As we grow older, our bodies go through natural changes, including aging our skin. These changes happen due to a mix of biological processes and environmental factors. Skin aging can be categorised into two main types: intrinsic (or chronological) and extrinsic. Internal physiological changes drive intrinsic aging and are something we can't avoid. On the other hand, extrinsic aging is caused by external factors like sun exposure, pollution, smoking, and other elements in our environment. The elderly population, typically those who are 65 years old and above, experience specific age-related changes in the structure and function of their skin, which makes them more susceptible to various dermatological conditions.

Changes in Elderly Skin

• Dryness and roughness occur due to thinning of the epidermis and a decrease in barrier function.
• Delayed healing is caused by a decrease in cell turnover and a reduced capacity for repair after injury.
• Uneven pigmentation
• Wrinkles and skin laxity occur due to a decrease in collagen and elastic fibers, as well as reduced subcutaneous fat.
• Reduced sensory perceptions
• Reduced ability to regulate body temperature
• Decreased sweat production caused by the regression of apocrine glands
• Reduced sebum production
• Hair changes to a white or grey colour.
• Slower nail growth
  

Common Geriatric Dermatoses

Pressure ulcers (Decubitus ulcers)

Pressure ulcers, also called bedsores, usually form on bony parts of the body and are frequently seen in critically ill individuals, quadriplegics, and people with diabetes. Being immobile can cause skin and tissue harm because of decreased oxygen flow, so healthcare experts need to properly assess and handle them. Preventive measures involve encouraging movement, regularly changing the position of bedridden patients, and ensuring proper skin care.

Xerosis

Dry skin (xerosis) is prevalent among the elderly and those with Chronic Kidney Disease, liver issues, or autoimmune disorders. Reduced moisture retention in aging skin can cause itching and discomfort, significantly impacting quality of life. Treatment involves moisturiser application, increased water intake, avoiding hot showers, and minimising soap use to preserve natural skin oils and prevent further dryness.

Asteatotic dermatitis:

Asteatotic dermatitis presents with dry, cracked, and fissured skin, commonly found on the extremities, especially during cold weather. People with eczema should limit bathing to 5-10 minutes and apply moisturiser to damp skin within 3 minutes after bathing. Dermatologists may also recommend topical corticosteroids and calcineurin inhibitors as needed.

Pruritus (Itching):

As noted earlier, pruritus, or itching, is frequently a result of xerosis, or dry skin. In older adults, pruritus can also stem from systemic conditions (comorbidities), age-related changes in the skin and nerves, and the use of multiple medications. Identifying the root cause is crucial, as it guides the choice of treatment or management is best to use. Some treatments for pruritus include topical corticosteroids, moisturisers, and antihistamines.

Stasis dermatitis:

Stasis dermatitis is a condition characterised by swelling, redness, and scaling of the skin, often occurring due to inadequate circulation in the legs. It is commonly observed in individuals with venous insufficiency or chronic venous stasis.Topical corticosteroids can be applied, and antiseptics or antibacterial agents may be given if a bacterial infection is present.

Solar lentigines:

Solar lentigines are small, darkened spots that can appear on areas of the skin exposed to the sun, such as the face, neck, and arms. Typically, these spots do not need treatment, but it is wise to see a dermatologist if there are any changes in their appearance, such as irregular shape, colour, or size, to rule out melanoma. Using sunscreen and other sun protection measures, like seeking shade and wearing a wide-brimmed hat, can help prevent solar lentigines.

Scabies infestation:

Scabies, caused by the Sarcoptes scabiei mite, is common among elderly nursing home residents, presenting as small, itchy, red lesions on various body parts. Itching intensifies at night, and treatment involves topical scabicides like permethrin to kill mites and prevent spread. Early treatment is crucial to curb transmission.

Infections:

Infections in older adults can come from bacteria, viruses, or fungi. Some of the most common skin infections include:

Cellulitis: Bacterial infection of the subcutaneous fat that mostly impacts the lower legs in older adults. Symptoms include red patches, plaques, or ulcers that may be tender and warm to the touch. Treatment typically involves the use of topical and systemic antibiotics.

Herpes zoster (Shingles):  Shingles are caused by the reactivation of the chickenpox virus, presenting as painful, grouped, red vesicles in a unilateral, dermatomal pattern. Treatment includes antivirals, wet-to-dry dressings, calamine lotion, and non-steroidal anti-inflammatory drugs for pain.

Onychomycosis: Onychomycosis is a fungal infection affecting the nails, most commonly affecting toenails, causing yellowish discoloration, thickening of the nail bed, and separation of the nail plate. Treatment involves oral antifungals to address the infection.

Drug eruptions: 

In older individuals with multiple health issues and medications, drug allergies can manifest suddenly, affecting any part of the body. Skin reactions can appear as widespread red spots or patches, flat or raised, often accompanied by fever and fatigue, necessitating dermatological consultation for proper management.

Benign and malignant tumours:

The elderly population experiences a higher occurrence of both benign and malignant tumours. These can include:

Seborrheic keratosis: Harmless condition characterised by warty, brown to black growths on the face, trunk, and limbs. Removal methods include electrosurgery, cryosurgery, or curettage.

Skin tags: Benign outgrowths of skin often seen in the neck and armpits, associated with conditions like diabetes and obesity. Larger tags are surgically removed, while smaller ones are treated with electrodesiccation.

Melanoma: Common in older individuals, often results from prolonged sun exposure. Lesions resemble brownish or black moles but with irregular borders and colour changes. It's advisable to consult a dermatologist for accurate diagnosis and treatment.

Basal cell carcinoma: The most common skin cancer, typically appears as a raised bump with rolled edges and visible blood vessels, often resulting from chronic sun exposure, especially on the face. Various treatment options are available, so consulting a dermatologist for proper diagnosis and management is recommended.

Key Points:

The primary objective for elderly skin is to maintain its health and hydration while preventing skin issues, which can also lead to mental and emotional strain. Sun protection remains crucial, along with the use of gentle, hypoallergenic skincare products. 

Consulting a dermatologist at the first sign of skin problems allows for early intervention. Managing skin issues in the elderly can be challenging due to their skin's structural changes, underscoring the importance of prevention over treatment.