiting factor for the patient (hopefully not the doctor) in monitoring for any malignant skin changes and as such we should be the eyes of the ageing patient. We should be tracking the skin for any discreet yet sinister lesions.

Visible indicators of age

Skin changes with age are not experienced by the individual alone but are the visible indicators of age. The cosmetic effects of skin wrinkling, greying of hair, thinning and sun damage are ever more present as life expectancy increases, with estimations that in Western Societies it will be reasonable to become a centenarian.³ This means that in considering treatment of ageing skin, those in their later decades may have many years of fruitful living ahead.

The consideration of life expectancy may not factor highly in consultations of non-malignant conditions however, maybe it should? The older generations will often attain ‘it was different in our time’ having preceded the €˜Slip! Slop! Slap!’ generations.⁴ This may be the very target group to direct sun awareness campaigns towards. As chronological age increases so too do total sun hour exposure and environmental insults. It is imperative when making a management plan to enforce the need for sun protection measures as those who are €˜older’ (with cumulative damage done) but may not necessarily be ‘wiser’.

We cannot halt the process of ageing and often in the dermatology clinic we are presented with the cosmetic manifestations of these changes. In consultation it is key to go back to the basic levels of patient ideas, concerns and expectations; these can be very illuminating and provide a variety of answers as diverse as our patients. To quote Hippocrates ‘Cure sometimes, treat often, comfort always.’⁵

We need to recognise the importance in conditions with the cosmetic impact the need for firm, rational reassurance. This is imperative in patient groups where skin changes may manifest even if treatment is pursued; such as the recurrence of solar lentigos and an increasing number of seborrheic warts with age.

For those skin conditions which do require treatment, especially topical treatments require a number of physical and socioeconomic factors for success in application:

Memory in order to recall which creams go where and when (creams do not easily fit into blister packs without a level of mess!)
Dexterity and eyesight to not only open the containers but also to apply to the appropriate areas, many of which may be hard to reach
Compliance, especially in cases where the regular application may be required despite a more gradual improvement or long term effect (an issue not isolated to the older generations)
Availability in collection and continuation of prescriptions.

The implications of these factors need careful consideration prior to prescription. A detailed social and functional history will benefit the overall outcome. In managing more complicated cases, Day Treatment Units can be utilised to ensure timely and consistent application. This does not come without limitations with regards to patient transport and time requirements. It may then be useful with older patients to have closer engagement with the next of kin and those providing care.

Surgical intervention

In patients requiring lesion removal, the issue of wound healing should have an impact when planning for surgical intervention. The robust healing response seen in young skin is blunted in older generations.² Close monitoring of the excision site for early signs of infection and regular dressing changes will reduce the likelihood of superficial infections. With regard to the procedure, use of electrosurgery in both cautery and cutting has been shown to cause burn injury to the surrounding tissue and the destructive effects of the heat generation may hinder rather than promote healing.⁶

On a positive point of skin ageing, excision of lesions may be assisted by the reduction in skin elasticity, providing excess skin for closure without significant impacts on cosmetic outcome.

Multi-system problems often manifest with dermatoses. The affliction of numerous comorbidities can be viewed as an inevitable outcome of ageing but in management, there may be scope to link these together for an overall diagnosis. In a dermatology clinic, we are required to undertake a full external examination. Such physical exposure of patients can reveal undisclosed afflictions and ailments to which other doctors have been shielded.

It is central to effective patient management to communicate such findings clearly to our colleagues. General practitioners may be scratching their heads, looking for a thread with which to tie together the many patient afflictions.

The linking thread throughout this brief consideration of the management of ageing skin is the importance of a holistic approach. The older generations are not simply entities afflicted by ailments and effective patient care in these groups comes down to a thorough focused history and examination.

It is important to recognise that skin change will abound in the older generations and an understanding of the underlying pathophysiology will assist with decisions in management. As life expectancy increases so will the number of ageing patients presenting to our clinics. Our suspicion of malignant change needs to be engaged for any new or changing lesion but equally, in non-malignant conditions, a clear picture of the patient’s expectations may assist in directing appropriate care.

Dr Naomi Ruth Jones, Core Medical Trainee Year 1, Sandwell and West Birmingham Hospitals

References

Patel T, Yosipovitch G. Therapy of pruritus. Expert Opin Pharmacotherapy 2010;11:1673-82.
Farage MA, Miller KW, Elsner P, Maibach HI. Functional and physiological characteristics of the aging skin. Aging Clinical and Experimental Research. 2008 Jun;20(3):195-200.
Farage MA¹, Miller KW, Berardesca E, Maibach HI. Clinical implications of aging skin: cutaneous disorders in the elderly. America Journal of Clinical Dermatology. 2009;10(2):73-86.
Slip, slop, slap Campaign AU on http://www.sunsmart.com.au/slip-slop-slap-original-sunsmart-campaign.html. Accessed 30^th September 2017
Hippocrates. Translated by Jones WHS. Volume IV. Cambridge, MA: Loeb Classical Library; 1931.
Bhattacharya V et al. Effect of surgical traumas on microcirculation. Indian Journal of Plastic Surgery. 2009 Jul-Dec; 42(2): 146€“149