Skin Problems in the Elderly

Essentials

• Asteatotic eczema due to dry skin and excessive washing should be recognized.
• Common skin disorders, such as atopic eczema or psoriasis, may begin in old age.
• The diagnosis is usually based on history and clinical picture; it is worthwhile examining the skin status thoroughly.
• Elderly people are more prone to develop adverse effects of topical (glucocorticoids) and systemic treatment (antimicrobials, glucocorticoids).

General

• Ageing affects the skin, making it more susceptible to drying, increasing skin folds and decreasing ventilation, causing irritation due to maceration, skin atrophy and impaired healing of wounds.
• Decreased or incorrect skin care and, on the other hand, excessive washing or use of detergents drying the skin make skin problems worse.
• Urinary and/or fecal incontinence often cause contact dermatitis in the groin and buttocks.
• Underlying diseases (such as diabetes) and their medication may cause skin problems and affect the treatment response.
• Skin problems affect the quality of life and wellbeing of the elderly.

The most common causes

Single skin lesions

• Skin tumours are common in the elderly. A malignant tumour should be suspected if the diagnosis of a skin lesion is uncertain and if it grows, becomes ulcerated, bleeds or will not heal. Skin biopsy will confirm the diagnosis.
• Actinic keratosis Precancerous Lesions Preceding Squamous Cell Carcinoma (Actinic Keratosis and Carcinoma in Situ, or Bowen's Disease)
  • Erythematous patches covered by hyperkeratosis which is difficult to detach
  • Often feels rough on palpation.
  • Typical sites include the face (picture F15), scalp, arms, backs of the hands
• Skin cancers Melanoma Basal Cell Carcinoma
  • Malignant skin tumours change and grow over time. Diagnosis can usually be made based on histology.
  • Lentigo maligna of the face (picture F17) and spinocellular carcinoma of the lower lip (picture F18) should be particularly kept in mind.
• Benign skin lesions
  • Seborrhoeic keratoses (picture F19), solar lentigos (picture F13), senile angiomas, fibromas (picture F20) and pigmented naevi are common.
• Induration and calluses
  • In areas susceptible to friction, caused by factors such as poorly fitting shoes or malposition

Ulcers

• Leg ulcers Treatment of Lower Extremity Ulcers
  • Failure of venous or arterial circulation, diabetes, local swelling
  • Elderly people often have mixed-type ulcers with several causes
• Posttraumatic ulcers
  • Common in the elderly in the legs, for example
  • Healing is also influenced by wound infection, any underlying diseases, medication and circulation; local swelling impairs the healing of such wounds.
• Pressure sores Prevention and Treatment of Pressure Ulcers
  • At the early stage, nonblanchable erythema of intact skin on an area subject to pressure
  • Remember early detection and prevention of pressure sores.
• Ulcers due to tumours
  • Tumours may present as poorly healing atypical ulcers; biopsy from the ulcer margin

Rarer skin problems

• Psoriasis Psoriasis
  • May not appear until in old age.
  • Typically situated on the scalp, palms and soles of feet, elbows and knees
• Bullous pemphigoid Chronic Bullous Diseases (Dermatitis Herpetiformis, Pemphigoid, Pemphigus)
  • Rare blistering autoimmune disease, usually in the elderly
  • Erythematous patches covered by blisters containing clear fluid, itching (picture F21)
  • Patients are usually in good general health.
• Lichen ruber planus Lichen Planus
  • Purplish itchy papules on the trunk and the limbs (picture F22)
  • May cause lesions on oral (picture F23) and genital mucosa.
• Drug-induced eczema Hypersensitivity to Drugs
  • More common in the elderly due to use of more medication
  • It is most important to confirm the temporal connection between the eczema and the drug.
• Allergic contact dermatitis Allergic Contact Dermatitis
  • Usually acute, itchy, clinically eczematous dermatitis
  • Sensitization to topical skin treatments
  • Common in patients with leg ulcers

Examination

• Duration and any variation of symptoms
• Occurrence of systemic symptoms (fever, malaise)
• History of skin disorders, such as atopic eczema or psoriasis
• Any aggravating factors (hobbies, washing habits)
• Living environment and washing facilities, any need for help
• A skin examination also includes the scalp, palms, soles of the feet, oral mucosa and nails.
• If scabies is suspected, a thorough examination of the skin and a dermatoscopic examination of the typical scabies sites are important.

Treatment

• Use of mild washing liquid or ointment, avoiding rubbing to dry
• Regular use of a non-medicated emollient ointment, particularly after washing
• Regular washing of flexural areas, topical treatments to reduce friction
• Appropriate UV protection
• Topical treatment should be preferred in the treatment of skin problems in the elderly due to its lesser adverse effects. Periodically repeated treatment or continuous maintenance treatment is often necessary.
• In dry (asteatotic) eczema, the skin requires regular use of ointments, and the use of a non-medicated emollient ointment alone with avoidance of drying factors may be sufficient. Topical glucocorticoids should be used for exacerbations.
• In eczematous diseases, the treatment of first choice on the trunk and limbs is intermittent mid- or high-potency topical glucocorticoids for 2 to 3 weeks at a time and for the face low-potency topical glucocorticoids intermittently for 1 to 2 weeks at a time.
• Regular use of non-medicated emollient ointments may prevent recurrence and exacerbations.
• For atopic eczema, topical calcineurin inhibitors (tacrolimus and pimecrolimus ointments) are also effective; both should be used in sufficiently long courses Atopic Eczema (Atopic Dermatitis) in Adults.
• Topical mild to mid-potency glucocorticoid solutions applied to the scalp and ointments applied to the skin are effective in the treatment of seborrhoeic eczema. Skin oil, for example, can be used to detach the crust on the scalp in the evening before washing. Topical azole antifungals (shampoo, solution or ointment) can also be used to alleviate the symptoms Seborrhoeic Dermatitis in the Adult.
• For intertrigo and other types of maceration, regular washing, keeping the skin dry and using gauze dressing pads to prevent skin folds from touching; daily zinc paste or talcum powder. In addition, intermittent treatment with an antimycotic ointment, miconazole powder or a combination ointment with mild glucocorticoid and antimycotic can be used twice daily for 1 to 2 weeks.
• For macerations, also the following extemporaneous preparations have been used:
  • Sulphur-hydrocortisone cream: Sulfur. medic. 2.0, Hydrocortison. 1.0, mixed with an emollient cream ad 100.0, to be used 1-2 times daily in courses of 1-2 weeks
  • Zinc paraffin: Zinc. oxid. 40.0, Paraff. liq. 60.0, to be used 1-2 times a day, as necessary
• For rosacea Rosacea primarily topical metronidazole, azelaic acid or ivermectin should be used.
• Impetigo Impetigo: for impetigo confined to a limited area, topical treatment with an antimicrobial ointment may be sufficient but for more extensive disease systemic antimicrobial treatment is necessary.
• Ringworm
  • Ringworm of the groin, trunk or feet can often be cured with topical treatment. In treatment-resistant cases, systemic treatment may be necessary.
  • In onychomycosis, long-term systemic treatment is often necessary. Treatment results are worse in the elderly than in younger patients, and the need for treatment must be carefully weighed against the potential advantages.
• Antifungal medicines have numerous interactions with other drugs.

Specialist consultation

• A dermatologist should be consulted in cases unresponsive to treatment and in unclear skin problems.
• In the case of a severe rash urgent consultation of a dermatologist should be considered.