Dialog Box

Senior Skin Health (60+ years)

What is normal?Suggestions for skin careCommon skin conditions

What is normal?

Ageing of the skin occurs naturally (intrinsic ageing), but is accelerated by exposure to UV irradiation from the sun or from past solarium uses (photoageing). Like every other organ in the body, skin is made up of cells. Each cell possesses DNA, the material that contains instructions for that cell’s purpose. Over a person’s lifespan, this DNA can be damaged. When that person is young, this damage can usually be efficiently repaired and the cell is able to continue functioning normally. However, with time, the ability of each cell to repair its DNA decreases. As a result, the DNA becomes progressively more damaged, and the cell loses its ability to function effectively. This is thought to be the basis of the ageing process.

Skin changes related to intrinsic (“normal”) ageing include a loss of elasticity and increased fragility, with aged skin being prone to injury and bruising (senile purpura). More seborrhoeic keratoses may occur. In addition, small, dilated blood vessels (telangiectases) may occur on the face.

Changes associated with photoageing (exposure to UV light) include the appearance of brown blotches (pigmentation) and freckles, which occur as a result of the skin’s response to sun exposure. Thickening and yellow discolouration of the skin (solar elastosis) may also be seen, and clusters of whiteheads and/or blackheads (solar comedones) are not uncommon.

In those with a long history of smoking, increased wrinkling and greyish discolouration of the skin is often noted, especially around the mouth. 

Suggestions for skin care

As this is the age group most at risk of developing skin cancer, it is important that individuals regularly check themselves for any new moles, suspicious looking spots, or for any changes in existing moles. If you notice one of these changes, it is best to see your doctor to make sure they are nothing dangerous. If you are fair skinned, have lots of moles, or a family history of skin cancer, it is a good idea to have your doctor perform regular skin checks.

Elderly skin is particularly vulnerable to damage from accidental trauma. Take care to avoid pulling or placing pressure on the skin to avoid bruising or tearing – while such forces may not leave so much as a mark on younger, more resilient skin, they make cause marked bruising in the elderly. Regular moisturising may make the skin less vulnerable.

Common Skin Conditions

Aged skin is vulnerable to developing many different skin problems. Of particular concern is skin cancer, with the elderly being at increased risk, resulting from cumulative sun exposure from a lifetime in the sun.

In addition, other factors may also contribute to this increased risk such as decreased DNA repair capacity of aged skin, as well as a degree of immunosuppression also related to sun exposure.

There are several different types of skin cancer, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma. As these conditions can be life-threatening if left untreated, early detection is very important. If you notice any skin changes, see your doctor.

 

Ageing Skin

Older adults experience significant signs of ageing skin. There are numerous factors that contribute to the appearance of aged skin, the most common being previous sun exposure.

Very commonly in Australia, older adults will have received regular exposure to ultraviolet radiation over their life and this will have had significant impact on their skin (particularly damage to the dermis, the underneath layer of the skin). This is known as photoageing. Dermatologists are able to advise on which of the thousands of skin care products available will have various effects on your skin. Some of the treatments that they might recommend include:

  • topical creams and lotions
  • injections to reduce lines, wrinkles and expression lines
  • use of Intense pulsed light therapy (IPL) or lasers
  • cosmetic surgery. 

Many medications are known to cause rashes or other skin problems in some people. Given that elderly individuals tend to be on more medications than younger people, drug reactions involving the skin are not uncommon in this age group. There are some drugs that are more often associated with drug reactions, and doctors can help with sorting this out.

About Ageing Skin


Alopecia

The term 'alopecia' refers to hair loss. While we all lose hair everyday (losing 50-100 hairs per day is considered normal), some people will develop disorders of hair loss, such as alopecia areata, or female and male pattern hair loss (androgenetic alopecia). If you experience sudden or significant hair loss or hair thinning, then you should consider seeing a dermatologist for a specialist medical diagnosis and advice.

About Alopecia


Bullous Pemphigoid

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.

Drug Eruptions

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 withdrawn. 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 and symptoms
  • Blistering of the skin 
  • Wide spread red rash
  • Painful skin
  • Ulceration of the muscous membranes (mouth, eyes, genitals)
  • Fever

If any of these symptoms are present, then the patient’s GP should be notified immediately. 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

  • Most 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.
  • Variable distribution but is generally symmetrical – the trunk and extremities are usually involved.
  • Most commonly caused by ampicillin and penicillin, sulphonamides, phenytoin, carbamazepine, gentamicin, NSAIDs.

Urticaria reactions

  • Occur within 24-36 hours of drug ingestion.
  • Most commonly caused by penicillins, sulphonamides and NSAIDs.
  • On rechallenge, lesions may develop within minutes.

Eczema

Eczema is a common condition in this age group, as it is for all ages. A discoid (nummular) pattern may be seen, which can either involve 'dry' (crusty, cracked) or 'wet' (oozing, blistering) oval-shaped patches. These can be various shades of pink, red or brown, and may be very itchy. 

Another skin condition common in the elderly includes asteatotic eczema, which frequently affects older people during the winter, when humidity drops and the skin dries out. The front of the shins are mainly involved, with the skin becoming very dry, cracked and quite itchy. Another common condition affecting the lower legs is venous eczema. This involves patches of eczema located over superficial veins.

About Eczema

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 hands.

In some patients, the surface texture of the skin assumes a cracked appearance.

Causes of asteatotic eczema:
  • 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
  • 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 worsen the problem by drying out the skin even more. A soap substitute should be used instead.
  • A topical steroid ointment may be needed if the above measures are not sufficient.

Occupational Contact Dermatitis

More people in Australia are working until they're older, and evidence shows that as we move beyond 'retirement age', there are still numerous possible health benefits to be derived from our engagement in an occupation.

However, even if you have been working for most of your life, your skin can still be susceptible to occupational contact dermatitis. This may be caused by irritant contact dermatitis or allergic contact dermatitis.

While irritant contact dermatitis is most common, there are also many potential causes of allergic contact dermatitis. This is a delayed hypersensitivity reaction, so people do not get itchy rashes straight away after contacting a chemical that causes allergy (allergen) - it can take hours or even a day or two. Important occupational allergens include chromate in cement and leather, hairdressing chemicals such as hair dye and bleach, and rubber chemicals in certain gloves.

It is said that 4000 chemicals (of a total of 100,000) can cause allergic contact dermatitis. The most common cause of non-occupational contact dermatitis is nickel from cheap jewellery. Other important allergens include fragrances and preservatives in skin care products.

About Occupational Contact Dermatitis

Pruritus (Skin Itch)

In many cases, especially in the elderly, itch is caused by dry skin (xerosis). It is made worse by low humidity, frequent bathing or application of irritants to the skin. Itch is temperature dependent i.e. it is generally worse when the person is warm or hot. So wear light clothes, keep the bedroom cool and use light bedclothes.

Causes:
  • Dry skin (xerosis)
  • Uremia
  • Cholestasis and liver disease
  • Haematological disease - Iron deficiency, polycythaemia vera
  • Malignant disease - Solid tumours, tymphomas
  • Endocrine disease - Thyroid disease, diabetes
  • HIV infection
  • Adverse drug reaction - Pruritus due to morphine and related drugs
Treatment

If you have dry skin, minimise shower time and have warm showers (not hot). Soap tends to dry out the skin further. Instead use an emulsifiable bath oil, bodywashes with neutral pH or soap substitutes.

Moisturise your skin with a greasy ointment or cream moisturiser. Moisturisers are most effective when applied immediately after a shower or bath. Examples of some useful moisturising creams include: Ego QV cream, Dermaveen cream, Hamiltons cream, Cetaphil cream, Dermeze, Aqueous cream. If unable to use an ointment, less greasy cream is next best. Lotions are also available, although they are usually less moisturising than creams or ointments.

Other treatments for pruritus (itch) include:

  • calamine and menthol cream for short-lived relief
  • corticosteroid ointments and creams, which are ineffective in itching or clinically normal skin (i.e. no rash to see)
  • antihistamines
  • doxepin
  • ultraviolet phototherapy (treatments supervised by a dermatologist). 

Psoriasis

Psoriasis is another skin condition frequently seen in older adults. It is characterised by red patches with a white, scaly surface, and can sometimes resemble eczema. These patches are of varying size and often affect the scalp, although people often present with more generalised psoriasis affecting much of the body. It tends to have a symmetrical distribution (i.e. occurs on both sides of the body).

There are many different prescription treatments available, but the field of psoriasis has recently been completely reinvigorated by the use of a new class of treatments, the 'biologics', which can be extremely effective in severe disease.

About Psoriasis

Scabies

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 humidity).

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.
Treatment

All members of the same house should be treated at the same time.

Permethrin cream (Quellada or Lycela) is the treatment of choice in Australia because of its effectiveness and low toxicity. 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 average adult.

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 washing. 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 infestation.

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 gloves.
  • 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

Seborrhoeic keratoses are benign lesions (i.e. not cancerous) 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.

Skin Cancer

Aged skin is vulnerable to developing many different skin problems. Of particular concern is skin cancer, with the elderly being at increased risk, resulting from cumulative sun exposure from a lifetime in the sun. In addition, other factors may also contribute to this increased risk such as decreased DNA repair capacity of aged skin, as well as a degree of immunosuppression also related to sun exposure.

At least 2 in 3 Australians will be diagnosed with skin cancer by the age of 70. Skin cancers will usually present as a spot, freckle or mole that is visibly different to the skin surrounding it. It is often a new spot but skin cancer can also be present in a pre-existing spot that has changed colour, size or shape.

It is important that you see a dermatologist if you have any marks or spots on your skin that are:

  • growing
  • changing shape
  • bleeding or itching

There are several different types of skin cancer, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma. As these conditions can be life-threatening if left untreated, early detection is very important. If you notice any skin changes, see your doctor.  

About Skin Cancer

Basal cell carcinoma (BCC):

This is the most common form of skin cancer and is caused by exposure to the sun over many years. This condition typically presents as a sore that does not heal. Alternatively, it may be a sore that bleeds, then heals completely, but then recurs. These often occur on areas that get a lot of sun exposure, such as the head and neck, but may occur anywhere on the body. Some people who experience multiple BCCs on the body may have inherited a genetic susceptibility to develop these. BCCs may have a 'pearly' edge, and are typically slow growing. 

Squamous cell carcinoma (SCC):

SCC is particularly associated with cumulative sun exposure. A SCC often presents as a rapidly growing skin-coloured scaly lump, which is firm to touch, and typically tender. As mentioned, actinic (solar) keratoses are red, scaly spots which are common on sun exposed areas in the elderly. Although not yet cancerous, these can develop into SCCs. 

Melanoma:

While BCCs and SCCs are more commonly associated with lots of sun exposure over time, melanomas are thought to be related to genetic factors, numbers of moles and a history of sunburns. They are the most dangerous type of skin cancer and can have a number of different appearances but are often dark and irregularly coloured. Most importantly, they change relatively quickly, over weeks but sometimes even days.

About Melanoma

Skin Infections

Two of the most common skin infections that affect the elderly are cellulitis and thrush.

Cellulitis

Cellulitis is caused by a bacterial infection of the skin that typically occurs after bacteria penetrate the skin after entering through a cut, break or ulcer in the skin. The most common bacteria involved are Staphylococcus or Streptococcus types.

Any part of the body may be affected, but the lower leg is a typical site. If both lower legs are affected (i.e. red, swollen) then the patient may have venous eczema rather than cellulitis, which requires different treatment.

Skin will be red, warm to touch, swollen and typically painful.

Treatment:
  • Oral antibiotics. If the infection is spreading, sometimes the patient may need intravenous antibiotics.
  • Prevention: monitor for any breaks or cuts in the skin. If there are, keep the area clean and cover with a dressing until healed.

Thrush (Candida)

Thrush is caused by a yeast infection. It typically occurs around moist, occluded areas of the skin (groin creases, under the breasts) or mucosal surfaces (in the mouth, genital area).

Symptoms are red, moist areas of skin, sometimes with small red lumps at the outermost edges of the rash (“satellite lesions”). In the mouth it usually presents as a white coating on a red base.

Predisposing factors are diabetes, treatment with antibiotics, and obesity.

Treatment
  • An imidazole cream e.g. clotrimazole or nystatin cream. In resistant cases, sometimes oral treatment (tablets) may be necessary.
  • Prevention: dry the problem areas thoroughly after showering, cease oral antibiotics unless necessary, consider testing for diabetes. 

Ulcers

Leg Ulcers

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 population.

Signs and symptoms
  • Brown or red discolouration of the skin
  • Breaks in the skin or open, non-healing wounds
  • Swelling of the lower legs
Causes:
  • Trauma or injury
  • Venous hypertension: varicose veins, deep venous thrombosis (DVT)
  • Arterial disease - atherosclerosis, diabetes, hypertension
  • Skin cancers
  • Connective tissue diseases
  • Infections
  • 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

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 foot.

Management of venous ulcers
  • Compression bandages are to be applied. 
  • 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 considered.
  • 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 debridement.  
  • 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. 
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