Common Skin Conditions in Geriatric Dermatology
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Introduction
According to current U.S. Census statistics, the population is getting older, with a greater percentage of the population in the over-65 age group. This trend is expected to continue well into the 21st century.1 Additionally, with the population of those age 80 and over also rapidly increasing, an increased emphasis on geriatric medicine is inevitable. Geriatric dermatology is a specialty that will receive particular attention.2
As people age, their chances of developing skin-related disorders increase. Two types of skin aging exist, which may be divided into intrinsic aging, which includes those changes that are due to normal maturity and occur in all individuals, and extrinsic aging, produced by extrinsic factors such as ultraviolet light exposure, smoking, and environmental pollutants. Decreased mobility, drug-induced disorders, and increased incidences of many chronic diseases are among the reasons elderly individuals are at heightened risk for skin diseases. Atherosclerosis, diabetes mellitus, human immunodeficiency virus (HIV), and congestive heart failure are some disease processes that can be detrimental to skin. These diseases are known to impede vascular efficiency and decrease immune responses, thereby reducing the body’s ability to heal.
Many histological changes occur with aging and photoaging (Tables I and II). Variation in cell size, shape, and staining results in epidermal dyscrasia of photoaged skin. Melanocytes decline and Langerhans’ cells (intradermal macrophages) decrease in density. The dermis becomes relatively acellular, avascular, and less dense, and the loss of functional elastic tissue results in wrinkles. The nerves, microcirculation, and sweat glands undergo a gradual decline, predisposing to decreased thermoregulation and sensitivity to burning. Nails undergo a slow decline in growth, with thinning of the nail plate, longitudinal ridging, and splitting. The subcutaneous fat layer atrophies on the cheeks and distal extremities, but hypertrophies on the waist of men and thighs of women.
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Table I: Aging Skin
Epidermal Changes
Melanocytes
Approximately 15% decline per decade
Density doubles on sun-exposed skin
Increased lentigines
Langerhans cells
Decreased density
Decreased responsiveness
Dermal changes
Decreased collagen--1% annual decline, altered fibers
Decreased density
Progressive loss of elastic tissue in the papillary dermis
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Table II: Skin Changes in Aging
Loss of elasticity and thinning of the skin
Clinical Results: xerosis, laxity, wrinkling, uneven pigmentation, easy tearing, traumatic pupura
Photoaging
Clinical Results: actinic keratoses, fine and coarse wrinkling, telangiectasia, blotchiness and pigmentary changes, elastotic skin with giant comedones
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Many elderly persons will spend their time in nursing homes and assisted living facilities.3 Caregivers and medical personnel can help decrease or prevent the development of many skin disorders in the elderly by addressing several factors. Included in factors to consider are the patient’s nutritional state, medical history, current medications, allergies, physical limitations, mental state, and personal hygiene.
This article will look at common skin disorders found in the elderly individual. These include xerosis, pruritis, eczematic dermatitis, purpura, and chronic venous insufficiency.
Xerosis
Xerosis is characterized by pruritic, dry, cracked, and fissured skin with scaling. Xerosis occurs most often on the legs of elderly patients but may be present on the hands and trunk. The appearance of xerotic skin is like a pattern of cracked porcelain. These cracks or fissures are present from epidermal water loss.
1. U.S. Bureau of the Census. Population projections of the United States by age, sex, race, and Hispanic origin: 1995-2050. Current Population Reports. Washington, DC: U.S. Government Printing Office, 1996a:25-1130. Available at: http://www.census.gov/prod/1/pop/p25-1130. Accessed September 17, 2007.
2. Norman R. The aging of the world’s population. In: Norman R, ed. Geriatric Dermatology. New York, NY:Parthenon Publishing; 2001:1-4.
3. Norman R. Dermatological problems and treatment in long-term/nursing-home care. In: Norman R, ed. Geriatric Dermatology. New York, NY: Parthenon Publishing; 2001:5-16.
4. Norman R. Xerosis and pruritus. Annals of Long-Term Care: Clinical Care and Aging 2001;9(12):35-40.
5. Aoyama H, Tanaka M, Hara M, et al. Nummular eczema: An addition of senile xerosis and unique cutaneous reactivities to environmental aeroallergens. Dermatology 1999;199(2):135-139.
6. Rogers J, Harding R, Mayo C, Rawlings A. Stratum corneum lipids: The effect of ageing and the seasons. Arch Dermatol Res 1996;288(12):765-770.
7. Weismann K, Wadskov S, Mikkelsen HI, et al. Acquired zinc deficiency dermatosis in man. Arch Dermatol 1978;114(10):1509-1511.
8. Rowe A, Mallon E, Rosenberger P, et al. Depletion of cutaneous peptidergic innervation in HIV-associated xerosis. J Invest Dermatol 1999;112(3):284-289.
9. Simon M, Bernard D, Minondo AM, et al. Persistence of both peripheral and non-peripheral corneodesmosomes in the upper stratum corneum of winter xerosis skin versus only peripheral in normal skin. J Invest Dermatol 2001;116(1):23-30.
10. Engelke M, Jensen J, Ekanayake-Mudiyanselage S, Proksch E. Effects of xerosis and ageing on epidermal proliferation and differentiation. Br J Dermatol 1997;137(2):219-225.
11. De Paepe K, Derde M, Roseeuw D, Rogiers V. Incorporation of ceramide 3B in dermatocosmetic emulsions: Effect on the transepidermal water loss of sodium lauryl sulphate-damaged skin. J Eur Acad Dermatol Venereol 2000;14(4),272-279.
12. Thaipisuttikul Y. Pruritic skin diseases in the elderly. J Dermatol 1998;25(3):153-157.
13. Jennings MB, Alfieri D, Ward K, Lesczczynski C. Comparison of salicylic acid and urea versus ammonium lactate for the treatment of foot xerosis. A randomized, double blind, clinical study. J Am Podiatr Med Assoc 1998;88(7):332-336.
14. Kempers S, Katz HI, Wildnauer R, Green B. An evaluation of the effect of an alpha hydroxy acid-blend skin cream in the cosmetic improvement of symptoms of moderate to severe xerosis, epidermolytic hyperkeratosis, and ichthyosis. Cutis 1998;61(5):347-350.
15. Wolf B, Paster A, Levy S. An alpha hydroxy acid derivative suitable for sensitive skin. Dermatol Surg 1996;22(5):469-473.
16. El Gammal C, Pagnoni A, Kligman A, Gammal S. A model to assess the efficacy of moisturizers--the quantification of soap-induced xerosis by image analysis of adhesive-coated discs (D-Squames). Clin Exp Dermatol 1996;21(5):338-343.
17. Rawlings A, Harding C, Watkinson A, et al. The effect of glycerol and humidity on desmosome degradation in stratum corneum. Arch Dermatol Res 1995;287(5):457-464.
18. Lazar A, Lazar P. Dry skin, water, and lubrication. Dermatol Clin 1999;9(1):45-51.
19. Johansson O, Virtanen M, Hilliges M. Histaminergic nerves demonstrated in the skin. A new direct mode of neurogenic inflammation. Exp Dermatol 1995;4(2):93-96.
20. Wahlgren C. Measurement of itch. Semin Dermatol 1995;14(4):277-284.
21. Woodward D, Nieves A, Spada C, et al. Characterization of a behavioral model for peripherally evoked itch suggests platelet-activating factor as a potent pruritogen. J Pharmacol Exp Ther 1995;272(2):758-765.
22. Fleischer A Jr. Pruritus in the elderly: Management by senior dermatologists. J Am Acad Dermatol 1993;28(4):603-609.
23. Seidenari S, Giusti G. Objective assessment of the skin of children affected by atopic dermatitis: A study of pH, capacitance, and TEWL in eczematous and clinically uninvolved skin. Acta Derm Venereol 1995;75:429-433.
24. Rukwied R, Lischetzki G, McGlone F, et al. Mast cell mediators other than histamine induce pruritus in atopic dermatitis patients: A dermal microdialysis study. Br J Dermatol 2000;142(6):1114-1120.
25. Graham J. A guide to atopic eczema [honours project]. Edinburgh, Scotland; Napier University, Department of Biological Sciences: 1997. Available at: http://www.biol.napier.ac.uk/BWS/COURSES/projects/eczema/itching.htm. Accessed September 17, 2007.
26. Kuen-kong L, Lai-yin C, Yuk-ming T, eds. Handbook of Dermatology & Venereology. 2nd ed. Western District, Hong Kong; Social Hygiene Service Department of Health; 1997.
27. Kosko D. Dermatologic manifestations of human immunodeficiency virus disease. Lippincotts Prim Care Pract 1997;1(1):50-61.
28. Robertson K, Mueller B. Uremic pruritus. Am J Health Syst Pharm 1996;53(18):2159-2170.
29. Drake L, Millikan L. The antipruritic effect of 5% Doxepin cream in patients with eczematous dermatitis. Doxepin Study Group. Arch Dermatol 1995;131(12):1403-1408.
30. Dermatology: Pruritis. In: Herting R, Toth PA, eds. University of Iowa Family Practice Handbook 3rd ed.
31. Habif T, Campbell J Jr, Quitadamo M, Zug K. Skin Disease: Diagnosis and Treatment. St. Louis, MO: Mosby;2001.
32. Moschella S. Skin diseases of the elderly. In: Norman R, ed. Geriatric Dermatology. New York, NY: Parthenon Publishing; 2001:17-34.
33. Fruensgaard K. Psychotherapeutic strategy and neurotic excoriations. Int J Dermatol 1991;30:198-203.
34. Fried RG. Evaluation and treatment of “psychogenic” pruritus and self excoriation. J Am Acad Dermatol 1994;30:993-999.
35. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. St. Louis, MO: Mosby; 1996.
36. Cotran R, Kumar V, Collins T. Robbins’ Pathological Basis of Disease. 6th ed. Philadelphia, PA: WB Saunders Co; 1999.
37. Keratoacanthoma. In: Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D, eds. Color Atlas and Synopsis of Clinical Dermatology. 4th ed. New York: McGraw-Hill; 2001:196-198.
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