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Geriatric dermatoses: A clinical review of skin diseases in an aging population

Article  in  International journal of dermatology · May 2012

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Review
Geriatric dermatoses: a clinical review of skin diseases in
an aging population
Mohammad Jafferany, MD, Trung V. Huynh, BS, Melissa A. Silverman, BA, and
Zohra Zaidi, MD

Psychodermatology Clinic, Department Abstract

of Psychiatry and Behavioral Sciences, Geriatric dermatoses are a challenging job for the physician in terms of diagnosis,
Synergy Medical Education Alliance,
management, and followup. Since skin of the elderly population is going through a lot of
MI 48603, USA
changes from both an intrinsic and extrinsic point of view, it is imperative for the physician
Correspondence to have a better understanding of the pathophysiology of geriatric skin disorders and their
Dr Mohammad Jafferany, MD specific management, which differs slightly from an adult population. This review focuses
Psychodermatology Clinic on a brief introduction to the pathophysiological aspects of skin disorders in elderly, the
Department of Psychiatry and
description of some common geriatric skin disorders and their management and the new
Behavioral Sciences
Synergy Medical Education Alliance
emerging role of psychodermatological aspects of geriatric dermatoses is also discussed.
1000 Houghton Ave At the end, ten multiple choice questions are also added to further enhance the knowledge
Saginaw base of the readers.
MI 48603
USA
E-mail: mjafferany@yahoo.com

Funding: Authors have no financial

disclosures to declare.

challenge to providers. History taking can be difficult.

Introduction
Management of dermatoses in older populations has
emerged as an important area of consideration today. As
the population over age 65 years increases and the num-
ber of patients in geriatric care facilities also climbs, the
incidence of geriatric skin diseases is becoming more
widely acknowledged. Currently, 37.3 million Americans
are senior citizens and, by 2050, the number is expected
to be 86.7 million, 21% of the population. Between
2006 and 2050, the projected percentage increase in
population 65 years and over is 147%. http://www.
census.gov/population/www/projections/summarytables.html
www.census.gov
Due to the degenerative and metabolic changes
occurring throughout the skin layers during the aging
process, elderly people are vulnerable to a wide variety of
dermatological conditions. Neurological and/or systemic
diseases, health and hygiene, socioeconomic status,
climate, color of skin, gender, nutrition, culture, and
personal habits, such as smoking or drinking, etc., may
also contribute a role in the genesis of cutaneous condi-
tions in the elderly population. The diagnosis of certain
dermatoses in the geriatric population poses a great
Patients often have multiple medical problems and regi-
mens with several medications. The clinical manifestation
of skin disorders may differ and may not present as
classically as they do in younger populations.1
Dermatoses of aged population vary from country to
country. A study from Turkey2 conducted on 4099 geriat-
ric patients found eczematous dermatitis to be the most
common disorder in the population studied, followed by
fungal infections, pruritus, bacterial infections, and viral
infections. A seasonal pattern was also noticed with geri-
atric dermatoses in Turkey. Infestations were most com-
mon in spring and summer months. Fungal infections
were common in summer. Pruritus was common in
autumn season. In another study from the same country
conducted in three senior homes on 300 elderly patients,
it was found that fungal infection (49.7%) and xerosis
(45.3%) were the most common dermatoses.3 In Singa-
pore, xerosis and asteatotic eczema were the most com-
mon disorders, followed by scabies, bacterial infections,
and eczematous dermatitis. Fungal and viral infections
were less common.4 In Taiwan, eczematous dermatitis
was most common, followed by fungal infection, xerosis,
benign tumors, and viral infections.5 In Tunisia, fungal 509

ª 2012 The International Society of Dermatology International Journal of Dermatology 2012, 51, 509–522
510 Review Geriatric dermatoses Jafferany et al.

infections were most common, followed by benign
tumors, eczematous dermatitis, keratinization disorders,
bacterial infections, viral infections, and finally xerosis.6
Skin changes in the aging skin
Two types of skin aging have been described: chronologi-
cal skin aging and photoaging. Both have different clini-
cal and histological features. Chronological skin aging is
characterized by physiological alteration in skin function.
Photoaging results from ultraviolet radiations, and the
effects are more prominent on exposed parts of skin.7
Skin changes in elderly population take the form of either
intrinsic or extrinsic changes. Intrinsic changes are
changes due to skin’s natural metabolic aging process.
These include thinning of the skin’s upper layer, diminish-
ing blood flow and compromising the skin’s inherent abil-
ity to nourish and repair cells. Changes in collagen
structure reduce overall elasticity. Moreover, a reduction
in immune function also contributes to the skin-aging
process by degrading the skin’s ability to defend against
bacterial assault.
Other intrinsic changes in skin in the elderly include
variable epidermal thickness, variation in size and shape,
fewer Langerhans’ cells, and fewer melanocytes, and there
may be occasional nuclei atypia. Decreased and irregular
epidermal turnover results in skin roughness and uneven
pigmentation. The capability of the skin to restrict water
loss does not change, but the skin is more permeable to
chemical substances. The chemical substances enter the
skin quickly but are removed slowly due to changes in
the dermal matrix and reduction in vasculature.8 There is
flattening of the dermoepidermal junction and thus a
smaller surface contact between the dermis and the epi-
dermis, resulting in less nutritional transfer and poor
adhesion between the dermis and the epidermis. This
leads to superficial abrasions with minor trauma and an
increased prevalence of bullous formation due to injury.
The wrinkling of the skin in old age is due to changes in
the dermis. The collagen bundles and elastic fibers are
fragmented and disoriented. There is a loss of dermal
thickness and reduction in mast cells and vasculature.
Age decreases the sensory perception and increases the
threshold of pain. Senile purpura is due to lack of support
of vasculature by collagen tissue and reduced perivascular
veil cells. Skin appendages also show a variety of changes.
The number of exocrine glands decreases with age, and
older people sweat less in response to heat. Apocrine
glands also regress with age and produce fewer odors.
The size of the sebaceous glands increases due to the
decreased turnover of cells, and these glands probably
produce less sebum. The hair slowly turns white in color;
graying starts in the temporal region of the scalp. In
males, eyebrows become bushier and hair grows in the
external auditory canal. In females, slight hirsutism
occurs as a result of endocrine changes. The linear growth
of nails also decreases with age. The ultraviolet light also
accelerates the intrinsic aging in the sun-exposed areas of
the body.9,10 The age-related changes due to alteration of
skin physiology are shown in Table 1.
Extrinsic changes may result from factors, such as UV
light exposure and environmental pollutants such as
smoking. A variety of skin changes have been seen in
aged skin due to prolonged exposure to sun. Sun expo-
sure contributes to a decline in dermatological integrity,
leading to skin that easily sags, breaks, bruises, and

Table 1 Age-related changes in skin physiology

Physiological changes Cutaneous effects

Decrease in skin lipids and barrier function Dryness

Decreased cell replacement
Decreased DNA repair
Fragmentation of collagen and elastic fibers
Reduced support of blood vessels
Decreased sensory perceptions
Impaired thermoregulation
Reduced hair growth and effects of androgen
Reduced function of apocrine glands
Reduced function of sebaceous glands
Reduced function of sweat glands
Decreased inflammatory response
Reduced subcutaneous fat
Flattening of dermal papillae
Reduced nail growth
Decrease in melanocytes
Roughness, delayed healing and uneven pigmentation
Increased photocarcinogenesis, malignancies
Wrinkles and lax skin, increased risk of pressure damage and decubitus ulcers
Purpuric lesions
Increased tendencies to injuries
Vulnerability to heat and cold
Color changes to gray, baldness, and male and female patterns of alopecia, bushier eyebrows,
and growth of hair in external auditory meatus in male
Reduced body odor
Decreased epidermal lipids
Risk of overheating and heat strokes
Delayed healing and vulnerability to infection
Increased risk of injury, less natural insulation, increased risk of hypothermia
Increased risk of blister formation and consequent infection
Decreased linear growth, onychogryphosis, longitudinal striations, dull and brittle nails
Gray hair, increased susceptibility to solar radiation

International Journal of Dermatology 2012, 51, 509–522 ª 2012 The International Society of Dermatology
Jafferany et al. Geriatric dermatoses Review 511

itches. The other factors related to photoaging include Table 2 Classification of common gerodermatoses
spots, spider veins on the face, rough and leathery skin,
and many other changes, which are described in the text Physical factors
under individual descriptions. The classification of com- Pressure sores (decubitus ulcers)
Xerosis
mon dermatological disorders is shown in Table 2.
Pruritus
Asteatotic dermatitis
Infections
Common geriatric dermatoses
Bacterial
Decubitus (pressure) ulcers Impetigo/folliculitis
Cellulitis
Decubitus (pressure) ulcers are one of the most common
Viral
lesions in elderly. High-risk individuals include critical care Herpes zoster
patients, quadriplegics, terminal cancer patients, diabetics, Molluscum contagiosum
patients with end-stage renal disease, and incontinent, Fungal
immobile, immunosuppressed, and malnourished individu- Onychomycosis
Tinea pedis
als. The word decubitus, derived from the Latin decumb-
Tinea cruris
ere, means ‘‘to lie down’’. These ulcers usually occur over Intertrigo
bony prominences. Pressure on tissue over an extended Infestations
period of time causes ischemia and results in tissue dam- Pediculosis
age. Two-thirds of pressure sores occur in patients over Scabies
Eczematous reactions
70 years old. The data from a national nursing homes sur-
Nummular eczema
vey11 in 2004 indicated a prevalence rate of 11%. Another Seborrheic dermatitis
study from New York State conducted in 619 nursing Contact dermatitis
homes reported an average incidence of 14.5%. The Photodermatoses
African-American population had a slightly higher ratio Solar elastosis
Nodular elastoidosis
than Caucasians.12 Edlich et al.13 reported that 14% of
Cutis rhomboidalis nuchae
patients in acute care suffer from pressure sores. Decubitus Poikilodermic changes
ulcers are staged from I to IV. Stage I is characterized by Neoplastic changes
non-blanchable erythema of intact skin. Stage II is charac- Benign
terized by necrosis with superficial to partial-thickness Seborrheic keratosis
Skin tags
involvement of the epidermis and/or dermis. Stage III is
Cherry angiomas
manifested by deep necrosis with full-thickness skin loss Leukoplakia
extending down to underlying fascia. Stage IV is character- Keratoacanthoma
ized by extensive necrosis into the underlying fascia, possi- Actinic keratosis
bly into muscle bone and supporting structures.14,15 Malignant
Actinic cheilitis
Prevention of decubitus ulcers includes ensuring proper
Basal cell carcinoma
nourishment, increasing mobility, using device repositioning Squamous cell carcinoma
schedules, reducing shearing forces, ensuring careful skin Malignant melanoma
care, reducing skin to skin contact and conducting daily skin Immunological
examinations in high-risk individuals.16 Complications of Bullous pemphigoid
Psychodermatoses
chronic ulceration include Marjolin ulcer, which is a cancer
Lichen simplex chronicus
arising in chronic wounds and burn scars, and malignant Prurigo nodularis
degeneration.17 Treatment of decubitus ulcers depends on Neurotic excoriations
staging and can range from simple cleansing and application Delusion of parasitosis
of protective ointment and devices to surgical debridement Dermatitis artefacta
Vascular compromise
and packing. Patients need frequent change of position to
Chronic venous insufficiency (stasis dermatitis)
prevent pressure over one site of ulcer. The ulcer should be Cutaneous drug reactions
kept as dry as possible. Nutritional consultations and cul- Nutritional changes
tures using gram stain prior to antibiotic therapy are also
beneficial.18,19
ranges from 29.5% to 58.3% in different long-term care
Xerosis facilities.20 It is due to the decrease in skin lipids both
Xerosis is one of the common skin disorders seen as age from the epidermis and sebaceous glands complicated
advances. The prevalence of xerosis varies widely, and by impaired epidermal permeability barrier hemostasis.21

ª 2012 The International Society of Dermatology International Journal of Dermatology 2012, 51, 509–522
512 Review Geriatric dermatoses
Dryness of the skin leads to pruritus. Scratching of the
skin breaks its continuity, leading to infection and derma-
titis. The chief complaint of xerosis is pruritus, which, if
not treated, may lead to asteatotic eczema. Anterior shins,
dorsi of hands, and forearms are the most commonly
affected sites. Affected skin becomes rough and scaly.
Xerosis can be exacerbated by soap, hot water, and low
indoor humidity. Treatments include increasing water
intake and moisturizing the skin. Emollients (petrolatum)
can be applied liberally, and use of a humidifier also
helps. Using excess soap removes the surface lipids and
increases the dryness of the skin. Moisturizers are the
mainstay of treatment; these should be liberally applied
after a bath, when the skin is moist.22,23
Asteatotic dermatitis
Asteatotic dermatitis (eczema craquele) is an eczematous
eruption common in the elderly but can be seen in any
age group. Asteatotic eczema is characterized by dry,
cracked, and fissured patches on the limbs. It is common
in winter. The sun, wind, and low humidity are predis-
posing factors. Asteatotic eczema is seen secondary to epi-
dermal lipid and free fatty acid depletion.24 Extensive or
generalized eczema craquele should be investigated for
internal malignancy, such as malignant lymphoma.25
In treating asteatotic dermatitis, the environment
should be humidified and irritants should be avoided.
Baths should be restricted and should not be hot. Soaps
should be avoided, and use of bath oils should be encour-
aged. Emollients should be used after bathing daily.
Urea-based weak corticosteroids are also helpful. Topical
steroids should be carefully used in the elderly, as the skin
is already thin and fragile.26 Topical pimecrolimus, an
immunomodulating agent, has also been indicated in the
treatment of asteatotic dermatitis.27,28
Pruritus
Pruritus or itch is most commonly caused by xerosis. It is
one of the most frequently reported symptoms in the
elderly population, and its prevalence is estimated to be
29%.29 The actual pathogenesis is poorly understood.
Age-related changes in the nerves leading to increased
touch and pain thresholds, possibly due to subclinical
neuropathy, have been suggested.30 Systemic disorders
have been implicated in 10–50% of cases and include
liver disease, hypothyroidism, iron deficiency anemia, ure-
mia, polycythemia, leukemia/lymphomas, atopic dermati-
tis, ichthyosis, thyroid disorders, chronic renal failure,
drug-induced disorders, etc. In a study from Thailand of
149 elderly patients, the most common causes of senile
pruritus found in order of prevalence were xerosis,
inflammatory eczematous conditions, lichen simplex chro-
nicus, cutaneous infections, psoriasis, urticaria, drug
International Journal of Dermatology 2012, 51, 509–522
Jafferany et al.
eruptions, and insect bites.31 The 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.32 It can be treated by correcting existing xerosis
or any underlying systemic cause. Topical steroids, anti-
histamines, soothing agents, and emollient creams all
have been employed. The psychogenic cause of pruritus
responds best to local or systemic doxepin.33
Stasis dermatitis
Stasis dermatitis (hypostatic eczema) occurs on the lower
legs because of underlying insufficient venous drainage.
Varicose veins are often present, and chronic pruritic der-
matitis develops with periods of exacerbations. The der-
matitis may be weepy or dry, scaly or lichenified.
Secondary bacterial infection may lead to cellulitis and
lymphangitis. Ulcers are the most common complication
of hypostatic eczema. Stasis dermatitis may present as a
solitary lesion mimicking a neoplasm, hence requiring
early recognition and evaluation.34,35 Venous hyperten-
sion, circulatory stasis, and modified condition sheer
stress play an important role in an inflammatory reaction
accompanied by leukocyte activation leading to venous
dermatitis and ulceration.36 The only effective way of
treating venous hypertension is by external compression
of the leg by bandaging or support stockings. This com-
presses the superficial veins so that the blood can flow to
the deeper veins. Gupta et al.37 evaluated the healing rate
and safety of the profore extra four-layer bandage system
in patients with leg ulcerations and found it to be safe
and effective. The patient should be encouraged to use
their calf muscles, so they need to be mobile and walking.
When sitting, the feet should be raised on a stool and
dorsiflexed frequently. Weak topical steroids should be
applied twice daily–once before applying the bandage or
stocking and once before going to bed. Any potent sensi-
tizer should be avoided; local antiseptics are preferable to
topical antibiotics for secondary infection. Kaur et al.38
conducted an open-label study on 25 patients and found
calcium dobesilate as an effective adjuvant therapy in
patients with venous ulcers and leg ulcerations.
Infections
A variety of infections including bacterial, viral, and fun-
gal may occur commonly in the elderly population.
Superficial bacterial infections caused by staphylococcus
and streptococcus are seen frequently due to alteration in
skin architecture and loss of barrier function caused by
ª 2012 The International Society of Dermatology
Jafferany et al.
various physical factors, malnourishment, and nutritional
deficiencies.14 Both bullous and non-bullous forms of
impetigo may develop. Topical and systemic antibiotics
are required for treatment. Cellulitis is an infection of the
subcutaneous fat, and it may coexist with erysipelas,
which is the infection of dermis and upper subcutaneous
tissue due to streptococcus pyogenes or staphylococcus
aureus. In the aged, it is often seen on the lower limbs
secondary to venous stasis. The clinical features of celluli-
tis are similar to those in adults. It differs from erysipelas
in being deeper and without a distinct edge. Treatment
consists of using soothing local topical agents. Calamine
lotion and ichthammol may be used. Local and systemic
antibiotics are often required for moderate and severe
infection. A single injection of procaine penicillin will
arrest the process. If no improvement occurs in a day,
penicillin-resistant staphylococcus should be suspected.
Macrolide antibiotics are used as an alternative, such as
clindamycin.
Viral infections
Viral infections, particularly herpes zoster, occur fre-
quently in old age secondary to impaired immune func-
tion. After recovery from chicken pox at a young age,
varicella zoster virus (VZV) becomes latent in dorsal root
ganglion. After decline in immunity, VZV is reactivated.
The infection occurs in a dermatomal pattern and is very
painful. The incidence of herpes zoster has been estimated
to be 1,000,000 cases annually, with higher numbers in
adults older than 60 years.39 It is characterized by a pro-
dromal sharp stabbing pain that occurs before the onset
of rash and may last throughout the course of vesicular
eruption. Herpes zoster infection may be associated with
a characteristic pain syndrome called post-herpetic neural-
gia. Post-herpetic neuralgia is a sequelae manifested by
sharp stabbing pain lasting for months to years after the
disappearance of the lesions. The pain may be provoked
by trivial stimuli. The incidence of post-herpetic neuralgia
is reported to range from 10% to 70% in herpes zoster
cases.40 Antivirals such as acyclovir, valacyclovir, and
famciclovir are the mainstay of treatment. The addition
of oral prednisolone to acyclovir treatment in reducing
pain and speed healing of the lesion has been suggested in
the past,41 but the latest recommendations suggest other-
wise.42 Topical treatments include topical lidocaine, wet
to dry dressings with tap water and aluminum acetate
(Burow’s solution), and bland lotions such as calamine
lotion. Nonsteroidal anti-inflammatory drugs may also be
used. Zoster vaccine (Zostavax) may be used for preven-
tion and proved cost effective; it reduced the burden of
illness by decreasing the incidence and severity.43,44
Herpes simplex virus (HSV) occurs as two types
causing infections on the skin: type I and type II. HSV-I
ª 2012 The International Society of Dermatology
Geriatric dermatoses Review 513
usually produces a disease around the mouth; and HSV-II
causes disease around the genitalia. Approximately 85%
of adults worldwide have antibodies to HSV-I; however,
only 20% are symptomatic. The infection rate of HSV-II
is approximately 16%, with only a quarter symptomatic.
When infection is clinically established, there is recur-
rence of symptoms that may or may not produce pain or
tingling before the blisters appear. In normal host, the
viral infection appears as a blister that heals after a few
days and is prevented from spreading by host immunity.
In conditions of impaired immunity, it does not heal, and
new blisters form and eventually ulcers form with serpigi-
nous borders. In severe immunodeficiency, dissemination
of lesions occurs. Kaposi’s varicelliform eruptions are
characterized by depressed immune response leading to
dissemination of atopic eczema upon exposure to HSV.45
Some patients with Alzheimer’s dementia with geno-
type APOE epsilon 4 allele may contain HSV-I virus.46
A recent review by Mori47 reported that HSV-I persists in
the brains of most aged individuals and may contribute
to the pathogenesis of Alzheimer’s disease. Similar views
were shared by Itzhaki and Wozniak,48 who suggested
that there is strong evidence for HSV-I being a major fac-
tor in Alzheimer’s disease and that appropriate treatment
may prevent the disease.
Molluscum contagiosum (MC), a pox virus infection,
may occur in the elderly population, particularly in
immunodeficiency states. The appearance of MC lesions
in adults should require evaluation for immunocompro-
mised state.49 MC lesions are characterized by
dome-shaped umbilicated papules and are transmitted by
skin-to-skin contact. Treatment includes cryotherapy and
electrodesiccation and curettage.
Fungal infections
Among the fungal infections, onychomycosis, tinea pedis,
tinea cruris, and candidiasis occur commonly in the aged
population. Onychomycosis or fungal infection of nails,
particularly toenails, is commonly encountered in the
geriatric population. It is caused by dermatophytes, most
commonly trichophyton rubrum, trichophyton mentagro-
phytes, epidermophyton floccosum, and candidal infec-
tions. In one study, of the 450 cases studied, 46.4% of
the patients had a single fungal organism cultured, 30.4%
had a mixed fungal infection cultured, and 23.1% had no
fungal growth. Saprophytes were found in 59.9% of the
526 total fungal organisms cultured, while dermatophytes
were found in only 23.8%.50 Clinical discoloration begin-
ning at the free edge of the nail or at the lateral nail fold
and subungual hyperkeratosis leading to separation of the
nail plate from the nail bed are some of the common
characteristics of onychomycosis. The diagnosis can be
established by potassium hydroxide preparation, fungal
International Journal of Dermatology 2012, 51, 509–522
514 Review Geriatric dermatoses
cultures and, in some cases, nail plate biopsy; less fre-
quently immunohistochemistry, restriction fragment
length polymorphism, and polymerase chain reaction
assays have been used.51 Newer antifungals such as fluco-
nazole, itraconazole, and terbinafine have proven useful
in the treatment of onychomycosis.52
Candidiasis manifests in the form of cutaneous, muco-
sal, paronychial, onychial, or chronic mucocutaneous or
granulomatous lesions. It is commonly seen in intertrigin-
ous areas where skin is warm and moist, such as sub-
mammary folds, inguinal, anogenital, and perioral areas.
The main predisposing factors are maceration, heat,
humidity, obesity, diabetes, antibiotic therapy, and che-
motherapy.53 It presents as a diffuse beefy red eruption
with satellite papules. When cutaneous candidiasis is pres-
ent in immunocompromised patients, such as with diabe-
tes, leukemia, lymphoma, transplants, or cancer, the
possibility of systemic candidiasis must be considered.
Direct microscopy for pseudohyphae and culture are com-
mon tests to perform for the diagnosis. Topical antifungal
creams such as imidazole or allylamine derivatives are
helpful in clearing the lesions, and keeping the area dry
hastens the recovery. Systemic antifungal agents such as
thiazole derivatives may be used when there is resistance
or poor response to topical treatment.
Tinea pedis, fungal infection of the feet, is seen com-
monly in interdigital webs but may occur on the sole of
the foot. Scaling, maceration, and fissuring is common.
Legge et al.54 conducted a prospective study on 80 elderly
patients and indicated a 40% likelihood of tinea pedis in
patients with otherwise asymptomatic interdigital pedal
macerations in this population. The study further
reported that an increase in age appears to correlate with
an increased incidence of interdigital tinea pedis. Diabetic
elders may be susceptible to interdigital fungal infection
at an earlier age. Newer generation antifungals, both
local and oral, are helpful.
Tinea cruris, the fungal infection of the groin area, is
characterized by erythematous, pruritic, and scaly erup-
tion with characteristic demarcation from unaffected skin.
Treatment includes topical and systemic antifungal ther-
apy.
Infestations
Scabies and pediculosis are the common infestations seen
in the elderly population, particularly in nursing homes.
A questionnaire study Ontario, Canada, found that 20%
of 130 institutions had problems with scabies during a
one-year period.55 Scabies is a contagious skin infection
caused by the mite Sarcoptes scabiei. The infection is
caused by close and prolonged contact from person to
person or through fomites. The first symptoms due to
International Journal of Dermatology 2012, 51, 509–522
Jafferany et al.
hypersensitivity to the scabies mite appear about two -
weeks after the infestation. The hypersensitivity pruritic
papules are generalized but occur predominantly over the
axillae and around the areola, wrists, finger webs,
periumbilical area, genitals, buttocks, and the thigh. The
primary manifestation is the scabetic burrow, found
predominantly on the wrist and interdigital spaces of the
fingers. Secondary lesions such as impetigo and eczemati-
zation are common due to scratching of the skin from
pruritus and may alter the clinical picture. Bullous lesions
are often present in the elderly population. The clinical
presentation of scabies in the elderly can vary markedly.
Many patients are not properly diagnosed because they
do not present with classic features. Many elderly patients
also suffer from asteatotic dermatitis and xerotic skin,
and increased itching due to scabies may be erroneously
attributed to the exacerbation of underlying skin disease.
Sometimes the itching may be brushed aside, and they are
labeled as having psychological itching.56 Norwegian sca-
bies may be seen in the elderly who are unable to scratch
due to some neurological disorder with skin anesthesia or
those who are unable to scratch due to physical limita-
tions.57 The presentation may mimic eczema, and the
delay in diagnosis may lead to an outbreak of scabies in
nursing homes.58 Diagnosis of scabies is made by mite or
ova feces identified in scrapings. Scabies is treated by
standard treatment methods in addition to specific
emphasis on comorbid xerotic skin.
Pediculosis is a lice infestation, which is subdivided into
pediculosis capitis (head lice) or phthirus pubis (pubic
lice). It commonly presents with pruritic papular eruption
in the infested area. It is transmitted through direct physi-
cal contact or with infested fomites. Examination of hair
reveals nits (eggs) cemented to the hair shaft. Pediculosis
is treated with permethrin. Nits should be combed out
using a special comb.
Eczematous lesions
Eczematous lesions occur in every age group, and the
elderly are no exceptions.59 The role of dryness of skin,
xerosis, and asteatotic eczema has already been discussed.
Nummular eczema is characterized by coin-shaped
macules, papules, or vesicles with oozing and crusting on
the surface. It occurs on the extremities mainly but may
occur at any site. It may be associated with changes in
humidity and temperature, and dryness of skin will wor-
sen it. Treatment includes topical steroids and avoidance
of soap or detergents. Seborrheic dermatitis is another
type of eczematous eruption noted in the elderly. It is
believed to be caused by Malassezia yeasts, which cause
an abnormal host response.60,61 The prevalence of sebor-
rheic dermatitis has been estimated to be about 31% in
ª 2012 The International Society of Dermatology
Jafferany et al.
the elderly population.62 Seborrheic dermatitis is charac-
terized by erythema and greasy red-brown papules cov-
ered with scaly yellow flakes and plaques. Seborrhea in
the elderly is often associated with diseases, such as par-
kinsonism, epilepsy, various CNS diseases, and trauma.63
The treatment consists of corticosteroids, keratolytic
agents, such as pyrithione zinc, sulfur, coal tar, and sali-
cylic acid. Antifungal agents in the form of medicated
shampoos may also be used.
Contact dermatitis is a fairly common type of eczema,
with an estimated 11% of the elderly population to be
suffering from it.62 The individual susceptibility in the
elderly population to contact dermatitis is relatively low,
secondary to a decreased ability to mount a delayed-type
hypersensitivity reaction due to an abnormal immune
response in the form of reduced Langerhans’ cells,
decrease in T-cells, and diminished vascular reactiv-
ity.64,65 A Scottish study66 conducted on 200 patients
with leg ulcer found that 81% of patients exhibited aller-
gic reactions to topical medications. Because leg ulcers
and stasis eczema are quite common in the elderly popu-
lation, the use of topical medications should be carefully
planned and monitored, and patch testing may be applied
where necessary and available in high-risk patients. Treat-
ment consists of discontinuation of offending medication
and use of topical corticosteroids and oral antihistamines.
Psychodermatological disorders
Increased awareness of psychocutaneous disorders is cur-
rently under discussion. Psychodermatological disorders
are characterized by skin disorders with psychological
impact and psychiatric disorders with skin manifesta-
tions.33,67 Psychocutaneous disorders of older age are
mainly self-induced disorders that only affect areas of the
body that can be accessible by hands. The role of psyche
is important in the causation and progression of the pre-
senting lesions. Unfortunately many physicians including
dermatologists are not aware of and insightful of the con-
nection between skin and mind, and in many cases a psy-
chodermatological approach is required in the treatment
of these disorders.68 Common psychodermatological dis-
orders seen in the older population include lichen simplex
chronicus, neurotic excoriations, prurigo nodularis (PN),
and delusion of parasitosis.
Lichen simplex chronicus presents with lichenified red
scaly plaque. Patients habitually rub and scratch with the
dominated hand. This is repeated until lichenification
occurs. A recent Spanish study investigated the personal-
ity differences between patients with lichen simplex chro-
nicus and the normal population and found that patients
with lichen simplex chronicus have a greater tendency to
pain avoidance, greater dependency on other people’s
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Geriatric dermatoses Review 515
desire, and are more conforming and dutiful compared
with the control group.69 In a Turkish study conducted
on 23 patients with lichen simplex chronicus on the
limbs, the authors suggested that damage to the periph-
eral nervous system, such as radiculopathy and neuropa-
thy, can play a critical role in the etiology of lichen
simplex chronicus on the limbs. Both nerve-root compres-
sion in magnetic resonance imaging scans and radiculopa-
thy in nerve-conduction studies are common findings in
asymptomatic subjects, but they seem to be more
common in patients with lichen simplex chronicus on
the limbs. Therefore, elderly patients with lichen simplex
chronicus should be evaluated for the possibility of
underlying neuropathic changes.70 Treatment is often
refractory, and varieties of modalities including steroids,
retinoids, immunosuppressives, naltrexone, and gabapen-
tin have been used with variable success. Behavior modifi-
cation along with water soaks and steroid ointments and
occluded dressing with steroid have also been helpful.71
PN usually presents with erythematous or hyperpig-
mented, scattered, and discrete keratotic nodules on the
extremities. These lesions are secondary to habitual
scratching and picking and in severe cases may ulcerate.
A psychometric study conducted on 20 patients with PN
found that symptoms of anxiety and depression associ-
ated with PN were more severe than the control group,
and some specific personality traits were identified with
the PN group. This evidence highlights the importance of
a psychological approach in the management of PN.72 As
with lichen simplex chronicus, the treatment is often
refractory, and similar therapeutic agents have been used
with variable success. Topical application of steroids,
doxepin cream, and habit reversal therapy may be help-
ful. Some case reports describe the useful effect of gaba-
pentin in the treatment of PN.73
Neurotic excoriations or pathological skin picking, a
type of impulse control disorder, are irregular skin lesions
not fitting into any other skin disease. The prevalence of
neurotic excoriations or pathological skin picking ranges
from 1.4% to 5.4% of the general population, with a
higher preponderance in females and psychiatric
patients.74 The lesions may present as a variety of excori-
ated papules at different stages of healing in the back-
ground of post-inflammatory scars. The patient often
admits to using his/her skin as an outlet for stress.
Odlaug and Grant75 studied the clinical characteristics
and medical complications associated with pathological
skin picking, and the most common comorbid conditions
found were trichotillomania (36.7%), nail biting (26.7%),
depression (16.7%) and obsessive compulsive disorder
(15%). Neurotic excoriations can be treated with a
psychotherapeutic approach, particularly cognitive behav-
ioral therapy with symptomatic treatment. Several
International Journal of Dermatology 2012, 51, 509–522
516 Review Geriatric dermatoses
pharmacological agents have been used with variable suc-
cess including, but not limited to, atypical antipsychotics,
antidepressants, lamotrigine, gabapentin, naltrexone, and
topiramate.76
In delusion of parasitosis, patients firmly believe that
their bodies are infested by some type of organisms
despite lack of supporting evidence.77 They often present
with small bits of excoriated skin, debris, and unrelated
insects or insect parts – the matchbox sign.78,79
The clinical picture may include bruising, contact
dermatitis, scratching, excoriation, and lichenification
secondary to self-inflicted scratches or attempted cures
with caustic substances.80 Delusional parasitosis has been
described in association with schizophrenia, psychotic
depression, drug-induced psychosis, cocaine use, amphet-
amine use, alcohol withdrawal, stroke, leprosy, and
peripheral neuropathy.81 Treatment approach should
be non-confrontal and non-judgmental. There are no
randomized placebo-controlled trials reported in the
literature regarding specific pharmacological agents.
However, several case reports and systematic reviews
suggest that use of atypical antipsychotics has proven
helpful.82–85 Dermatology, psychiatry, and primary care
physician liaisons are very important in the successful
treatment of this chronic resistant-to-treatment condition.
Drug eruptions
Sudden onset of skin lesion in a patient without any prior
skin disease should always raise the suspicion of drug
eruption. Elderly patients are likely to be on several med-
ications because of multiple medical disorders. From a
physiological standpoint, respiratory, excretory, and met-
abolic functions are generally deteriorated in the elderly,
and multiple drugs are apt to accumulate in the body,
leading to a high incidence of drug eruptions. The inci-
dence of drug eruptions in the general population is
reported to be 10–30% of all reported adverse drug reac-
tions.86 The most common eruptions seen in the elderly
population are exanthematic eruptions;87 they take the
form of maculopapular, morbilliform, or erythematous
lesions. The other presentations could be vasculitis, fixed
drug eruptions, erythema multiforme, urticaria, contact
dermatitis, purpura, and photodermatitis.88 Drug-induced
vasculitis appears as purpuric maculopapular eruption
mainly on limbs and may be accompanied by systemic
symptoms such as fever, aching, and fatigue. The loss of
dermal collagen and fat coupled with vascular fragility
may predispose the elderly to traumatic purpuric lesions.
Many elderly are on different medications that may cause
thrombocytopenia, leading to purpura. Drugs most com-
monly associated with thrombocytopenia include penicil-
lin, quinine, quinidine, thiazides, methyldopa, and
International Journal of Dermatology 2012, 51, 509–522
Jafferany et al.
heparin. Fixed drug eruption is another type of drug
eruption that may present as rounded single
erythematous or bullous lesions, which typically recur at
the same spot upon re-challenging with the same medica-
tion. The common sites are hands, feet, genitals, and
around the mouth or eyes. Erythema multiforme is
another drug-induced lesion due to hypersensitivity reac-
tion characterized by target-like lesions on the extremities
and trunk accompanied by systemic symptoms. It may
take the form of minor or major form. The latter may
present as more serious life-threatening Stevens–Johnson
syndrome or toxic epidermal necrolysis. In diagnosing
drug eruptions in the elderly, it is necessary to obtain a
detailed history of the patient’s drug use from his or her
family if the patient is not able to recall each of them.
Medical history and physical examination are also impor-
tant in reaching the correct diagnosis. The standard treat-
ment is discontinuation of the causative therapeutic agent
and substitution with another drug.
Neoplasms
Both benign and malignant neoplasms have been noticed
in the elderly population with increased frequency. Sebor-
rheic keratosis, also known as seborrheic warts, is not
related to seborrhea. It is the most common benign lesion.
The cause is unknown, and lesions appear as brown or
black papules or plaques that have a characteristic net-
work of indentation or crypts on their surface; they have
an abrupt edge that gives the appearance of plasticine
stuck on the surface of the skin. Commonly affected sites
are the trunk, face, and proximal extremities. Six subtypes
of seborrheic keratosis have been described: dermatosis
papulosa nigra; stucco keratosis; inverted follicular kerato-
sis; large cell acanthoma; lichenoid keratosis; and flat
seborrheic keratosis. Several of the subtypes may act as
cutaneous markers for internal malignancy and should be
monitored closely for any atypical changes.89 The sudden
appearance of multiple seborrheic keratoses – Leser–
Trelat signs – is indicative of an internal malignancy,
usually of an adenocarcinoma of the stomach.90 Sebor-
rheic keratosis is easily removed by curettage, cryosurgery,
or electrosurgery.
Skin tags are common in the elderly; the common site is
the neck and around the axillary folds. They are common
mesenchymal tumors, often multiple, and usually 1–4 mm
in size. Occasionally, they reach diameters >3 cm. Skin tags
may be a manifestation of aging; they may also be associ-
ated with obesity, diabetes mellitus, pregnancy, and some
endocrine disorders. Small lesions are treated with electro-
dessication; larger lesions should be excised.
Cherry angiomas, also called Campbell de Morgan
spots or senile angiomas, usually present as bright red or
ª 2012 The International Society of Dermatology
Jafferany et al.
purple lesions mainly on the trunk or upper extremities.
They could be left untreated, but if there is a cosmetic
concern, they could be treated with electrocoagulation or
laser coagulation.
Both pigmented and non-pigmented malignant tumors
of the skin are predominant in the aged population, prob-
ably due to lowered immunity and the harmful effects of
ultraviolet light on their skin. The incidence of melano-
mas is increasing. This may be due to the decrease of the
ozone layer, exposure to sunlight, outdoor activities, etc.
Protection against sunlight is vital to prevent melanomas.
Malignant melanomas, particularly lentigo melanoma,
may occur in the elderly population and present as
brownish or black plaques, with irregular borders and
irregular pigmentation.91
Basal cell carcinoma is the most common but least
malignant skin tumor. It is recognized by the pearly pap-
ules, rolled edges, and telangiectasia. They also have a
history of bleeding. Squamous cell carcinomas present as
irregular growths with an indurated base. These malig-
nant tumors have many variants and should be diagnosed
at an early stage. Tumors are treated by excision; those
that have spread beyond the skin would need a more rad-
ical approach.
Keratoacanthoma is a condition that presents with an
erythematous dome-shaped, 1–10 cm nodule with a kera-
tin plug in the center, mostly on the sun-exposed areas
such as the face and dorsum of the hands. It is often con-
sidered to be a subtype of cutaneous squamous cell carci-
noma. Squamous cell carcinoma arising in
keratoacanthoma has been found in 5.7% of cases in a
series of 3465 cases. The incidence rises to 13.9% in
patients older than 90 years.92 Leukoplakia is a premalig-
nant condition associated with alcohol and/or tobacco. It
commonly appears as white patches on mucosal surfaces,
which cannot be rubbed off. It is treated with electro- or
cryosurgery or with topical fluorouracil.
Photodermatoses
Photodermatoses are a variety of skin changes that may
occur due to prolonged exposure to solar light. Actinic
dermatitis is a condition resulting from abnormal photo-
sensitivity and is clinically similar to contact allergic der-
matitis and should be distinguished from drug-induced
photosensitivity. Victor et al.93 conducted a 20-year retro-
spective analysis of 76 patients and found that the num-
ber of reactions to medications increased, and sunscreens
and antimicrobial agents were the most frequent allergens
eliciting photoallergic contact dermatitis, and there was a
decrease in photoallergic contact dermatitis caused by fra-
grances. In diagnosing actinic dermatitis, photo-patch
testing and patch testing may be helpful in difficult cases.
ª 2012 The International Society of Dermatology
Geriatric dermatoses Review 517
Management of the condition requires sunlight avoidance
and use of sunscreens, topical emollients, and topical cor-
ticosteroids. Oral corticosteroids and immunosuppressive
therapy such as azathioprine may be indicated but should
be used with caution in the elderly.94
Actinic keratosis is a premalignant scaly lesion that
develops on the skin exposed to UVB. Common sites are
the backs of the hands, forehead, and the ears. Clinically
they appear as scaly hyperpigmented or erythematous
plaques that may ulcerate. It is the initial manifestation
of a continuum of clinical and histological abnormalities
that progresses to invasive squamous cell carcinoma.95
There is usually a period of several years between the
development of actinic keratosis and its transformation to
squamous cell carcinoma. Actinic keratosis should be
treated before it progresses to invasive squamous cell car-
cinoma. Destructive modalities such as cryosurgery using
liquid nitrogen and electrodesiccation and curettage are
the mainstays of therapy.
Actinic elastosis is another condition that refers specifi-
cally to the degenerative histological alterations seen by
light microscopy in sun-damaged skin. Multiple factors,
including anatomic site, extent of sun exposure, and other
physical or environmental factors, affect the clinical
appearance of these changes.96 It manifests as small yel-
lowish papules and plaques on the face or back of the
hands. The skin assumes a dull yellowish color with deep
furrows and wrinkles.
Nodular elastoidosis, which is also known as Favre–
Racouchot syndrome, is seen mainly around the eyes and
extends onto the cheeks in the elderly, especially in men.
The lesions consist of comedones, follicular cysts, and
large folds of furrowed and yellowish skin.97 Cutis rhom-
boidalis nuchae is a condition where the skin over the
back of the neck becomes thickened, rough, and leathery,
and the normal skin markings become exaggerated. The
condition is often seen in farmers, sailors, or those people
who are exposed to excessive sunlight.
Actinic cheilitis is a premalignant condition character-
ized by skin changes occurring on the lower lips; exces-
sive sunlight produces dryness, scaling, atrophy, and
telangiectasia. Fissures, leukoplakia, and carcinoma may
develop. Focal actinic cheilitis is easily treated with cryo-
surgery or electrosurgery. Extensive actinic cheilitis
requires 5-fluorouracil, carbon dioxide laser, or scalpel
vermilionectomy for adequate treatment.98
Nutritional disorders
Age-related changes such as chronic illnesses, malabsorp-
tion, impaired metabolism, immobility, depression, eating
disorders, social deprivation, alcoholism, drugs, and pov-
erty make the aging population susceptible to a variety of
International Journal of Dermatology 2012, 51, 509–522
518 Review Geriatric dermatoses
nutritional disorders. Several authors have discussed the
process of glycation, which is the non-enzymatic reaction
between free amino acids and reducing sugars. In the
skin, this reaction creates new residues or formations of
cross-links (advanced glycation end-products) in the
extracellular matrix of the dermis. The formation of these
bridges between dermal molecules is supposed to be
responsible for loss of elasticity or other properties of the
dermis observed during aging. Glycation may therefore
play an important role in chronologic aging.99,100
Nutritional deficiencies vary from country to country
due to the difference in social customs, food intake, and
climate.101 The cutaneous signs of chronic ill health may
include hair loss, hyperpigmentation of the skin, and dry
and brittle nails. Women with advanced age are particu-
larly prone to deficiencies in vitamins B12, A, C, and D,
calcium, iron, zinc, and other trace elements, with conse-
quent skin changes.102 Zinc deficiency may be acquired
as found in liver and pancreatic disease or due to malab-
sorption. The patients are listless and depressed. An
eczematous eruption is seen in areas of trauma, such as
knees, ankles, malleolar regions, and elbows. Seborrheic
dermatitis-like lesions are seen on the face. Hair growth
is sparse, and total alopecia may occur. Zinc deficiency
also leads to retardation of the growth of nails. Zinc sup-
plementation leads to rapid improvement and a return to
normal levels of serum alkaline phosphatase. Iron defi-
ciency results in an iron deficiency anemia, manifested by
pallor, weakness, irritability, palpitations, sore tongue,
angular stomatitis, loss of hair, and koilonychia.
Vitamin C deficiency resulting in scurvy manifests in
small perifollicular hemorrhages. Niacin deficiency results
in pallegra, which presents on the skin as skin photosensi-
tivity, roughened texture of the skin, erythema, and vesi-
cle and bullae formation.
Appropriate nutritional intake and ruling out possible
systemic diseases that may cause vitamin and trace ele-
ments deficiencies and palliative care is the standard of
treatment in nutritional deficiencies.
Bullous pemphigoid
Bullous pemphigoid is a disease found primarily in the
elderly population at age 60 years and over. The
reported incidence ranges from 4.47 to 13.4 new cases
per million per year.103 It is a chronic autoimmune dis-
ease characterized by bullous eruption on normal skin or
on an urticarial base. There is a presence of circulating
and tissue-specific antibodies to hemidesmosomal pro-
teins present in the basement membrane of the epithe-
lium, ultimately resulting in a separation between the
dermis and epidermis and the formation of bullae.104
Bullae are tense and develop on both non-erythematous
International Journal of Dermatology 2012, 51, 509–522
Jafferany et al.
and erythematous skin. Bullae may also appear on muco-
sal surfaces in up to one-third of cases. Nikolsky’s sign
is negative on clinical exam. Confirmation is done by
histology, immunofluorescence immune electron micros-
copy, and molecular biology techniques. The precipita-
tion of the disease is associated with ultraviolet
irradiation, x-ray therapy, and exposure to certain drugs
and photochemotherapy. Topical steroids and systemic
anti-inflammatory and immunosuppressive agents have
been used to control the disease.105,106 Mucous mem-
brane pemphigoid is characterized by conjunctiva and
blisters in the mouth, conjunctivae and nose. It is also
commonly seen in the elderly population.107 The patient
should be immediately referred to an ophthalmologist
upon diagnosis to prevent blindness. Topical steroids
containing artificial tears and immunomodulating thera-
pies such as methotrexate, mycophenolate, monoclonal
antibodies, and topical tacrolimus have been helpful.108
Pemphigus vulgaris and paraneoplastic pemphigus erup-
tion are also frequently seen in the elderly. Immunofluo-
rescence has been helpful in the diagnosis.
Treatment guidelines for managing skin
disease in the elderly
Management of cutaneous disorders in the elderly popu-
lation is a challenge. Treatment compliance is affected
by several factors including declining cognitive status
such as loss of memory and dementia, physical limita-
tions, and impaired sensory functions. From a psychoso-
cial standpoint, this population is dependent on others,
and many have no stable housing or nutrition. Polyphar-
macy is very common secondary to many medical prob-
lems, thus increasing the odds of cutaneous drug
reactions. Several patients use over-the-counter medica-
tions, homeopathic medications, and herbal supplements.
This should very specifically be asked about from
patients or their caregivers, as many do not view them
as drugs. To maximize the efficacy and compliance, the
treatment regimen should be kept as simple as possible,
such as topical treatments; however, it is important to
consider the cutaneous structural fragility, intrinsic skin
changes and other comorbid conditions, and the patient’s
physical and cognitive status.109 A systematic review of
topical skin care in senior homes was conducted by Aus-
tralian researchers, and it was found that the quality of
evidence for interventions to improve or maintain the
skin condition in the elderly was poor, and effectiveness
of topical skin intervention was variable and dependent
upon the skin condition being treated.110 This fact high-
lights another challenge in the management of skin dis-
ease in the elderly, pointing towards the importance of
skilled nursing.
ª 2012 The International Society of Dermatology
Jafferany et al. Geriatric dermatoses Review 519

Conclusion a. Trichophyton rubrum

b. Candidiasis
In conclusion, dermatological problems in the elderly
c. Malassezia furfur
population are very common. They are visible and can
d. Trichophyton mentagrophytes
often add to the psychological stress in the geriatric popu-
e. Sarcoptes scabiei
lation. The skin is not only the largest organ of the body
but also a strong part of the immune system that protects 6. All of the following are premalignant conditions,
us from the external environment. It bears the brunt of except:
aging from both the external and internal environments, a. Actinic cheilitis
resulting in pathological processes that can ultimately b. Actinic keratosis
affect the health and quality of life of older patients. A c. Actinic elastosis
proper understanding of geriatric dermatoses is crucial d. Cutaneous horn
for the dermatologist practicing with the geriatric popula- e. Seborrheic keratosis
tion.
7. Extrinsic aging of the skin is due to which one of the
‘Like a candle in a holy place, so is the beauty of an
following:
aged face’. Take care of the elderly.
a. UVA
b. Broadband UVB
Multiple-choice questions (See answers on c. Narrowband UVB
page 522) d. UVC
1. The elderly population is vulnerable to a wide variety e. Visible light
of dermatological conditions secondary to structural
8. Xerosis is the most common disorder of the aged
and metabolic changes in the skin.
population, which of the following two are responsi-
a. True
ble for it:
b. False
a. Decrease in sebaceous secretions
2. Leukoplakia may present as which of the following? b. Decrease in eccrine secretions
a. White patches on mucosal surfaces that can be c. Decrease in apocrine secretions
rubbed off easily d. Decrease in epidermal lipids
b. Scaly hyperpigmented plaques e. Impaired thermoregulation
c. White patches on mucosal surfaces that cannot be
9. Which one of the following is most significant in pro-
rubbed off
ducing cutaneous aging?
d. Small yellowish papules and plaques on the face or
a. Nutrition
back of the hands
b. Systemic disease
e. Severely pruritic itchy plaques
c. Environmental effect
3. In the treatment of xerosis and senile pruritus, the d. Smoking and drinking
following is/are the treatment of choice: e. Psychological stress
a. Thorough washing of entire skin with soap or any
10. Uneven pigmentation of the aged skin is due to
other detergent
which one of the following:
b. Antipsychotics
a. Fragmentation of collagen and elastic tissue
c. Lubricants and emollients
b. Flattening of the dermo-epidermal junction
d. Immunosuppressants
c. Decreased epidermal cell replication
e. Antidepressants
d. Reduced effect of androgens
4. The following treatment options have been reported e. Decreased inflammatory response
to be most helpful in treating patients with delusions
of parasitosis.
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Answers
1. a
2. c
3. c
4. d
5. b
6. c&d
7. a&d
8. a
9. c
10. c
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