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4.0 Objectives Structure Objectives Introduction Prevalence l~nportanceof Geriatric Skin Diseases Demiatological Exa~niiiatio~i Aging of Skin 4.5.I Clirc~nologicalAging 4.5.2 I'holoagi~~g 4.5.3 (ila!,ing ol'l lair lnflarn~iiatorySkin Disolders 4.6.1 Scnile Pn~rilus , 4.6.2 Senile Xerosis 4.6.3 Eczcnins 4.6.4 Senile Pur.pu~.aof Un~eman 4.6.5 Atlversc Cu~ancousDrug I<caclion 4.6.6 Ulccrs Autoimnlune Blistering Disorders 4.7.1 Bullous I'crnlpliigoid 4.7.2 Pcmphigus Vulgaris Infections and Infestations 4.8.1 I lcrpcs Zoslur 4.8.2 1)cl.malop liylosi s 4-83 Cantlidiasis 4.8.4 Baccclial Inli.c~ions 4.8.5 Parasilic Inl'csca~io~~s Neoplasms 4.9.1 Benign 'I'LIITIOLI~S 4.9.2 Premalignan~I.esions 4.9.3 Malignant l'umo~~rs 4.9.4 General Core in [lie Geriatric Skin I'ntie~lts 4.10 Let Us Sum Up 4.1 1 Key Words 4.12 Answers to Check Your Progress 4.13 Further Readings 4.0 OBJECTIVES After reading this unit, you should be able to: 9 describe the prevale~iceand impact of cornmon dermatological problerns seen in elderly people; 9 enumerate the structural and functional alterations in cutaneous aging process and differentiate between chronologically aged and photoaged skin; 9 discuss the salient features of colnlnon inflammatory, benign and malignant geriatric skin disorders; and @ manage the coinmon geriatric dermatological problems and identify the diseases that may need institutional care and specialized management. Dermatological problems are frequently seen among the elderly. Both males and females are affected with some variation in the frequency, onset and type orderrnatoses. The exact incidence of the derlnatological problems in the el?erly is difficult to assess bccause of very little data available exclusive to this age group. A federal sponsored study in A~nericaobserved that 40% ofthe aged people between 65 to 74 years suffered fiom a skin disease, sufficie~ltlysevere to warrant a visit by the physician. Inflammatory diseases and cutaneous neoplasia are more common in the elderly than in the general population, as revealed in several survey studies. Universally encountered and the most frequent problems of old age are cuta!leous aging, graying of hair and diffuse thinning of hair. 'The comlno11 inflammatory geriatric dermatoses include pruritus, xerosis, eczemas, drug reactions, solar elastosis, viral infections (herpes zoster), fi~ngalinfections (candidiasis and onycl~omycosis),bacterial infections (furuncles and cellulitis), parasitic infestations (scabies) and autoimmune blistering diseases (pemphigoid and pemphigus). Among the bcnign neoplasia are skin tags, lentigines, senile angiom;~~, seborrheic keratoses and melanocytic nevi. The common premnlignant lesions include solar keratosis, Bowen's disease, and lentigo maligna. Basal cell carcinoma, and sqilalnous cell carcinoma and ~nalignantmelanoma are the most frcilucntly seer1 skin cancers. Yet, some ofthe inflammatory and benign neoplastic disorders such as psoriasis. vascular and melanocytic nevi presentilig in the younger and middle ages of lifi may progress into old age. In the changing socio-cultu~.alscenario, many men and wolnen remain sexually active well into old age and may suffer from various sexually transmitted tliseases i~icluding1-1 IV infection. 4.3 IMPORTANCE OF GERIATRIC SKIN DISEASES The impact of skin diseases in the elderly is enornlous and may vary from significant physical disco~nfortand filnctional disability to serious emotional distress. Of all, cos~lletic unacceptability is the most distressing. Visible signs of several geriatric dermatoses such as scaly plaques, pigmented patches, blisters, ulcers and exudative lesions are looked down with fear, apprehension and suspicion ofcontagious tlature. Dry, wrinkled, saggingand less attractive appearance of the aged skin and its perception by the society, imposesa serious psychological trauma and inferiority complex in the concerned individual. 'I'his is responsible for the huge amount of money spent on the products labeled as age-retarders and anti-aging prod~rctsand the flourishing market of cosmetic and pl~ar~~aceuticalind~~stries. Some of the skin diseases in the elderly lnay produce considerable cutaneous discomfort. Generalized pruritus is perhaps the colnlnonest feature in many geriatric skin diseases that may interfere with daily activities including sleep disturbances. Some of the cutaneous disorders such as auto-immune blistering diseases and malignant neoplasms result ill serious physical morbidity which often progress relentlessly and may result in fatal outcome, due to se~~ious secondary infections. 4.4 DERMATOLOGICAL EXAMINATION Age associated vascular and immunological alterations make the skin findings more subtle in elderly patients than in younger individuals having the same disease. Establishing the diagnosis kl iscellrneous Qisol-ders in the elderly is therefore, an art and requires certain important considerations. To arrive at the etiology ofthe disorder, and its activity, severity and acuity, the patient needs an ndequate and co~nprehensiveinterrogation by the doctor. A history pertaining to his chief complaints, evolution of the lesions, past, episodes, previous medication, bathing habits and exposure to harsh detergents, should be carefully recorded in order to diagnose, elicit the cause and establish prognostic criteria. Special attention must be devoted to his general health and associated systemic disease. Der~natologicexaininationshould ideally be perfor~nedin natural light. The entire skin including the appendages must be inspected and the clinical details about the distribution, morphology of the primary and secondary skin lesions. their symmetry and consistency should be recorded. Various techniques ofexamination like diascopy(pressingthe lesion with aglass slide), stroking the skin for der~nograpliism,inspecting scales ancl hair, after removing with a forceps, are important. Examination of mucous membranes, hair, nails, genitalia and feet of [lie elderly require special attention. Other systelns should also be examined in pertinent cases. Routine laboratory investigations of blood, urine, stool and pus may help to supple~nentthe diagnosis. The physicia~lmust also consider the individual's social and personal conditions, living habits, financial position and emotional adjustments not only in making a diagnosis but also while prescribing appropriate tllerapy. Clieck Your Progress 1 Write Trne (T) or False (F): I) Derlnatological proble~nsare not very common in elderly. (T/F) 2) Generalized priorities is the comnionest feature in many geriatric skin diseases. f j (-r/~) 3) Dermatological examination is best done in a tubelight. (?T/F) 4.5 AGING OF SKIN Before we learn about the diagnosisand management ofbolnmon dermatological problems, let us study about the changes in skin with aging. The appearance of skin is an important factor in the visual determination of rnan's age and his personality. Aging is an inevitable and un'iversal phenomenon that occurs in every living being with the passage of time. Tlie quest to understand the secrets of aging dates back to the dawn ofcivilization and reflects strongly the human desire to increase the life expectancy and perpetuate the everlasting youthful look. Yates viewed old age or senescence as a set of age-driven catabolic events. 'There are two basic concepts of aging. Tliepr~~g~~~utictheuq/ states that aging is a preordai~ledprocess due to an inherant genetic programme, monitored at a rate,characteristic of each species while the srochastic theoly states that aging is produced by random cumulative environmental damage to genes and proteins. Now, it is generally agreed that aging is the result of interactive process of both these events. Cutaneous aging is of two types: (I) chronologic aging, and (2) photoaging. Chronologic aging, also referred to as trueor intrinsic aging, isa universal and inevitable process attributable to the passage of time alone, whereas the photoaging or extrinsic aging is the acceleration of changes seen during intrinsic aging due to the cumulative effect of chronic exposure to sunfigllt. Differentiation between these two types of aging is important because the photoaging is associated with the development of premalignar~tkeratoses that can be prevented by avoiding sun exposure. 4.5.1 Chronological Aging Var~onsstructural and functional alterations are seen during the intrinsic aging ofskin. Clinically. the aged skin is characterized by dryness, fine shallow wrinkles, smooth unblemished surface, uneven pigmentation, loss of elasticity resulting in "ragging", anitnation lines on the face seen as 'frown lines' and 'crows feet' and a number of benign growths (Fig. 4.1). I:ig.4.1: ( III IIIIII~O~IL,I~III~ trl Il~c ~~III \l~i,tr~~~g IIIII! ~lt;~llt~r\ +\I l~~l,lcrIJ~~I 111u I,~cc .~rril ,1111111i111o11 lil~es(crow's fcct) ltenr outcr cnntl~uaof tlre uyulitls I-listologically, the tilost corisistent and striki~iyfcatu~~i OF aged skin is [he flat ~eningof dernioepider~naljunctio~i with significa~itreduction in tilt! nunibcr of rcte ridgcs and interdigitating dermal papillae. L3cca~tseof this, tlic coliesio~iul'dcr~iioepitlcl~~~li~l junction is weakened and there is less ~.csistaticcto thc sliotlritiy fc1rces. 'I'liis accoun~sfbr tllc prcdiluction of aged skin to abrilsio~isand lslistcrs following a niinot. rralrniu. C'lia~igcsin tlie sulvi;~cl:lipid film and decrcase in epidermal tillagrin, nffect ilic barrier ti~rictio~icontributing to dry and llrlky skin. Epidernial cell turnover is decl-eased with aging. Marked declilie in the
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