Aging skin: skin care and differential diagnoses for the elder mountaineer.
According to a recent Mayo Clinic study, skin related complaints are the most common reason that patients visit doctors. (1) The elderly population is particularly at risk for skin related problems given the cumulative intrinsic and extrinsic damage inflicted upon the skin with aging. Further, the prevalence of some dermatologic conditions increase with aging, ranging from relatively benign xerosis to potentially lethal skin cancers. Part one of this article reviews the pathophysiologic changes to the skin with aging and discusses approaches to optimize skin care. Part two discusses common rashes encountered in the elderly with an emphasis on treatment. Finally, part three focuses on recognition of skin cancer given that nonmelanoma skin cancers are more common than all other malignancies combined in the elderly.
Part 1: Skin Aging
Skin aging is a complex biological process involving two main contributors: genetics and environment. Chronological or intrinsic skin aging is an inevitable, inherent genetic process that occurs with time. Reactive oxygen species generated during oxidative cellular metabolism and telomere shortening with subsequent cellular divisions lead to an eventual cellular death and cellular senescence. (2) Ultraviolet radiation (UVR) is the most important environmental factor involved in premature skin aging. Photoaging refers to the cumulative damage obtained from chronic ultraviolet (UV) light exposure.
As the top layer of the skin, the epidermis functions as barrier protection against harmful substances and prevents water loss. The stratum corneum, the outermost layer of the epidermis, thickens variably with aging. (3) Desquamation of the stratum corneum also slows throughout life leading to a buildup of corneocytes. Conversely, the amount of intercellular lipids within the epidermis decreases as skin ages. Filaggrin and its subsequent product, natural moisturizing factor (NMF), serve as key components of the stratum corneum to aggregate keratins. As aging of the skin occurs, filaggrin levels and thus NMF levels decrease, while the pH of the skin increases. It is the accumulation of these changes that lead to dull, xerotic, toughened skin with an increased propensity for pruritis. (3)
Deep to the epidermis is the dermis, comprised of collagens I and III, elastins, proteoglycans, and fibronectin. Complex networks that exist within the extracellular matrix of the dermis provide structural support, elasticity, tautness, and bind large amounts of water. (4) A reduced number and strength of papillary dermal microfibrils, disorganized elastic fibers, degeneration and disorganization of collagen, and a weakening of fibril networks lead to wrinkles, laxity of the skin, and propensity for easy bruising or senile purpura. (2,3) UVR contributes to the degradation of collagen and the extracellular matrix.
The foundation of optimal skin care in the elderly includes cleansing, moisturizing, and protecting from excessive sun exposure. Cleansing removes environmental contaminants, personal secretions, and desquamated corneocytes. As soaps and detergents can greatly exacerbate dry skin, using gentle emollient cleansers is recommended. Taking less frequent showers and avoiding bathing with hot water are additional steps to combat dry skin. To restore natural moisture to the stratum corneum, occlusives, emollients, and humectants should be used. Occlusives, such as petroleum jelly and lanolin based ointments, are greasy materials that seal in moisture by forming an impermeable barrier on the skin. Emollients are mixtures of water and oil which act to decrease evaporation on the skin, similar to occlusives but with shorter-lived effects. Humectants are substances with a high affinity for water, thereby driving increased fluidity into the epidermis. Common humectants include urea, glycerin, and alpha hydroxy acids such as lactic acid and glycolic acid. Treatment with acid based humectants is particularly effective given the age-induced increased pH of the skin. Blaak et al., have found that long-term treatment with lotion of pH of 4.0 results in significant improvement of the stratum corneum barrier function and also with the appearance of dry skin in elderly patients.5 Sun protection is recommended to decrease the rate of photoaging. Sunscreen with a sun protection factor (SPF) of 30 or above with broad spectrum UV protection (against both UVA and UVB rays), reapplied every 2-3 hours is ideal. If diminished vitamin D level is a concern for the patient, oral supplementation should be considered. (6)
Ultimately, aging of the skin is an inseparable combination of intrinsic aging and photoaging, although the latter can remarkably exacerbate the rate and severity at which we age. Adequate moisturizing to compensate for diminished cutaneous lipids, as well as strict sun protection to decrease photoaging effects, are staples of skin care in the elderly.
Part 2: Common Rashes
There are numerous rashes seen in the elderly population, some of which are almost exclusively seen in old age. Below are the most commonly seen rashes encountered in the elderly in the outpatient setting, beginning with eczematous dermatoses, followed by immune-mediated and inflammatory dermatoses, and concluding with infectious rashes.
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Part 2a. Eczematous Dermatoses
Xerosis of skin may be a primary finding or secondary manifestation of chronic medical conditions such as hypothyroidism. It presents with dry, flaky skin with or without associated pruritus. (Figure 1). It may be localized or generalized. Senescent skin changes such as decreased sebum, lipids, and sweat as well as reduced barrier repair, contribute to xerosis and pruritus. (4) Optimized skin care, paramount in treating this condition, was previously discussed.
Seborrheic dermatitis presents with scaly, oily patches and plaques predominantly on areas with higher density of sebaceous glands such as the scalp, eyebrows, nasolabial folds, and infrequently, the chest. The rash may be pruritic, although often it is asymptomatic. Treatment with topical ketoconazole 2% shampoo or cream can provide relief. Low potency topical steroids can also be used in short duration, but prolonged use on the face should be avoided.
Seborrheic dermatitis has a chronic, relapsing course. Patients with immunosuppression or underlying neurologic disorders such as Parkinson's disease have more severe presentations and are more refractory to therapy. (7,8)
Nummular eczema, which presents as coin-shaped erythematous, eczematous plaques favoring the lower extremities, tends to be more common in the elderly. Often, allergic contact dermatitis to a topically applied allergen triggers this condition. Treatment can prove challenging. Patients require optimization of skin care and avoidance of any identifiable offending agent. Minimizing topical products, switching to fragrance-free hygiene products, and frequent moisturizing with a petrolatum-based ointment may be helpful. Patch testing should be considered to screen for allergens contributing to contact dermatitis.
Stasis dermatitis, another eczematous dermatitis favoring the lower extremities, is associated with underlying venous stasis, which worsens with increasing age. Pathogenesis involves a damaged capillary permeability barrier and passage of fluid and plasma proteins into the tissue, as well as chronic inflammation and microangiopathy. (4) Stasis dermatitis presents as pruritic, eczematous, hyperpigmented patches on distal lower extremities. Optimization of skin care, compression stockings, and topical corticosteroids should be considered for treatment. (2,4) Referral to a vascular specialist might be needed to determine if surgical intervention is indicated.
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Contact dermatitis, another eczematous dermatitis, can be divided into an allergic form, which requires prior sensitization, and an irritant form, which does not require sensitization (Figure 2). The former is seen with chronic exposure to allergens and may develop within a short or long period after the exposure has begun, while the latter is seen with more acute exposure to irritants. Allergens commonly encountered include preservatives, metals such as nickel, and fragrances. (4) Patch testing for common allergens and strict avoidance of reactive allergens will usually lead to resolution of the rash.
Part 2b. Immune-Mediated and Inflammatory Dermatoses
Rosacea's incidence increases with age, especially in the Caucasian population. Rosacea most commonly presents as erythematous patches with telangiectasias on the cheeks and nose. Occasionally, inflammatory papules and pustules can occur, but it is the absence of comedones that distinguishes rosacea from acne. (2,4) Phymatous changes, characterized by proliferation of sebaceous glands, and ocular involvement are less common variants of rosacea. (4) Triggers such as ultraviolet light, dry skin, heat, stress, hot beverages, and spicy foods are common. Trigger avoidance is paramount to treatment success. Sun protection and moisturizers also play an important role in controlling rosacea flares. Topical metronidazole, sulfur based washes, and azelaic acid are commonly used treatments. Papulopustular rosacea as well as ocular rosacea require oral antimicrobials, often of the tetracycline family.
Drug eruptions can be seen in any age group: however, the increased number of prescription and over-the-counter drugs used by the elderly makes this a concern for this population. Patients typically present with a morbiliform, relatively symmetric eruption involving the trunk and extremities. There are a variety of drug eruptions with differing lag times between medication exposure and onset of the rash. However, the most common exanthematous drug eruptions appear within 7 to 21 days of initiating a new medication and may appear even after a drug has been discontinued. (4) Obtaining an accurate history is essential. Some drug eruptions may have concomitant systemic involvement and any complaints of skin pain, fever, cutaneous desquamation, and mucous membrane involvement should raise concern for a more serious medication reaction such as toxic epidermal necrolysis. (4)
Bullous pemphigoid is a disease of the elderly and presents as pruritic tense bullae favoring the flexural creases, and sometimes as erythematous urticarial plaques. (4) Prompt diagnosis with skin biopsy and immunofluorescence studies is crucial. Medications, especially furosemide, can trigger bullous pemphigoid and should be discontinued if implicated. (9) Long tapers of corticosteroids with or without other immunosuppressive medications are often needed to control the disease.
Part 2c. Infectious Rashes
Tinea infections are common and may involve the feet (tinea pedis), inguinal region (tinea cruris), and less often the scalp (tinea capitis) or hands (tinea manuum). (4) Tinea infections can also be generalized (tinea corporis). Onychomycosis is a common co-existing finding, especially with tinea pedis. Treatment should take into consideration the involved sites and may include topical or oral antifungals. Diabetic patients may benefit from concomitant treatment of onychomycosis and interdigital tinea pedis given the increased risk of cellulitis in this population.
Herpes zoster usually presents as a unilateral dermatomal vesicular eruption with associated pain. Immunization is recommended in the elderly population and the Center for Disease Control and Prevention (CDC) recommends herpes zoster vaccine for use in people aged 60 and above. (10) Immunization decreases the incidence of herpes zoster by 51.3 percent, while reducing the incidence of postherpetic neuralgia by 66.5 percent. (11) Treatment with antivirals should preferably be initiated within 72 hours of onset of symptoms.
Infestations may also be seen in this age group. Scabies infestations are particularly rampant in long-term healthcare facilities. Sudden onset of a pruritic eruption in the setting of a long-term care facility should prompt a high index of suspicion for scabies. Interdigital and genital skin is preferentially involved. Topical permethrin 5% cream and oral ivermectin are both effective treatments, and should be repeated after 10-14 days. Care must be taken to clean and wash personal items as well as bedding and clothing at the hottest setting available, preferably with steam. Household members may also require treatment of scabies.
Part 3: Skin Cancers
The three most common types of skin cancers seen in adults include basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. The annual incidence of non-melanoma skin cancers (NMSC), including the basal cell and squamous cell carcinomas, is estimated at 230 per 100,000 people in the US, making the occurrence of NMSC more common than all other cancers combined. An estimated 20% of Americans will develop NMSC in their lifetimes. (4)
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Approximately four times more common than squamous cell carcinoma, basal cell carcinoma (BCC) is the most common type of NMSC. BCC occurs most commonly on the face, neck, upper chest, shoulders, and back in sun-exposed areas. Early identification and surgical removal is the best treatment approach. Commonly described as pearly pink papules with telangiectasias, BCCs are often slow-growing and persistent in nature (Figure 3). Bleeding without associated trauma, recurrent skin breakdown, and scab formation are common presenting clinical complaints.
BCCs should be surgically removed to avoid further growth and destruction of the surrounding tissues and to prevent possible metastasis. Case reports of metastatic BCCs are exceedingly rare.
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Squamous Cell Carcinoma (SCC) is the second most common type of skin cancer. Actinic keratoses (AKs), are precursors to SCCs with approximately 0.1% of AKs evolving into SCCs each year. AKs range in appearance from rough patches of skin to erythematous hyperkeratotic papules. Treatment options for actinic keratoses include cryotherapy or field therapy with 5-fluorouracil, imiquimod, ingenol mebutate, or photodynamic therapy. Progression of an AK or a de novo SCC is most commonly seen in sun exposed areas including arms, hands, face, head and neck. Clinically, SCCs often present as painful, pink papules that have a hard, keratotic surface (Figure 4). The keratoacanthoma type of SCC can grow very rapidly, over several weeks and classically forms a crateriform nodule with a central keratotic core. (4) Bleeding of SCCs occurs less commonly when compared to BCC.
Patients with immunosuppression, including people with HIV or iatrogenic immune suppression from organ transplantation, have an incidence of squamous cell carcinoma up to 250 times higher than baseline patient risk. (4) In contrast to the general population, SCCs are the most common skin malignancy among the immunosuppressed. SCCs metastasize in >5% of cases. This risk of metastasis increases with increased tumor thickness as well as with certain high risk cancer locations including the ear, lips, and mucosa. (4)
Melanoma is the skin cancer associated with the greatest morbidity and mortality, killing 8000 people in the United States each year. (12) Melanoma is strongly linked to sun exposure and tanning bed use. The ABCDE's of Melanoma is a useful tool to help physicians and patients alike with melanoma detection (Figure 5). Early detection of melanoma is critical. Patient self examinations as well as full body skin examinations by trained healthcare professionals are crucial for early identification.
The high mortality associated with melanoma is attributed to its unpredictable pattern of metastasis. Unlike SCC, which rarely metastasizes when the cancer is small in size, melanoma can metastasize when the primary tumor is extremely small. Melanoma frequently metastasizes when the primary tumor becomes invasive. Dermatological evaluation and screening for early detection is vital. Excision with wide local margins and possible adjuvant therapy with novel immune checkpoint inhibitors and targeted chemotherapy agents are the preferred treatments. Research on new metastatic melanoma treatments is ongoing and results from this work may change the future of melanoma therapy.
For all skin cancers the most important aspects of prevention are vigilant sun protection, diligent self examinations to look for evolution of skin lesions and full body skin checks by a trained healthcare provider.
Skin care and skin disease provide a unique challenge in the elderly population. The lifelong accumulation of sun damage, along with the intrinsic skin changes of aging, result in a thickened, yet weakened, epidermal barrier. Skin rashes, infestations, and infections are common in this population, and may represent concomitant underlying illnesses or medication reactions. Further, management of skin cancer in the elderly comes with significant associated morbidity and mortality. Sun protection, moisturizing and frequent dermatological screenings are paramount to skin health in the Elder Mountaineer.
Objectives Skin related complaints are common in the elderly. The aim of this article is to review the physiologic skin changes associated with aging, and to improve recognition and treatment of skin problems occurring in advanced age.
Zachary Zinn, MD
Assistant Professor, WVU SOM, Section of Dermatology
Sarah Ellison, MD
PGY2 Dermatology Resident, WVU
Hayley Leight, BA
4th Year Medical Student, WVU
Jason Meeker, MD
PGY3 Dermatology Resident, WVU
Omid Jalali, MD
PGY4 Dermatology Resident, WVU
Corresponding Author: Zachary Zinn, MD, Assistant Professor, West Virginia University Section of Dermatology, 1 Medical Center Drive, Box 9158, Morgantown, WV 26506. Email: email@example.com.
Disclosure: Drs. Zinn, Ellison, Meeker, Jalali and Ms. Leight disclosed discussion of off-label use for ivermectin.
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(2.) Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York, NY: McGraw Hill; 2008.
(3.) Gilchrest BA, Krutmann J. Skin Aging. Berlin: Springer; 2006.
(4.) Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2012.
(5.) Blaak J, Kaup O, Hoppe W, et al. A Long-Term Study to Evaluate Acidic Skin Care Treatment in Nursing Home Resident: Impact on Epidermal Barrier Function and Microflora in Aged Skin. Skin Pharmacol Physiol. 2015;28(5):269-279.
(6.) American Academy of Dermatology. Prevent skin cancer. American Academy of Dermatology Website. https://www.aad.org/spot-skin-cancer/learn-aboutskin-cancer/prevent-skin-cancer. Published 2015. Accessed October 15, 2015.
(7.) Gupta A, Bluhm R. Seborrheic dermatitis. J Eur Acad Dermatol Venereol. 2004;18:13-26.
(8.) Mathes BM, Douglass MC. Seborrheic dermatitis in patients with the acquired immunodeficiency syndrome. J Am Acad Dermatol 1985;13:947-51.
(9.) Lee JJ, Downham TF. Furosemide-induced bullous pemphigoid: case report and review literature. J Drugs Dermatol. 2006;5:562-564.
(10.) U.S. Department of Health and Human Services Center for Disease Control and Prevention. Recommended Adult Immunization Schedule United States 2015. Center for Disease Control and Prevention Website. http://www.cdc.gov/vaccines/schedules/downloads/adult/adultcombinedschedule.pdf. Published February 2015. Accessed September 5, 2015.
(11.) Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352(22):2271- 2284.
(12.) U.S. Department of Health and Human Services Center for Disease Control and Prevention. Melanoma Surveillance in the United States. Cancer Prevention and Control. http://www.cdc.gov/cancer/dcpc/research/articles/melanoma_supplement.htm. Updated November 2, 2011. Accessed September 10, 2015.
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|Title Annotation:||Special CME Issue|
|Author:||Zinn, Zachary; Ellison, Sarah; Leight, Hayley; Meeker, Jason; Jalali, Omid|
|Publication:||West Virginia Medical Journal|
|Date:||May 1, 2016|
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