An ageing population
The median age of the Australian population has increased by four years over the last two decades, from 33.4 years in 1994 to 37.3 years in 2014.
Between now and 2050 the number of older people (65 to 84) is expected to more than double and the number of very old people (85 and older) is expected to more than quadruple.
The proportion of people aged 65 years or over is also projected to increase from 13% in 2010 to 23% by 2050.
This population ageing is projected to have several implications for Australia*.
Skin healthcare is one crucial area that will have to evolve to the demands of our ageing population.
What happens to my skin as I get older?
We all know that as we grow older wrinkles and other signs of aging begin to appear on our skin. Did you know your skin has many functions and they decline with age? Skin ageing is not just about the skin’s changing appearance on the outside.
Some of the functions of your skin that decline with age include:
- = Barrier function
- = Cell replacement
- = DNA repair
- = Epidermal hydration
- = Immune responsiveness
- = Mechanical protection
- = Sebum production
- = Sensory perception
- = Sweat production
- = Thermoregulation
- = Vitamin D production
- = Wound healing
Photoaging of skin
Photoaging refers to the damage that is done to the skin by prolonged exposure over a person’s lifetime to ultraviolet (UV) radiation, primarily from the sun. Many of the changes in the skin that occur as we get older are accelerated by sun exposure
|Photoaged versus intrinsically aged skin of an elderly man. Sun-exposed skin above the collar line is prominently wrinkled.|
Wrinkles and sun spots are the two types of photoaging we are most familiar with, and spend a lot of money trying to avoid, but there are many different signs of photoaging that appear on our skin as we get older. These include:
- Dryness (roughness) – roughness caused by a lack of moisture in the skin.
- Actinic keratosis - a
rough, scaly patch on your skin that develops from years of exposure to the sun.
Actinic keratosis is most commonly found on your face, lips, and ears, back of
your hands, forearms, scalp or neck.
- Irregular pigmnentation - freckling, lentigines (small brown patches of skin)
- Wrinkling - fine
surface lines, deep furrows
- Elastosis - a
condition in which skin appears yellow and thickened as a result of sun damage.
- Telangiectasia - a
condition in which there are visible small linear red blood vessels (broken capillaries).
- Venous lake - a
small blood vessel (vein) in the skin, which over time has become enlarged.
- Purpura - reddish-purple
spots, which look like bruises, caused by blood vessels bursting and blood
pooling under the skin.
- Inelasticity - skin elasticity is the skin’s ability to stretch and then go back to normal once the need to stretch is gone. Reduced skin elasticity is a fact of ageing for most people.
Many of these signs of aging will occur in all of us over time but you can slow them down by protecting your skin from the sun.
Learn more about how sunscreen protects our skin from the sun's damaging UV rays.
Smoking and skin ageing
Like sun exposure, smoking cigarettes is another preventable
cause of skin ageing.
Cigarette smoking exacerbates photoageing and there is a direct correlation between the number of pack-years smoked and the severity of wrinkling, greyish discolouration, acne-like changes (comedones), and dropping of the face.
Smokers also display poor wound-healing capacity and
increased incidence of skin cancers.
more about how smoking can lead to premature skin ageing.
How can I prevent skin ageing?
It’s the billion dollar question. The truth is, we cannot completely prevent signs of age from appearing on our skin. Fortunately, there are a few steps we can take to prevent premature skin ageing.
- Always apply
sunscreen when the UV Index is above 3. In order to be effective, sunscreen
must be broad-spectrum (protect against both UVA and UVB) and must be reapplied
every two to four hours. Broad-spectrum sunscreens are better at protecting
against DNA damage and photocarcinogenesis, and in delaying skin cancer
development compared with non-broad-spectrum sunscreens. You should use a
sunscreen that is SPF 50+.
- Avoid or minimise your time in the sun - between 10am-3pm from September to April when the UV levels are generally high. Please note: If you live in northern Australia (QLD, NT and WA) you should avoid exposure to the sun between 10am-3pm throughout the entire year.
- Wear a protective broad-brimmed or legionnaire-style hat, shirt made from high UPF material with a collar and long sleeves, and long pants or skirt.
- Seek shade when outdoors when the UV Index is above 3.
- Do not start smoking or, if you do smoke, try to give it up.
Treating or preventing dry skin will smooth the surface of
the skin, and assist the removal of dead cells from the top layers of the skin.
If you have dry skin, you should minimise the time you spend
in hot showers (have shorter, warm showers instead).
Use an emulsifiable bath oil or body washes with ‘neutral’ pH or ‘soap’ substitutes.
Apply a moisturiser. This is usually more effective if used
immediately after a shower or bath. Use greasier moisturisers in winter, when
your skin is more likely to be dry.
more about how to treat dry skin, particularly in winter.
Specific skin problems in old age
Pruritus (skin itch)
Causes of pruritis include:
- Cholestasis and liver disease
- Haematological disease
- Iron deficiency, polycythaemia vera
- Solid tumours, tymphomas
- Thyroid disease, diabetes
- HIV infection
- Adverse drug reaction
- Pruritus due to morphine and related drugs
Management of pruritus
In many cases, especially in the elderly, pruritis is caused
by dry skin. It is made worse by low humidity, and frequent bathing or
application of irritants to the skin.
Pruritis is temperature dependent, so wear light clothes,
keep the bedroom cool, and use light bedclothes.
Moisturise you skin with an ointment or cream moisturiser.
Moisturisers are most effective when applied immediately after a shower or
Other treatments for pruritus (itch) include:
- Calamine and menthol cream: short-lived relief
- Corticosteroid ointments and creams: ineffective in itching or clinically normal skin (i.e. no rash to see)
- Ultraviolet phototherapy
Asteatotic eczema "winter eczema"
A patient will often ascribe the onset to an event or change in life that is quite trivial, for example the installation of central heating or a particularly cold, dry winter.
The condition occurs particularly on the legs, arms and
In some patients, the surface texture of the skin assumes a
Causes of asteatotic eczema include:
- Frequent washing is certainly a causative factor in susceptible individuals and central heating may also play a part by reducing atmospheric humidity.
- Cold, dry weather, particularly for elderly people.
Asteatotic eczema can remain for months, relapsing each
winter and clearing in the summer, but eventually becoming permanent.
Irritation in this form of eczema is often intense, and worse with changes of temperature, particularly when undressing at night.
Treatment options for asteatotic eczema include:
- Central heating should be humidified where possible, and abrupt temperature changes should be avoided.
- Wool is usually poorly tolerated and possible damaging by irritation.
- Baths are best restricted and should not be hot.
- Emollients should be used after bathing or daily.
- This is one of the forms of eczema in which soaps and detergent cleansers can be harmful.
Scabies is an infectious disease that can be caught by close
contact. This includes sharing the same bed or clothing, or even just living in
the same house as a person with scabies.
Any close physical contact such as nursing, or caring for an
individual can spread the mite.
Away from the host, scabies mites survive for 24 to 36 hours
at room temperature conditions (21 degrees Celsius and 40-80% relative
Clinical features of scabies:
- Itching is usually the most obvious manifestation of scabies
- The itch is often worst at night and when the patient is warm
- The onset of itch occurs 3-4 weeks after the infection is acquired, and coincides with a widespread rash
- Reinfection provokes immediate symptoms
- The pathognomonic lesions of scabies are burrows - wrists, borders of the hand, sides of the fingers and the finger web spaces, the feet and, in males, on the genitalia
Permethrin cream (Quellada or Lycela) is the treatment of
choice in Australia because of its effectiveness and low toxicity.
All members of the same house should be treated at the same
Before going to bed apply 5% permethrin cream to the whole
body except the head and neck.
It takes around 30ml of permethrin cream to cover the
Make sure the cream is applied to all body parts, paying
particular attention to the elbows, breasts, groin/genitals, hands and feet (including
under the nails). If one burrow is spared then the infestation will persist.
The cream should be left on for at least 8 hours before
If you go to the toilet overnight and wash your hands, you
should reapply the cream to your hands.
All bed linen and clothes should then be changed and washed
(wash with hot water to kill the mite and its eggs).
Any clothing or bedding that can’t be washed should be put aside for 7 days before using (e.g. placed in a plastic bag).
All members of the family and close physical contact should
be treated, whether symptomatic or not. The treatment of all household members
is often repeated at 7-10 days to maximise chance of eradication of the
Institutional outbreaks of scabies
- All patients
or residents should be examined to detect any cases of severe or crusted
scabies, and such individuals should be isolated until cured.
- Any personnel
coming into contact with such a patient should wear long-sleeve gowns and
- All individuals
on an affected ward or in residential homes, and all medical and nursing staff
and their families, should receive prophylaxis with a topical scabicide.
- Bedding should be laundered.
Seborrhoeic Keratoses are benign lesions that occur with increasing age. They are usually asymptomatic but may be itchy.
Seborrhoeic Keratoses are most frequent on the face and the
upper trunk. The most common appearance is that of a warty plaque, which
appears to be stuck on the surface of the skin, varying from dirty yellow to
black in colour.
No treatment is usually necessary. If required, removal may
be possible with a small sharp curette, cautery or freezing.
In Australia, every year:
- Skin cancers account for 70% of all newly-diagnosed cancers
- Two in three Australians will be diagnosed with skin cancer by the time they are 70
- Australia has one of the highest incidences of skin cancer in the world, at nearly four times the rates in Canada, the USA and the UK
- Over 400,000 Australians are treated for skin cancer each year - over 1,000 people each day
- Over 1,800 Australians die from skin cancer each year
- Each year, many more people die from skin cancer than from road accidents in Australia
- Almost 70% of Australians who die from skin cancer are men
- Sun exposure has been identified as the cause of around 99% of non-melanoma skin cancers and 95% of melanoma in Australia
Types of skin cancer include:
- Non-melanoma skin cancer
-Basal cell carcinoma
-Squamous cell carcinoma
Symptoms of Skin Cancer
Early warning signs of skin cancer can vary however
some important symptoms to keep an eye out for are listed below. If in doubt
have any lesion of concern checked by your GP or Dermatologist.
Melanomas may be diagnosed using the ABCDE method:
A - Asymmetry
B - Border
C - Colour variation
D - Diameter
(usually over 6mm)
E - Evolution
(change and growing larger)
Other skin cancers can be pink, red or skin
coloured. They are commonly found on sun exposed sites like the face, neck and
arms. Important signs include:
- Change in size, shape or elevation
If any of these occur it is very important to consult your GP or dermatologist as soon as possible.
Learn more about skin
Learn more about
A leg ulcer is simply a break in the skin of the
leg, which allows air and bacteria to get into the underlying tissue. This is
usually caused by an injury, often a minor one that breaks the skin. In most
people, a leg ulcer will heal up without difficulty within a week or two.
Leg ulcers are a common presentation in the elderly
Besides trauma or injury, other causes of leg
- Varicose veins
- Arterial disease - Artherosclerosis, diabetes, hypertension
- Skin cancers
- Connective tissue diseases
- Pyoderma gangrenosum – a rare skin condition that causes large, painful sores to develop on the skin, most often on the legs
- Blistering disorders
Venous ulcers are wounds that are thought to occur due to
improper functioning of venous valves, usually of the legs.
Venous ulcers are caused by malfunction of the veins in the
lower limbs. The ulcer may be preceded by patchy redness or discolouration of
an intense bluish red colour.
The ulcer is characteristically situated on the medial lower
aspect of the leg.
Venous ulcers do not usually develop initially below the
level of the malleoli (the bony prominence on each side of the ankle) or on the
Management of venous ulcers
- Compression bandages
- Exercise and movement are to be encouraged
- When resting,
legs should be elevated, ideally with the ulcer just above the level of the
heart to ensure the maximum reduction in venous pressure.
- Patients should
always be instructed to sleep in a bed
- Weight control
and adequate intake of essential vitamins and minerals in a balanced diet is
essential for wound healing.
- The contribution
of other medical conditions, particularly heart and chest problems, needs to be
- Smoking should be stopped and excessive alcohol intake should be curtailed
- Cleansing of
the ulcer should be kept simple. Irrigation of the ulcer with warmed tap water
or sterile saline is usually sufficient.
- It is customary
to remove slough, eschar and bacterial biofilms from the ulcer bed by
- Dressings should keep the ulcers moist but not wet
- Ideally, a
dressing should be left undisturbed for as long as possible so the ulcer can
get on with the job of healing.
A drug eruption is an adverse drug reaction of the skin. Most drug-induced cutaneous reactions are mild and disappear when the offending drug is withdran. Drugs can also cause hair and nail changes, affect the mucous membranes, or cause itching without outward skin changes.
Drug eruptions are common in elderly patients and can vary
from mild to life-threatening.
Signs of a serious drug eruption include:
Blistering of the skin
Mucosal involvement (mouth, eyes, genitals)
Once a patient has developed a drug reaction, they will
always remain allergic to that drug, and should avoid it in the future.
Common drug eruptions include:
- Exanthematic (maculopapular) reactions
frequent of all cutaneous reactions to drugs, and can occur after almost any
drug at any time up to 2-3 weeks after administration.
may be accompanied by fever, pruritus and eosinophilia.
o The distribution is variable but is generally symmetrical – the trunk and extremities are usually involved.
commonly caused by: Ampicillin and penicillin, sulphonamides, phenytoin,
carbamazepine, gentamicin, NSAIDs
within 24-36 hours of drug ingestion
commonly caused by penicillins, sulphonamides and NSAIDs
rechallenge, lesions may develop within minutes
Bullous pemphigoid is a blistering disease of elderly
people. Onset is usually after 60 years of age, with an average onset around 80
years of age.
This condition often starts with itch and raised, red
lesions. Large, tense blisters may develop during later stages on the disease.
Bullous pemphigoid disease duration is usually 3-6 years, with
most patients achieving complete remission off treatment.
Bullous pemphigoid can be fatal, particularly in the active blistering phase in elderly people, and about one-third of untreated patients die.
The aim of treatment is to suppress disease activity with
the minimum dose of drugs necessary. During prolonged treatment, it is
advisable to aim for the presence of a blister once every few weeks, so as to
be certain that the patient is not being over-treated.
Topical and systemic steroids are the mainstay of treatment.