Am J Clin Dermatol. 2009;10(2):73-86. doi: 10.2165/00128071-200910020-00001.

Clinical implications of aging skin: cutaneous disorders in the elderly.

Farage MA, Miller KW, Berardesca E, Maibach HI.
Source
The Procter & Gamble Company, Winton Hill Business Center, Cincinnati, Ohio, USA. farage.m@pg.com

Abstract
Aging skin undergoes progressive degenerative change. Structural and physiologic changes
that occur as a natural consequence of intrinsic aging combined with the effects of a lifetime
of ongoing cumulative extrinsic damage and environment insult (e.g. overexposure to solar
radiation) can produce a marked susceptibility to dermatologic disorders in the elderly. As skin
ages, the vasculature progressively atrophies. The supporting dermis also deteriorates, with
collagen and elastin fibers becoming sparse and increasingly disordered. These changes
leave the elderly increasingly susceptible to both vascular disorders such as stasis dermatitis
and skin injuries such as pressure ulcers and skin tears, with a steadily decreasing ability to
effect skin repair. A parallel erosion of normal immune function produces higher levels of
autoimmune skin disorders such as bullous pemphigoid, benign mucous membrane
pemphigoid, paraneoplastic pemphigoid, and pemphigus vulgaris. Lichen sclerosus, an
autoimmune disorder often occurring in the genital area in older women, is not common but is
an important development because of the potential for substantial discomfort as well as
serious complications. The prevalence of polypharmacy in this population increases the risk
for autoimmune drug reactions, and diagnosis should be undertaken with an awareness that
polypharmacy in this population creates a greatly increased susceptibility to drug eruptions
that can mimic other cutaneous disorders. Immunologic senescence in the elderly also sets
the stage for potential reactivation of the Varicella zoster virus, in which initial dermatologic
involvement expands into the major sensory ganglia. Known as shingles, this disorder can be
excruciatingly painful with the potential to cause blindness if the optic nerve becomes
involved. Dermatoses such as xerosis, pruritus, and eczema are also widespread in the
elderly, create substantial suffering in those afflicted, and often prove recalcitrant to treatment.
Individual susceptibility to specific types of contact dermatitis changes over the lifetime, and
seborrheic dermatitis is substantially more prevalent in the elderly. It is not uncommon for
older patients to have multiple impairments, with the potential for cognitive dysfunction as well
as impaired vision, hearing, or mobility. In addition, they may not have adequate housing or
nutrition, or the financial resources necessary for adequate compliance. Physicians must take
into consideration the patient's physical ability to comply with the recommended therapy as
well as socioeconomic factors that may impact on compliance. Simple topical regimens are
preferable wherever possible in order to maximize compliance and, therefore, efficacy. Extra
effort may be necessary to ensure that instructions are accurately followed and that ongoing
compliance with the regimen prescribed is actually achieved. Management of dermatologic
disorders in the elderly is often less than optimal, due to the fact that the special needs and
limitations of this population are not adequately considered. Treatments should consider the
intrinsic differences between younger and older patients that may impact on diagnosis and
therapy choice. The aged patient is often afflicted with numerous co-morbidities that can
influence the choice of therapy. Skin integrity in the elderly is compromised, and safety
concerns are increased with the long-term use of any medication prescribed. In addition, the
prevalence of polypharmacy in the aged population substantially increases the risk of
cutaneous drug reactions, which can profoundly complicate accurate diagnosis of
dermatologic disorders. The aged population also needs to be more closely monitored
because of increased fragility of the skin and the physical limitations that may hinder
compliance with prescribed regimens.
PMID: 19222248 [PubMed - indexed for MEDLINE]
-----------------Drugs Aging. 2002;19(7):503-14.

Viral skin infections in the elderly: diagnosis and management.

Bansal R, Tutrone WD, Weinberg JM.
Source
Department of Dermatology, St. Luke's-Roosevelt Hospital Center, 1090 Amsterdam Avenue, New York, NY
10025, USA.

Abstract
Over the past several years, there have been advances in the diagnosis and treatment of
cutaneous viral diseases in elderly patients. Herpes zoster is caused by reactivation in adults
of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years,
aciclovir was the gold standard of antiviral therapy for the treatment of herpes zoster.
Famciclovir and valaciclovir are newer antivirals, which offer less frequent administration.
Postherpetic neuralgia (PHN) refers to pain lasting 2 months or more after an acute attack of
herpes zoster. The pain may be constant or intermittent. The treatment of established PHN
may include topical anaesthetics, analgesics, tricyclic antidepressants and anticonvulsants,
and nonpharmacological therapy may be used to complement such treatment. Therapeutic
strategies to prevent PHN include the use of oral corticosteroids, nerve blocks, and treatment
with standard antiviral therapy. The three most recently discovered human herpes viruses
(HHV-6, HHV-7 and HHV-8), in common with the other members of the family, may cause a
primary infection, establish latent infection in a specific set of cells in their host, and then
reactivate if conditions of altered immunity develop. These viruses have been associated with
an array of disorders, which are important for the clinician to recognise. Cytomegalovirus
(CMV) is a member of the herpesvirus family that is very prevalent worldwide. More than 80%
of primary infections and 20% of reactivation-producing symptoms occur in transplant
populations. Treatment options include intravenous administration of ganciclovir, foscarnet or
cidofovir. Herpes simplex virus (HSV) most commonly affects the genital and perioral regions.
In the elderly, HSV infection is typically manifest at the vermilion border of the lip. The main
concern of recurrent herpes labialis in the elderly is related to potential autoinoculation of the
eye or genital area. Treatment with aciclovir, famciclovir or valaciclovir is indicated for these
infections. Molluscum contagiosum is caused by a poxvirus, which produces cutaneous
lesions that appear as small, firm, umbilicated papules. Immunocompromised patients often
do not respond to the usual destructive therapies, and intravenous or topical cidofovir may be
useful in these patients.
PMID: 12182687 [PubMed - indexed for MEDLINE]
-------------------South Med J. 2012 Nov;105(11):600-6. doi: 10.1097/SMJ.0b013e31826f5d17.

Elderly adults and skin disorders: common problems for

nondermatologists.
Na CR, Wang S, Kirsner RS, Federman DG.
Source
Department of Medicine and Diagnostic Radiology, Yale University School of Medicine, New Haven,
Connecticut, USA.

Abstract
Diseases of elderly adults are becoming increasingly important as life expectancy gradually
rises worldwide. To promote healthy aging, it is important to understand the skin changes
associated with aging. This review focuses on the special considerations for some of the
more common dermatological disorders in elderly adults and examines presentation,
contributing factors, and association with systemic diseases.
PMID: 23128804 [PubMed - indexed for MEDLINE]
-----------------------

Am Fam Physician. 1993 May 1;47(6):1445-50.

Common dermatoses in the elderly.

Beacham BE.
Source
University of Maryland School of Medicine, Baltimore.

Abstract
Common dermatoses in the elderly include xerosis, pruritus, contact dermatitis, acne rosacea,
stasis dermatitis, bullous pemphigoid and herpes zoster. Physicians must be able to
recognize these pathologic changes superimposed on the intrinsic and extrinsic effects of
aging. Diagnosis is dependent on clinical appearance and supportive laboratory studies.
Management is based on correct diagnosis.

Comment in
Treatment of stasis dermatitis and ulceration. [Am Fam Physician. 1994]
Oral corticosteroids and postherpetic neuralgia. [Am Fam Physician. 1993]
-----------Drugs Aging. 2004;21(12):767-77.

Management of autoimmune skin disorders in the elderly.

Loo WJ, Burrows NP.
Source
Department of Dermatology, Addenbrooke's NHS Trust, Cambridge, UK. wjloo@hotmail.com

Abstract
Senescence of the skin immunological system may explain why the elderly population has an
increased susceptibility to certain autoimmune skin disorders. These disorders are
characterised by the production of either antibodies that react with host tissue or immune
effector T cells that are autoreactive. Bullous pemphigoid is the most common autoimmune
blistering disease in the elderly. Although oral corticosteroids are the best established therapy,
high-potency topical corticosteroids are very useful as initial treatment and, in the elderly,
should be used instead of oral prednisolone wherever possible. Pemphigus is a chronic
blistering disease of which there are two main subtypes: vulgaris and foliaceous.
Paraneoplastic pemphigus is a unique clinical, histological and immunologically distinct
autoimmune mucocutaneous disease which tends to be relentlessly progressive. Lichen
sclerosus presents specific complications and a small but definite increased risk of squamous
cell carcinoma in elderly patients. It is important to be aware of practical issues such as the
difficulty in applying topical corticosteroids, the mainstay treatment of this condition.
Dermatomyositis is an autoimmune systemic disorder where the skin and muscles are the
most commonly affected organs. Tumour-associated disease occurs more commonly in
elderly patients and has a poorer prognosis. Management of the disease includes
sunscreens, topical or systemic corticosteroids, antimalarials, oral immunosuppressants or
intravenous immunoglobulins. It is important to bear in mind that old age modifies the
management of skin diseases because of physical and social circumstances as well as the
unwanted adverse effects of medications. Polypharmacy results in an increased risk of drug
interactions and, therefore, drug regimens need to be kept as simple as possible. Druginduced autoimmune skin eruptions are common amongst the elderly and usually resolve
when the offending drug is discontinued.

----------Dermatol Clin. 2004 Jan;22(1):115-23, vii.

Clinicopathologic attributes of common geriatric dermatologic entities.

Keehn CA, Morgan MB.
Source
Department of Pathology, University of South Florida College of Medicine, 12901 Bruce B. Downs Boulevard,
Tampa, FL 33612, USA.

Abstract
Certain dermatologic lesions may initially present or be more commonly ascribed to the
elderly. These disorders encompass a diverse array of etiologically unrelated degenerative,
autoimmune, idiopathic, and neoplastic conditions that may dramatically impact the quality of
life and produce significant morbidity and mortality. As the population ages, a more complete
understanding of the clinical and histopathologic features unique to the geriatric dermatologic
patient is essential.
PMID: 15018015 [PubMed - indexed for MEDLINE]
-------------Drugs Aging. 2002;19(7):503-14.

Viral skin infections in the elderly: diagnosis and management.

Bansal R, Tutrone WD, Weinberg JM.
Source
Department of Dermatology, St. Luke's-Roosevelt Hospital Center, 1090 Amsterdam Avenue, New York, NY
10025, USA.

Abstract
Over the past several years, there have been advances in the diagnosis and treatment of
cutaneous viral diseases in elderly patients. Herpes zoster is caused by reactivation in adults
of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years,
aciclovir was the gold standard of antiviral therapy for the treatment of herpes zoster.
Famciclovir and valaciclovir are newer antivirals, which offer less frequent administration.
Postherpetic neuralgia (PHN) refers to pain lasting 2 months or more after an acute attack of
herpes zoster. The pain may be constant or intermittent. The treatment of established PHN
may include topical anaesthetics, analgesics, tricyclic antidepressants and anticonvulsants,
and nonpharmacological therapy may be used to complement such treatment. Therapeutic
strategies to prevent PHN include the use of oral corticosteroids, nerve blocks, and treatment
with standard antiviral therapy. The three most recently discovered human herpes viruses
(HHV-6, HHV-7 and HHV-8), in common with the other members of the family, may cause a
primary infection, establish latent infection in a specific set of cells in their host, and then
reactivate if conditions of altered immunity develop. These viruses have been associated with
an array of disorders, which are important for the clinician to recognise. Cytomegalovirus
(CMV) is a member of the herpesvirus family that is very prevalent worldwide. More than 80%
of primary infections and 20% of reactivation-producing symptoms occur in transplant
populations. Treatment options include intravenous administration of ganciclovir, foscarnet or
cidofovir. Herpes simplex virus (HSV) most commonly affects the genital and perioral regions.
In the elderly, HSV infection is typically manifest at the vermilion border of the lip. The main
concern of recurrent herpes labialis in the elderly is related to potential autoinoculation of the
eye or genital area. Treatment with aciclovir, famciclovir or valaciclovir is indicated for these
infections. Molluscum contagiosum is caused by a poxvirus, which produces cutaneous
lesions that appear as small, firm, umbilicated papules. Immunocompromised patients often
do not respond to the usual destructive therapies, and intravenous or topical cidofovir may be
useful in these patients.
PMID: 12182687 [PubMed - indexed for MEDLINE]
----------

Ir Med J. 2005 Feb;98(2):46-7.

Chronic kidney disease in the elderly; a silent epidemic.

Martin A, Mellotte G, O'Neill D.
Source
Depts of Medical Gerontology and Nephrology, Trinity Centre for Health Sciences, Adelaide & Meath Hospital,
Dublin 24. arhc@amnch.ie

Abstract
Chronic kidney disease has been shown to be associated with significant increases in
mortality and morbidity even in early stages. Despite this it is rarely diagnosed, actively
investigated or managed in the elderly. We set out to establish the prevalence of CKD and
identify causative factors in a consecutive series of referrals to a geriatric medical clinic. We
calculated glomerular filtration rates (GFR) for 101 patients attending a geriatric medical clinic
using the Cockroft and Gault formula, and collected data on medications and relevant past
medical history. Mild CKD (GFR <60ml/min) was present in 80% of the group. Only 10% of
these patients had serum creatinine >130(mmol/L. hypertension was present in 50% and only
9% were diabetic. Almost one third were on inappropriate drugs or dosages; most commonly
non-steroidal anti-inflammatory drugs (99%). Chronic kidney disease is extremely common in
older people attending a geriatric medical clinic and carries significant risks. CKD will not be
detected by serum creatinine alone in 90% of cases. Routine calculation of GFR should be
used to provide a more accurate measure of renal impairment and allow earlier intervention,
risk factor reduction and improve prescribing practices.
PMID: 15835511 [PubMed - indexed for MEDLINE]
--------------Minerva Endocrinol. 2011 Sep;36(3):211-31.

Thyroid diseases in elderly.

Faggiano A, Del Prete M, Marciello F, Marotta V, Ramundo V, Colao A.

Source
National Cancer Institute, Fondazione G. Pascale, Federico II University, Naples, Italy. afaggian@unina.it

Abstract
Thyroid diseases are the commonest endocrine disorders in the general population. In most
of the cases, they are consistent with benign conditions which may be asymptomatic or affect
people at a variable extent. Since they often represent chronic conditions their prevalence
increases by age and reaches in elderly the highest rates. Thyroid nodules are a common
clinical finding. Most subjects with thyroid nodules have few or no symptoms. Thyroid nodules
are more commonly non-functioning. However, in elderly, toxic multinodular goiter is the most
frequent cause of spontaneous hyperthyroidism and often, it emerges insidiously from
nontoxic multinodular goiter. Although autoimmune thyroiditis is the most common cause of
hypothyroidism in elderly subjects, other causes, such as drugs, neck radiotherapy,
thyroidectomy or radioiodine therapy, are frequently observed among these subjects. A small
subset of medications including dopamine agonists, glucocorticoids and somatostatin analogs
affect thyroid function through suppression of TSH. Other medications that may affect TSH
levels are metformin, antiepileptic medications, lithium carbonate and iodine-containing
medications. Other drugs can alter T4 absorption, T4 and T3 transport in serum and
metabolism of T4 and T3, such as proton-pump inhibitors and antacids, estrogens, mitotane
and fluorouracil, phenobarbital and rifampin. Amiodarone administration is associated with
thyrotoxicosis or hypothyroidism. Thyroid cancer has similar characteristics in elderly as in
general population, however the rate of aggressive forms such as the anaplastic histotype, is
higher in older than younger subjects. Diagnosis of thyroid diseases includes a
comprehensive medical history and physical examination and appropriate laboratory tests. A
correct diagnosis of thyroid diseases in the elderly is crucial for proper treatment, which
consists in the removal of medications that may alter thyroid function, in the use of levo-

thyroxine in case of hypothyroidism, anti-thyroid drugs in case of hyperthyroidism and use of

surgery, radioiodine therapy and percutaneous ablative procedures in selected cases. In
conclusion, thyroid diseases in patients older than 60 years deserve attention from different
points of view: the prevalence is different from the young adult; symptoms are more nuanced
and makes difficult the diagnosis; age and comorbidity often force therapeutic choices and
may limit safety and efficacy of therapy. Finally, in elderly patients for whom specific therapy is
necessary, more gradual and careful therapeutic approach and close follow-up are
recommended in order to minimize the alterations of thyroid function which are induced by
many drugs commonly used in clinical practice.
PMID: 22019751 [PubMed - indexed for MEDLINE]
------------------

Int J Dermatol. 2012 May;51(5):509-22. doi: 10.1111/j.1365-4632.2011.05311.x.

Geriatric dermatoses: a clinical review of skin diseases in an aging

population.
Jafferany M, Huynh TV, Silverman MA, Zaidi Z.
Source
Psychodermatology Clinic, Department of Psychiatry and Behavioral Sciences, Synergy Medical Education
Alliance, MI 48603, USA. mjafferany@yahoo.com

Abstract
Geriatric dermatoses are a challenging job for the physician in terms of diagnosis,
management, and followup. Since skin of the elderly population is going through a lot of
changes from both an intrinsic and extrinsic point of view, it is imperative for the physician to
have a better understanding of the pathophysiology of geriatric skin disorders and their
specific management, which differs slightly from an adult population. This review focuses on a
brief introduction to the pathophysiological aspects of skin disorders in elderly, the description
of some common geriatric skin disorders and their management and the new emerging role of
psychodermatological aspects of geriatric dermatoses is also discussed. At the end, ten
multiple choice questions are also added to further enhance the knowledge base of the
readers.
2012 The International Society of Dermatology.
PMID: 22515576 [PubMed - indexed for MEDLINE]

-----------------Semin Cutan Med Surg. 2011 Jun;30(2):113-7. doi: 10.1016/j.sder.2011.04.002.

Pruritus in elderly patients--eruptions of senescence.

Berger TG, Steinhoff M.
Source
Department of Dermatology, University of California San Francisco, San Francisco, CA 94143, USA.
bergert@derm.ucsf.edu

Abstract
Geriatric patients are frequently afflicted by pruritic dermatoses. Most pruritic elderly patients
present with a skin eruption. The high prevalence of pruritic inflammatory skin disorders in
elderly patients is a consequence of three physiological changes that occur with aging: (1) the
epidermal barrier repair is diminished; (2) the immune systems of elderly patients are
activated and have defective Th1 function along with enhanced Th2 function
(immunosenescense); and (3) neurodegenerative disorders may lead to pruritus by their
central or peripheral effects. These consequences of aging may all afflict the same patient,
explaining why elderly people often have multiple overlapping skin conditions. The following
article outlines the pathogenesis of the most common forms of pruritic skin disease in elderly

patients and the hallmarks that allow the dermatologist to establish an accurate diagnosis and
also suggests a management strategy for each common type of pruritic skin disease in the
elderly patient.
Copyright 2011. Published by Elsevier Inc.
PMID: 21767773 [PubMed - indexed for MEDLINE] PMCID: PMC3694596 Free PMC Article

-------------------J Am Acad Dermatol. 2013 Apr;68(4):521.e1-10; quiz 531-2. doi: 10.1016/j.jaad.2012.10.063.

Geriatric dermatology: Part I. Geriatric pharmacology for the

dermatologist.
Endo JO, Wong JW, Norman RA, Chang AL.
Source
Department of Dermatology, University of Wisconsin-Madison, Madison, Wisconsin, USA.

Abstract
Issues related to prescribing dermatologic drugs in the elderly are less recognized than agerelated skin findings. This is related in part to the lack of a standardized residency training
curriculum in geriatric dermatology. As the number of elderly patients rises in the United
States, drug-related iatrogenic complications will become increasingly important. This review
discusses age-related changes in pharmacokinetics and pharmacodynamics of common
dermatologic drugs. These changes include volume of distribution, renal function, liver toxicity
from interactions of commonly prescribed drugs, and medications that can decompensate
cognition in the older patient population. We outline seven prescribing principles related to
older dermatology patients, including useful strategies to reduce polypharmacy and improve
drug adherence, using an evidence-based approach whenever possible.
Copyright 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights
reserve
---------------

Skin Therapy Lett. 2010 Sep;15(8):5-9.

The management of chronic pruritus in the elderly.

Patel T, Yosipovitch G.
Source
Division of Dermatology, Department of Medicine, University of Tennessee Health Science Center, Memphis,
TN, USA.

Abstract
The elderly in North America represent the fastest growing segment of the population and the
most common skin complaint in this age group is pruritus. The multitude of variables that
come with advanced age means that the management of pruritus in the elderly poses a
particular therapeutic challenge. Pruritus in advanced age may result from a variety of
etiologies, although xerosis is the most common. In addition, certain cutaneous and systemic
diseases that are associated with pruritus are more prevalent in the elderly. At present, there
is no universally accepted therapy for pruritus. Currently, management of pruritus in the
elderly must take an individualistically tailored approach with consideration of the patient's
general health, the severity of symptoms, and the adverse effects of treatment. Physical and
cognitive limitations, multiple comorbid conditions, and polypharmacy are some aspects that
can influence the choice of treatment in this age group.
PMID: 20844849 [PubMed - indexed for MEDLINE] Free full text

-----------------