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: [email protected]

Funding: Authors have no financial

disclosures to declare.

challenge to providers. History taking can be difficult.

Introduction
Patients often have multiple medical problems and regi-
Management of dermatoses in older populations has mens with several medications. The clinical manifestation
emerged as an important area of consideration today. As of skin disorders may differ and may not present as
the population over age 65 years increases and the num- classically as they do in younger populations.1
ber of patients in geriatric care facilities also climbs, the Dermatoses of aged population vary from country to
incidence of geriatric skin diseases is becoming more country. A study from Turkey2 conducted on 4099 geriat-
widely acknowledged. Currently, 37.3 million Americans ric patients found eczematous dermatitis to be the most
are senior citizens and, by 2050, the number is expected common disorder in the population studied, followed by
to be 86.7 million, 21% of the population. Between fungal infections, pruritus, bacterial infections, and viral
2006 and 2050, the projected percentage increase in infections. A seasonal pattern was also noticed with geri-
population 65 years and over is 147%. http://www. atric dermatoses in Turkey. Infestations were most com-
census.gov/population/www/projections/summarytables.html mon in spring and summer months. Fungal infections
www.census.gov were common in summer. Pruritus was common in
Due to the degenerative and metabolic changes autumn season. In another study from the same country
occurring throughout the skin layers during the aging conducted in three senior homes on 300 elderly patients,
process, elderly people are vulnerable to a wide variety of it was found that fungal infection (49.7%) and xerosis
dermatological conditions. Neurological and/or systemic (45.3%) were the most common dermatoses.3 In Singa-
diseases, health and hygiene, socioeconomic status, pore, xerosis and asteatotic eczema were the most com-
climate, color of skin, gender, nutrition, culture, and mon disorders, followed by scabies, bacterial infections,
personal habits, such as smoking or drinking, etc., may and eczematous dermatitis. Fungal and viral infections
also contribute a role in the genesis of cutaneous condi- were less common.4 In Taiwan, eczematous dermatitis
tions in the elderly population. The diagnosis of certain was most common, followed by fungal infection, xerosis,
dermatoses in the geriatric population poses a great 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 smaller surface contact between the dermis and the epi-
tumors, eczematous dermatitis, keratinization disorders, dermis, resulting in less nutritional transfer and poor
bacterial infections, viral infections, and finally xerosis.6 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.
Skin changes in the aging skin
The wrinkling of the skin in old age is due to changes in
Two types of skin aging have been described: chronologi- the dermis. The collagen bundles and elastic fibers are
cal skin aging and photoaging. Both have different clini- fragmented and disoriented. There is a loss of dermal
cal and histological features. Chronological skin aging is thickness and reduction in mast cells and vasculature.
characterized by physiological alteration in skin function. Age decreases the sensory perception and increases the
Photoaging results from ultraviolet radiations, and the threshold of pain. Senile purpura is due to lack of support
effects are more prominent on exposed parts of skin.7 of vasculature by collagen tissue and reduced perivascular
Skin changes in elderly population take the form of either veil cells. Skin appendages also show a variety of changes.
intrinsic or extrinsic changes. Intrinsic changes are The number of exocrine glands decreases with age, and
changes due to skin’s natural metabolic aging process. older people sweat less in response to heat. Apocrine
These include thinning of the skin’s upper layer, diminish- glands also regress with age and produce fewer odors.
ing blood flow and compromising the skin’s inherent abil- The size of the sebaceous glands increases due to the
ity to nourish and repair cells. Changes in collagen decreased turnover of cells, and these glands probably
structure reduce overall elasticity. Moreover, a reduction produce less sebum. The hair slowly turns white in color;
in immune function also contributes to the skin-aging graying starts in the temporal region of the scalp. In
process by degrading the skin’s ability to defend against males, eyebrows become bushier and hair grows in the
bacterial assault. external auditory canal. In females, slight hirsutism
Other intrinsic changes in skin in the elderly include occurs as a result of endocrine changes. The linear growth
variable epidermal thickness, variation in size and shape, of nails also decreases with age. The ultraviolet light also
fewer Langerhans’ cells, and fewer melanocytes, and there accelerates the intrinsic aging in the sun-exposed areas of
may be occasional nuclei atypia. Decreased and irregular the body.9,10 The age-related changes due to alteration of
epidermal turnover results in skin roughness and uneven skin physiology are shown in Table 1.
pigmentation. The capability of the skin to restrict water Extrinsic changes may result from factors, such as UV
loss does not change, but the skin is more permeable to light exposure and environmental pollutants such as
chemical substances. The chemical substances enter the smoking. A variety of skin changes have been seen in
skin quickly but are removed slowly due to changes in aged skin due to prolonged exposure to sun. Sun expo-
the dermal matrix and reduction in vasculature.8 There is sure contributes to a decline in dermatological integrity,
flattening of the dermoepidermal junction and thus a 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 Roughness, delayed healing and uneven pigmentation
Decreased DNA repair Increased photocarcinogenesis, malignancies
Fragmentation of collagen and elastic fibers Wrinkles and lax skin, increased risk of pressure damage and decubitus ulcers
Reduced support of blood vessels Purpuric lesions
Decreased sensory perceptions Increased tendencies to injuries
Impaired thermoregulation Vulnerability to heat and cold
Reduced hair growth and effects of androgen 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 function of apocrine glands Reduced body odor
Reduced function of sebaceous glands Decreased epidermal lipids
Reduced function of sweat glands Risk of overheating and heat strokes
Decreased inflammatory response Delayed healing and vulnerability to infection
Reduced subcutaneous fat Increased risk of injury, less natural insulation, increased risk of hypothermia
Flattening of dermal papillae Increased risk of blister formation and consequent infection
Reduced nail growth Decreased linear growth, onychogryphosis, longitudinal striations, dull and brittle nails
Decrease in melanocytes Gray hair, increased susceptibility to solar radiation

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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

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512 Review Geriatric dermatoses Jafferany et al.

Dryness of the skin leads to pruritus. Scratching of the eruptions, and insect bites.31 The management of pruritus
skin breaks its continuity, leading to infection and derma- in the elderly must take an individualistically tailored
titis. The chief complaint of xerosis is pruritus, which, if approach, with consideration of the patient’s general
not treated, may lead to asteatotic eczema. Anterior shins, health, the severity of symptoms, and the adverse effects
dorsi of hands, and forearms are the most commonly of treatment. Physical and cognitive limitations, multiple
affected sites. Affected skin becomes rough and scaly. comorbid conditions, and polypharmacy are some aspects
Xerosis can be exacerbated by soap, hot water, and low that can influence the choice of treatment in this age
indoor humidity. Treatments include increasing water group.32 It can be treated by correcting existing xerosis
intake and moisturizing the skin. Emollients (petrolatum) or any underlying systemic cause. Topical steroids, anti-
can be applied liberally, and use of a humidifier also histamines, soothing agents, and emollient creams all
helps. Using excess soap removes the surface lipids and have been employed. The psychogenic cause of pruritus
increases the dryness of the skin. Moisturizers are the responds best to local or systemic doxepin.33
mainstay of treatment; these should be liberally applied
after a bath, when the skin is moist.22,23 Stasis dermatitis
Stasis dermatitis (hypostatic eczema) occurs on the lower
Asteatotic dermatitis legs because of underlying insufficient venous drainage.
Asteatotic dermatitis (eczema craquele) is an eczematous Varicose veins are often present, and chronic pruritic der-
eruption common in the elderly but can be seen in any matitis develops with periods of exacerbations. The der-
age group. Asteatotic eczema is characterized by dry, matitis may be weepy or dry, scaly or lichenified.
cracked, and fissured patches on the limbs. It is common Secondary bacterial infection may lead to cellulitis and
in winter. The sun, wind, and low humidity are predis- lymphangitis. Ulcers are the most common complication
posing factors. Asteatotic eczema is seen secondary to epi- of hypostatic eczema. Stasis dermatitis may present as a
dermal lipid and free fatty acid depletion.24 Extensive or solitary lesion mimicking a neoplasm, hence requiring
generalized eczema craquele should be investigated for early recognition and evaluation.34,35 Venous hyperten-
internal malignancy, such as malignant lymphoma.25 sion, circulatory stasis, and modified condition sheer
In treating asteatotic dermatitis, the environment stress play an important role in an inflammatory reaction
should be humidified and irritants should be avoided. accompanied by leukocyte activation leading to venous
Baths should be restricted and should not be hot. Soaps dermatitis and ulceration.36 The only effective way of
should be avoided, and use of bath oils should be encour- treating venous hypertension is by external compression
aged. Emollients should be used after bathing daily. of the leg by bandaging or support stockings. This com-
Urea-based weak corticosteroids are also helpful. Topical presses the superficial veins so that the blood can flow to
steroids should be carefully used in the elderly, as the skin the deeper veins. Gupta et al.37 evaluated the healing rate
is already thin and fragile.26 Topical pimecrolimus, an and safety of the profore extra four-layer bandage system
immunomodulating agent, has also been indicated in the in patients with leg ulcerations and found it to be safe
treatment of asteatotic dermatitis.27,28 and effective. The patient should be encouraged to use
their calf muscles, so they need to be mobile and walking.
Pruritus When sitting, the feet should be raised on a stool and
Pruritus or itch is most commonly caused by xerosis. It is dorsiflexed frequently. Weak topical steroids should be
one of the most frequently reported symptoms in the applied twice daily–once before applying the bandage or
elderly population, and its prevalence is estimated to be stocking and once before going to bed. Any potent sensi-
29%.29 The actual pathogenesis is poorly understood. tizer should be avoided; local antiseptics are preferable to
Age-related changes in the nerves leading to increased topical antibiotics for secondary infection. Kaur et al.38
touch and pain thresholds, possibly due to subclinical conducted an open-label study on 25 patients and found
neuropathy, have been suggested.30 Systemic disorders calcium dobesilate as an effective adjuvant therapy in
have been implicated in 10–50% of cases and include patients with venous ulcers and leg ulcerations.
liver disease, hypothyroidism, iron deficiency anemia, ure-
mia, polycythemia, leukemia/lymphomas, atopic dermati-
Infections
tis, ichthyosis, thyroid disorders, chronic renal failure,
drug-induced disorders, etc. In a study from Thailand of A variety of infections including bacterial, viral, and fun-
149 elderly patients, the most common causes of senile gal may occur commonly in the elderly population.
pruritus found in order of prevalence were xerosis, Superficial bacterial infections caused by staphylococcus
inflammatory eczematous conditions, lichen simplex chro- and streptococcus are seen frequently due to alteration in
nicus, cutaneous infections, psoriasis, urticaria, drug skin architecture and loss of barrier function caused by

International Journal of Dermatology 2012, 51, 509–522 ª 2012 The International Society of Dermatology
Jafferany et al. Geriatric dermatoses Review 513

various physical factors, malnourishment, and nutritional usually produces a disease around the mouth; and HSV-II
deficiencies.14 Both bullous and non-bullous forms of causes disease around the genitalia. Approximately 85%
impetigo may develop. Topical and systemic antibiotics of adults worldwide have antibodies to HSV-I; however,
are required for treatment. Cellulitis is an infection of the only 20% are symptomatic. The infection rate of HSV-II
subcutaneous fat, and it may coexist with erysipelas, is approximately 16%, with only a quarter symptomatic.
which is the infection of dermis and upper subcutaneous When infection is clinically established, there is recur-
tissue due to streptococcus pyogenes or staphylococcus rence of symptoms that may or may not produce pain or
aureus. In the aged, it is often seen on the lower limbs tingling before the blisters appear. In normal host, the
secondary to venous stasis. The clinical features of celluli- viral infection appears as a blister that heals after a few
tis are similar to those in adults. It differs from erysipelas days and is prevented from spreading by host immunity.
in being deeper and without a distinct edge. Treatment In conditions of impaired immunity, it does not heal, and
consists of using soothing local topical agents. Calamine new blisters form and eventually ulcers form with serpigi-
lotion and ichthammol may be used. Local and systemic nous borders. In severe immunodeficiency, dissemination
antibiotics are often required for moderate and severe of lesions occurs. Kaposi’s varicelliform eruptions are
infection. A single injection of procaine penicillin will characterized by depressed immune response leading to
arrest the process. If no improvement occurs in a day, dissemination of atopic eczema upon exposure to HSV.45
penicillin-resistant staphylococcus should be suspected. Some patients with Alzheimer’s dementia with geno-
Macrolide antibiotics are used as an alternative, such as type APOE epsilon 4 allele may contain HSV-I virus.46
clindamycin. A recent review by Mori47 reported that HSV-I persists in
the brains of most aged individuals and may contribute
Viral infections to the pathogenesis of Alzheimer’s disease. Similar views
Viral infections, particularly herpes zoster, occur fre- were shared by Itzhaki and Wozniak,48 who suggested
quently in old age secondary to impaired immune func- that there is strong evidence for HSV-I being a major fac-
tion. After recovery from chicken pox at a young age, tor in Alzheimer’s disease and that appropriate treatment
varicella zoster virus (VZV) becomes latent in dorsal root may prevent the disease.
ganglion. After decline in immunity, VZV is reactivated. Molluscum contagiosum (MC), a pox virus infection,
The infection occurs in a dermatomal pattern and is very may occur in the elderly population, particularly in
painful. The incidence of herpes zoster has been estimated immunodeficiency states. The appearance of MC lesions
to be 1,000,000 cases annually, with higher numbers in in adults should require evaluation for immunocompro-
adults older than 60 years.39 It is characterized by a pro- mised state.49 MC lesions are characterized by
dromal sharp stabbing pain that occurs before the onset dome-shaped umbilicated papules and are transmitted by
of rash and may last throughout the course of vesicular skin-to-skin contact. Treatment includes cryotherapy and
eruption. Herpes zoster infection may be associated with electrodesiccation and curettage.
a characteristic pain syndrome called post-herpetic neural-
gia. Post-herpetic neuralgia is a sequelae manifested by Fungal infections
sharp stabbing pain lasting for months to years after the Among the fungal infections, onychomycosis, tinea pedis,
disappearance of the lesions. The pain may be provoked tinea cruris, and candidiasis occur commonly in the aged
by trivial stimuli. The incidence of post-herpetic neuralgia population. Onychomycosis or fungal infection of nails,
is reported to range from 10% to 70% in herpes zoster particularly toenails, is commonly encountered in the
cases.40 Antivirals such as acyclovir, valacyclovir, and geriatric population. It is caused by dermatophytes, most
famciclovir are the mainstay of treatment. The addition commonly trichophyton rubrum, trichophyton mentagro-
of oral prednisolone to acyclovir treatment in reducing phytes, epidermophyton floccosum, and candidal infec-
pain and speed healing of the lesion has been suggested in tions. In one study, of the 450 cases studied, 46.4% of
the past,41 but the latest recommendations suggest other- the patients had a single fungal organism cultured, 30.4%
wise.42 Topical treatments include topical lidocaine, wet had a mixed fungal infection cultured, and 23.1% had no
to dry dressings with tap water and aluminum acetate fungal growth. Saprophytes were found in 59.9% of the
(Burow’s solution), and bland lotions such as calamine 526 total fungal organisms cultured, while dermatophytes
lotion. Nonsteroidal anti-inflammatory drugs may also be were found in only 23.8%.50 Clinical discoloration begin-
used. Zoster vaccine (Zostavax) may be used for preven- ning at the free edge of the nail or at the lateral nail fold
tion and proved cost effective; it reduced the burden of and subungual hyperkeratosis leading to separation of the
illness by decreasing the incidence and severity.43,44 nail plate from the nail bed are some of the common
Herpes simplex virus (HSV) occurs as two types characteristics of onychomycosis. The diagnosis can be
causing infections on the skin: type I and type II. HSV-I established by potassium hydroxide preparation, fungal

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

cultures and, in some cases, nail plate biopsy; less fre- hypersensitivity to the scabies mite appear about two -
quently immunohistochemistry, restriction fragment weeks after the infestation. The hypersensitivity pruritic
length polymorphism, and polymerase chain reaction papules are generalized but occur predominantly over the
assays have been used.51 Newer antifungals such as fluco- axillae and around the areola, wrists, finger webs,
nazole, itraconazole, and terbinafine have proven useful periumbilical area, genitals, buttocks, and the thigh. The
in the treatment of onychomycosis.52 primary manifestation is the scabetic burrow, found
Candidiasis manifests in the form of cutaneous, muco- predominantly on the wrist and interdigital spaces of the
sal, paronychial, onychial, or chronic mucocutaneous or fingers. Secondary lesions such as impetigo and eczemati-
granulomatous lesions. It is commonly seen in intertrigin- zation are common due to scratching of the skin from
ous areas where skin is warm and moist, such as sub- pruritus and may alter the clinical picture. Bullous lesions
mammary folds, inguinal, anogenital, and perioral areas. are often present in the elderly population. The clinical
The main predisposing factors are maceration, heat, presentation of scabies in the elderly can vary markedly.
humidity, obesity, diabetes, antibiotic therapy, and che- Many patients are not properly diagnosed because they
motherapy.53 It presents as a diffuse beefy red eruption do not present with classic features. Many elderly patients
with satellite papules. When cutaneous candidiasis is pres- also suffer from asteatotic dermatitis and xerotic skin,
ent in immunocompromised patients, such as with diabe- and increased itching due to scabies may be erroneously
tes, leukemia, lymphoma, transplants, or cancer, the attributed to the exacerbation of underlying skin disease.
possibility of systemic candidiasis must be considered. Sometimes the itching may be brushed aside, and they are
Direct microscopy for pseudohyphae and culture are com- labeled as having psychological itching.56 Norwegian sca-
mon tests to perform for the diagnosis. Topical antifungal bies may be seen in the elderly who are unable to scratch
creams such as imidazole or allylamine derivatives are due to some neurological disorder with skin anesthesia or
helpful in clearing the lesions, and keeping the area dry those who are unable to scratch due to physical limita-
hastens the recovery. Systemic antifungal agents such as tions.57 The presentation may mimic eczema, and the
thiazole derivatives may be used when there is resistance delay in diagnosis may lead to an outbreak of scabies in
or poor response to topical treatment. nursing homes.58 Diagnosis of scabies is made by mite or
Tinea pedis, fungal infection of the feet, is seen com- ova feces identified in scrapings. Scabies is treated by
monly in interdigital webs but may occur on the sole of standard treatment methods in addition to specific
the foot. Scaling, maceration, and fissuring is common. emphasis on comorbid xerotic skin.
Legge et al.54 conducted a prospective study on 80 elderly Pediculosis is a lice infestation, which is subdivided into
patients and indicated a 40% likelihood of tinea pedis in pediculosis capitis (head lice) or phthirus pubis (pubic
patients with otherwise asymptomatic interdigital pedal lice). It commonly presents with pruritic papular eruption
macerations in this population. The study further in the infested area. It is transmitted through direct physi-
reported that an increase in age appears to correlate with cal contact or with infested fomites. Examination of hair
an increased incidence of interdigital tinea pedis. Diabetic reveals nits (eggs) cemented to the hair shaft. Pediculosis
elders may be susceptible to interdigital fungal infection is treated with permethrin. Nits should be combed out
at an earlier age. Newer generation antifungals, both using a special comb.
local and oral, are helpful.
Tinea cruris, the fungal infection of the groin area, is
Eczematous lesions
characterized by erythematous, pruritic, and scaly erup-
tion with characteristic demarcation from unaffected skin. Eczematous lesions occur in every age group, and the
Treatment includes topical and systemic antifungal ther- elderly are no exceptions.59 The role of dryness of skin,
apy. xerosis, and asteatotic eczema has already been discussed.
Nummular eczema is characterized by coin-shaped
macules, papules, or vesicles with oozing and crusting on
Infestations
the surface. It occurs on the extremities mainly but may
Scabies and pediculosis are the common infestations seen occur at any site. It may be associated with changes in
in the elderly population, particularly in nursing homes. humidity and temperature, and dryness of skin will wor-
A questionnaire study Ontario, Canada, found that 20% sen it. Treatment includes topical steroids and avoidance
of 130 institutions had problems with scabies during a of soap or detergents. Seborrheic dermatitis is another
one-year period.55 Scabies is a contagious skin infection type of eczematous eruption noted in the elderly. It is
caused by the mite Sarcoptes scabiei. The infection is believed to be caused by Malassezia yeasts, which cause
caused by close and prolonged contact from person to an abnormal host response.60,61 The prevalence of sebor-
person or through fomites. The first symptoms due to rheic dermatitis has been estimated to be about 31% in

International Journal of Dermatology 2012, 51, 509–522 ª 2012 The International Society of Dermatology
Jafferany et al. Geriatric dermatoses Review 515

the elderly population.62 Seborrheic dermatitis is charac- desire, and are more conforming and dutiful compared
terized by erythema and greasy red-brown papules cov- with the control group.69 In a Turkish study conducted
ered with scaly yellow flakes and plaques. Seborrhea in on 23 patients with lichen simplex chronicus on the
the elderly is often associated with diseases, such as par- limbs, the authors suggested that damage to the periph-
kinsonism, epilepsy, various CNS diseases, and trauma.63 eral nervous system, such as radiculopathy and neuropa-
The treatment consists of corticosteroids, keratolytic thy, can play a critical role in the etiology of lichen
agents, such as pyrithione zinc, sulfur, coal tar, and sali- simplex chronicus on the limbs. Both nerve-root compres-
cylic acid. Antifungal agents in the form of medicated sion in magnetic resonance imaging scans and radiculopa-
shampoos may also be used. thy in nerve-conduction studies are common findings in
Contact dermatitis is a fairly common type of eczema, asymptomatic subjects, but they seem to be more
with an estimated 11% of the elderly population to be common in patients with lichen simplex chronicus on
suffering from it.62 The individual susceptibility in the the limbs. Therefore, elderly patients with lichen simplex
elderly population to contact dermatitis is relatively low, chronicus should be evaluated for the possibility of
secondary to a decreased ability to mount a delayed-type underlying neuropathic changes.70 Treatment is often
hypersensitivity reaction due to an abnormal immune refractory, and varieties of modalities including steroids,
response in the form of reduced Langerhans’ cells, retinoids, immunosuppressives, naltrexone, and gabapen-
decrease in T-cells, and diminished vascular reactiv- tin have been used with variable success. Behavior modifi-
ity.64,65 A Scottish study66 conducted on 200 patients cation along with water soaks and steroid ointments and
with leg ulcer found that 81% of patients exhibited aller- occluded dressing with steroid have also been helpful.71
gic reactions to topical medications. Because leg ulcers PN usually presents with erythematous or hyperpig-
and stasis eczema are quite common in the elderly popu- mented, scattered, and discrete keratotic nodules on the
lation, the use of topical medications should be carefully extremities. These lesions are secondary to habitual
planned and monitored, and patch testing may be applied scratching and picking and in severe cases may ulcerate.
where necessary and available in high-risk patients. Treat- A psychometric study conducted on 20 patients with PN
ment consists of discontinuation of offending medication found that symptoms of anxiety and depression associ-
and use of topical corticosteroids and oral antihistamines. 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
Psychodermatological disorders
a psychological approach in the management of PN.72 As
Increased awareness of psychocutaneous disorders is cur- with lichen simplex chronicus, the treatment is often
rently under discussion. Psychodermatological disorders refractory, and similar therapeutic agents have been used
are characterized by skin disorders with psychological with variable success. Topical application of steroids,
impact and psychiatric disorders with skin manifesta- doxepin cream, and habit reversal therapy may be help-
tions.33,67 Psychocutaneous disorders of older age are ful. Some case reports describe the useful effect of gaba-
mainly self-induced disorders that only affect areas of the pentin in the treatment of PN.73
body that can be accessible by hands. The role of psyche Neurotic excoriations or pathological skin picking, a
is important in the causation and progression of the pre- type of impulse control disorder, are irregular skin lesions
senting lesions. Unfortunately many physicians including not fitting into any other skin disease. The prevalence of
dermatologists are not aware of and insightful of the con- neurotic excoriations or pathological skin picking ranges
nection between skin and mind, and in many cases a psy- from 1.4% to 5.4% of the general population, with a
chodermatological approach is required in the treatment higher preponderance in females and psychiatric
of these disorders.68 Common psychodermatological dis- patients.74 The lesions may present as a variety of excori-
orders seen in the older population include lichen simplex ated papules at different stages of healing in the back-
chronicus, neurotic excoriations, prurigo nodularis (PN), ground of post-inflammatory scars. The patient often
and delusion of parasitosis. admits to using his/her skin as an outlet for stress.
Lichen simplex chronicus presents with lichenified red Odlaug and Grant75 studied the clinical characteristics
scaly plaque. Patients habitually rub and scratch with the and medical complications associated with pathological
dominated hand. This is repeated until lichenification skin picking, and the most common comorbid conditions
occurs. A recent Spanish study investigated the personal- found were trichotillomania (36.7%), nail biting (26.7%),
ity differences between patients with lichen simplex chro- depression (16.7%) and obsessive compulsive disorder
nicus and the normal population and found that patients (15%). Neurotic excoriations can be treated with a
with lichen simplex chronicus have a greater tendency to psychotherapeutic approach, particularly cognitive behav-
pain avoidance, greater dependency on other people’s ioral therapy with symptomatic treatment. Several

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

pharmacological agents have been used with variable suc- heparin. Fixed drug eruption is another type of drug
cess including, but not limited to, atypical antipsychotics, eruption that may present as rounded single
antidepressants, lamotrigine, gabapentin, naltrexone, and erythematous or bullous lesions, which typically recur at
topiramate.76 the same spot upon re-challenging with the same medica-
In delusion of parasitosis, patients firmly believe that tion. The common sites are hands, feet, genitals, and
their bodies are infested by some type of organisms around the mouth or eyes. Erythema multiforme is
despite lack of supporting evidence.77 They often present another drug-induced lesion due to hypersensitivity reac-
with small bits of excoriated skin, debris, and unrelated tion characterized by target-like lesions on the extremities
insects or insect parts – the matchbox sign.78,79 and trunk accompanied by systemic symptoms. It may
The clinical picture may include bruising, contact take the form of minor or major form. The latter may
dermatitis, scratching, excoriation, and lichenification present as more serious life-threatening Stevens–Johnson
secondary to self-inflicted scratches or attempted cures syndrome or toxic epidermal necrolysis. In diagnosing
with caustic substances.80 Delusional parasitosis has been drug eruptions in the elderly, it is necessary to obtain a
described in association with schizophrenia, psychotic detailed history of the patient’s drug use from his or her
depression, drug-induced psychosis, cocaine use, amphet- family if the patient is not able to recall each of them.
amine use, alcohol withdrawal, stroke, leprosy, and Medical history and physical examination are also impor-
peripheral neuropathy.81 Treatment approach should tant in reaching the correct diagnosis. The standard treat-
be non-confrontal and non-judgmental. There are no ment is discontinuation of the causative therapeutic agent
randomized placebo-controlled trials reported in the and substitution with another drug.
literature regarding specific pharmacological agents.
However, several case reports and systematic reviews
Neoplasms
suggest that use of atypical antipsychotics has proven
helpful.82–85 Dermatology, psychiatry, and primary care Both benign and malignant neoplasms have been noticed
physician liaisons are very important in the successful in the elderly population with increased frequency. Sebor-
treatment of this chronic resistant-to-treatment condition. 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
Drug eruptions
black papules or plaques that have a characteristic net-
Sudden onset of skin lesion in a patient without any prior work of indentation or crypts on their surface; they have
skin disease should always raise the suspicion of drug an abrupt edge that gives the appearance of plasticine
eruption. Elderly patients are likely to be on several med- stuck on the surface of the skin. Commonly affected sites
ications because of multiple medical disorders. From a are the trunk, face, and proximal extremities. Six subtypes
physiological standpoint, respiratory, excretory, and met- of seborrheic keratosis have been described: dermatosis
abolic functions are generally deteriorated in the elderly, papulosa nigra; stucco keratosis; inverted follicular kerato-
and multiple drugs are apt to accumulate in the body, sis; large cell acanthoma; lichenoid keratosis; and flat
leading to a high incidence of drug eruptions. The inci- seborrheic keratosis. Several of the subtypes may act as
dence of drug eruptions in the general population is cutaneous markers for internal malignancy and should be
reported to be 10–30% of all reported adverse drug reac- monitored closely for any atypical changes.89 The sudden
tions.86 The most common eruptions seen in the elderly appearance of multiple seborrheic keratoses – Leser–
population are exanthematic eruptions;87 they take the Trelat signs – is indicative of an internal malignancy,
form of maculopapular, morbilliform, or erythematous usually of an adenocarcinoma of the stomach.90 Sebor-
lesions. The other presentations could be vasculitis, fixed rheic keratosis is easily removed by curettage, cryosurgery,
drug eruptions, erythema multiforme, urticaria, contact or electrosurgery.
dermatitis, purpura, and photodermatitis.88 Drug-induced Skin tags are common in the elderly; the common site is
vasculitis appears as purpuric maculopapular eruption the neck and around the axillary folds. They are common
mainly on limbs and may be accompanied by systemic mesenchymal tumors, often multiple, and usually 1–4 mm
symptoms such as fever, aching, and fatigue. The loss of in size. Occasionally, they reach diameters >3 cm. Skin tags
dermal collagen and fat coupled with vascular fragility may be a manifestation of aging; they may also be associ-
may predispose the elderly to traumatic purpuric lesions. ated with obesity, diabetes mellitus, pregnancy, and some
Many elderly are on different medications that may cause endocrine disorders. Small lesions are treated with electro-
thrombocytopenia, leading to purpura. Drugs most com- dessication; larger lesions should be excised.
monly associated with thrombocytopenia include penicil- Cherry angiomas, also called Campbell de Morgan
lin, quinine, quinidine, thiazides, methyldopa, and spots or senile angiomas, usually present as bright red or

International Journal of Dermatology 2012, 51, 509–522 ª 2012 The International Society of Dermatology
Jafferany et al. Geriatric dermatoses Review 517

purple lesions mainly on the trunk or upper extremities. Management of the condition requires sunlight avoidance
They could be left untreated, but if there is a cosmetic and use of sunscreens, topical emollients, and topical cor-
concern, they could be treated with electrocoagulation or ticosteroids. Oral corticosteroids and immunosuppressive
laser coagulation. therapy such as azathioprine may be indicated but should
Both pigmented and non-pigmented malignant tumors be used with caution in the elderly.94
of the skin are predominant in the aged population, prob- Actinic keratosis is a premalignant scaly lesion that
ably due to lowered immunity and the harmful effects of develops on the skin exposed to UVB. Common sites are
ultraviolet light on their skin. The incidence of melano- the backs of the hands, forehead, and the ears. Clinically
mas is increasing. This may be due to the decrease of the they appear as scaly hyperpigmented or erythematous
ozone layer, exposure to sunlight, outdoor activities, etc. plaques that may ulcerate. It is the initial manifestation
Protection against sunlight is vital to prevent melanomas. of a continuum of clinical and histological abnormalities
Malignant melanomas, particularly lentigo melanoma, that progresses to invasive squamous cell carcinoma.95
may occur in the elderly population and present as There is usually a period of several years between the
brownish or black plaques, with irregular borders and development of actinic keratosis and its transformation to
irregular pigmentation.91 squamous cell carcinoma. Actinic keratosis should be
Basal cell carcinoma is the most common but least treated before it progresses to invasive squamous cell car-
malignant skin tumor. It is recognized by the pearly pap- cinoma. Destructive modalities such as cryosurgery using
ules, rolled edges, and telangiectasia. They also have a liquid nitrogen and electrodesiccation and curettage are
history of bleeding. Squamous cell carcinomas present as the mainstays of therapy.
irregular growths with an indurated base. These malig- Actinic elastosis is another condition that refers specifi-
nant tumors have many variants and should be diagnosed cally to the degenerative histological alterations seen by
at an early stage. Tumors are treated by excision; those light microscopy in sun-damaged skin. Multiple factors,
that have spread beyond the skin would need a more rad- including anatomic site, extent of sun exposure, and other
ical approach. physical or environmental factors, affect the clinical
Keratoacanthoma is a condition that presents with an appearance of these changes.96 It manifests as small yel-
erythematous dome-shaped, 1–10 cm nodule with a kera- lowish papules and plaques on the face or back of the
tin plug in the center, mostly on the sun-exposed areas hands. The skin assumes a dull yellowish color with deep
such as the face and dorsum of the hands. It is often con- furrows and wrinkles.
sidered to be a subtype of cutaneous squamous cell carci- Nodular elastoidosis, which is also known as Favre–
noma. Squamous cell carcinoma arising in Racouchot syndrome, is seen mainly around the eyes and
keratoacanthoma has been found in 5.7% of cases in a extends onto the cheeks in the elderly, especially in men.
series of 3465 cases. The incidence rises to 13.9% in The lesions consist of comedones, follicular cysts, and
patients older than 90 years.92 Leukoplakia is a premalig- large folds of furrowed and yellowish skin.97 Cutis rhom-
nant condition associated with alcohol and/or tobacco. It boidalis nuchae is a condition where the skin over the
commonly appears as white patches on mucosal surfaces, back of the neck becomes thickened, rough, and leathery,
which cannot be rubbed off. It is treated with electro- or and the normal skin markings become exaggerated. The
cryosurgery or with topical fluorouracil. condition is often seen in farmers, sailors, or those people
who are exposed to excessive sunlight.
Actinic cheilitis is a premalignant condition character-
Photodermatoses
ized by skin changes occurring on the lower lips; exces-
Photodermatoses are a variety of skin changes that may sive sunlight produces dryness, scaling, atrophy, and
occur due to prolonged exposure to solar light. Actinic telangiectasia. Fissures, leukoplakia, and carcinoma may
dermatitis is a condition resulting from abnormal photo- develop. Focal actinic cheilitis is easily treated with cryo-
sensitivity and is clinically similar to contact allergic der- surgery or electrosurgery. Extensive actinic cheilitis
matitis and should be distinguished from drug-induced requires 5-fluorouracil, carbon dioxide laser, or scalpel
photosensitivity. Victor et al.93 conducted a 20-year retro- vermilionectomy for adequate treatment.98
spective analysis of 76 patients and found that the num-
ber of reactions to medications increased, and sunscreens
Nutritional disorders
and antimicrobial agents were the most frequent allergens
eliciting photoallergic contact dermatitis, and there was a Age-related changes such as chronic illnesses, malabsorp-
decrease in photoallergic contact dermatitis caused by fra- tion, impaired metabolism, immobility, depression, eating
grances. In diagnosing actinic dermatitis, photo-patch disorders, social deprivation, alcoholism, drugs, and pov-
testing and patch testing may be helpful in difficult cases. erty make the aging population susceptible to a variety of

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

nutritional disorders. Several authors have discussed the and erythematous skin. Bullae may also appear on muco-
process of glycation, which is the non-enzymatic reaction sal surfaces in up to one-third of cases. Nikolsky’s sign
between free amino acids and reducing sugars. In the is negative on clinical exam. Confirmation is done by
skin, this reaction creates new residues or formations of histology, immunofluorescence immune electron micros-
cross-links (advanced glycation end-products) in the copy, and molecular biology techniques. The precipita-
extracellular matrix of the dermis. The formation of these tion of the disease is associated with ultraviolet
bridges between dermal molecules is supposed to be irradiation, x-ray therapy, and exposure to certain drugs
responsible for loss of elasticity or other properties of the and photochemotherapy. Topical steroids and systemic
dermis observed during aging. Glycation may therefore anti-inflammatory and immunosuppressive agents have
play an important role in chronologic aging.99,100 been used to control the disease.105,106 Mucous mem-
Nutritional deficiencies vary from country to country brane pemphigoid is characterized by conjunctiva and
due to the difference in social customs, food intake, and blisters in the mouth, conjunctivae and nose. It is also
climate.101 The cutaneous signs of chronic ill health may commonly seen in the elderly population.107 The patient
include hair loss, hyperpigmentation of the skin, and dry should be immediately referred to an ophthalmologist
and brittle nails. Women with advanced age are particu- upon diagnosis to prevent blindness. Topical steroids
larly prone to deficiencies in vitamins B12, A, C, and D, containing artificial tears and immunomodulating thera-
calcium, iron, zinc, and other trace elements, with conse- pies such as methotrexate, mycophenolate, monoclonal
quent skin changes.102 Zinc deficiency may be acquired antibodies, and topical tacrolimus have been helpful.108
as found in liver and pancreatic disease or due to malab- Pemphigus vulgaris and paraneoplastic pemphigus erup-
sorption. The patients are listless and depressed. An tion are also frequently seen in the elderly. Immunofluo-
eczematous eruption is seen in areas of trauma, such as rescence has been helpful in the diagnosis.
knees, ankles, malleolar regions, and elbows. Seborrheic
dermatitis-like lesions are seen on the face. Hair growth
Treatment guidelines for managing skin
is sparse, and total alopecia may occur. Zinc deficiency
disease in the elderly
also leads to retardation of the growth of nails. Zinc sup-
plementation leads to rapid improvement and a return to Management of cutaneous disorders in the elderly popu-
normal levels of serum alkaline phosphatase. Iron defi- lation is a challenge. Treatment compliance is affected
ciency results in an iron deficiency anemia, manifested by by several factors including declining cognitive status
pallor, weakness, irritability, palpitations, sore tongue, such as loss of memory and dementia, physical limita-
angular stomatitis, loss of hair, and koilonychia. tions, and impaired sensory functions. From a psychoso-
Vitamin C deficiency resulting in scurvy manifests in cial standpoint, this population is dependent on others,
small perifollicular hemorrhages. Niacin deficiency results and many have no stable housing or nutrition. Polyphar-
in pallegra, which presents on the skin as skin photosensi- macy is very common secondary to many medical prob-
tivity, roughened texture of the skin, erythema, and vesi- lems, thus increasing the odds of cutaneous drug
cle and bullae formation. reactions. Several patients use over-the-counter medica-
Appropriate nutritional intake and ruling out possible tions, homeopathic medications, and herbal supplements.
systemic diseases that may cause vitamin and trace ele- This should very specifically be asked about from
ments deficiencies and palliative care is the standard of patients or their caregivers, as many do not view them
treatment in nutritional deficiencies. 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
Bullous pemphigoid
consider the cutaneous structural fragility, intrinsic skin
Bullous pemphigoid is a disease found primarily in the changes and other comorbid conditions, and the patient’s
elderly population at age 60 years and over. The physical and cognitive status.109 A systematic review of
reported incidence ranges from 4.47 to 13.4 new cases topical skin care in senior homes was conducted by Aus-
per million per year.103 It is a chronic autoimmune dis- tralian researchers, and it was found that the quality of
ease characterized by bullous eruption on normal skin or evidence for interventions to improve or maintain the
on an urticarial base. There is a presence of circulating skin condition in the elderly was poor, and effectiveness
and tissue-specific antibodies to hemidesmosomal pro- of topical skin intervention was variable and dependent
teins present in the basement membrane of the epithe- upon the skin condition being treated.110 This fact high-
lium, ultimately resulting in a separation between the lights another challenge in the management of skin dis-
dermis and epidermis and the formation of bullae.104 ease in the elderly, pointing towards the importance of
Bullae are tense and develop on both non-erythematous skilled nursing.

International Journal of Dermatology 2012, 51, 509–522 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.
References
a. Topical steroids
b. Antihistamines 1 Farage MA, Miller KW, Berardesca E, Maibach HI.
c. Immunosuppressants Clinical implications of aging skin: cutaneous
d. Antipsychotics disorders in the elderly. Am J Clin Dermatol 2009;
e. Antidepressants 10: 73–86.
2 Yalcin B, Tamer E, Toy GG, et al. The prevalence of
5. Beefy red erythema and irritation with satellite skin diseases in the elderly: analysis of 4099 geriatric
lesions in the breast area or groin is often caused by: patients. Int J Dermatol 2006; 45: 672–676.

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

3 Kilic A, Gul U, Aslan E, Soylu S. Dermatologic findings and murine skin. J Invest Dermatol 2007; 127:
in the senior population of nursing homes in Turkey. 2847–2856.
Arch Gerontol Geriatr 2008; 47: 93–98. 22 Hoffman L, Subramanyan K, Johnson AW, Tharp MD.
4 Yap BK, Siew GM, Goh LC. Pattern of skin diseases in Benefits of an emollient body wash for patients with
the elderly at the National Skin Centre (Singapore) chronic winter dry skin. Dermatol Ther 2008; 21:
1990. Singapore Med J 1994; 35: 147–150. 416–421.
5 Liao YH, Chen KH, Tseng MP, Sun CC. Pattern of skin 23 Cork MJ, Danby S. Skin barrier breakdown: a
diseases in a geriatric population in Taiwan: a 7 year renaissance in emollient therapy. Br J Nurs 2009; 18:
survey from the outpatient clinic of a university medical 872–877.
center. Dermatology 2001; 203: 308–313. 24 Akimoto K, Yoshikawa N, Higaki Y, et al. Quantitative
6 Souissi A, Zeglaoul F, El Fekih N, et al. Skin diseases in analysis of stratum corneum lipids in xerosis and
the elderly: a multicentre Tunisian study. Ann Dermatol asteatotic eczema. J Dermatol 1993; 20: 1–6.
Venereol 2006; 133: 231–234. 25 Sparsa A, Liozon E, Boulinguez S, et al. Generalized
7 Hashizume H. Skin aging and dry skin. J Dermatol eczema craquale as a presenting feature of systemic
2004; 31: 603–609. lymphoma: a report of seven cases. Acta Derm Venereol
8 Frenske NA, Lober CW. Skin changes of aging: 2005; 85: 333–336.
pathological implications. Geriatrics 1990; 45: 27–35. 26 Davies A. Management of dry skin conditions in older
9 Farage MA, Miller KW, Elsner P, et al. Functional and people. Br J Community Nurs 2008; 13: 250–257.
physiological characteristics of the aging skin. Aging 27 Day I, Lin AN. Use of pimecrolimus cream in disorders
Clin Exp Res 2008; 20: 195–200. other than atopic dermatitis. J Cutan Med Surg 2008;
10 Farage MA, Miller KW, Elsner P, Maibach HI. 12: 17–26.
Structural characteristics of the aging skin: a review. 28 Schulz P, Bunselmeyer B, Brautigam M, Luger TA.
Cutan Ocul Toxicol 2007; 26: 343–357. Pimecrolimus cream 1% is effective in asteatotic
11 Park-Lee E, Caffrey C. Pressure Ulcers among Nursing dermatitis: a result of randomized double blind vehicle
Home Residents: United States, 2004. NCHS data brief, controlled study in 40 patients. J Eur Acad Dermatol
no 14. Hyattsville, MD:National Center for Health Venereol 2007; 21: 90–94.
Statistics, 2004. 29 Fleischer ABJ. Pruritus in the elderly. Adv Dermatol
12 Cai S, Mukamel DB, Temkin-Greener H. Pressure ulcer 1995; 10: 41–60.
prevalence among black and white nursing home 30 Nusbaun NJ. Aging and sensory senescence. South Med
residents in New York State: evidence of racial J 1999; 92: 267–275.
disparity. Med Care 2010; 48: 233–239. 31 Thaipisuttikul Y. Pruritic skin diseases in the elderly.
13 Edlich RF, Winters KL, Woodards CR, et al. Pressure J Dermatol 1998; 25: 153–157.
ulcer prevention. J Long Term Eff Med Implants 2004; 32 Patel T, Yosipovitch G. The management of chronic
14: 285–304. pruritus in the elderly. Skin Therapy Lett 2010; 15: 5–9.
14 Norman RA. Geriatric dermatology. Dermatol Ther 33 Jafferany M. Psychodermatology: a guide to
2003; 16: 260–268. understanding common psychocutaneous disorders.
15 Norman R. Dermatologic problems and treatment in long Prim Care Companion J Clin Psychiatry 2007; 9: 203–
term/nursing home care. In: Norman R, ed. Geriatric 213.
Dermatology. New York: Parthenon, 2001: 5–16. 34 Weaver J, Billings SD. Initial presentation of stasis
16 Jaul E. Assessment and management of pressure ulcers dermatitis mimicking solitary lesions: a previously
in the elderly: current strategies. Drugs Aging 2010; 27: unrecognized clinical scenario. J Am Acad Dermatol
311–325. 2009; 61: 1028–1032.
17 Esther RJ, Lamps L, Schwartz HS. Marjolin ulcers: 35 Blessing K. Malignant melanoma in stasis dermatitis.
secondary carcinomas in chronic wounds. J South Histopathology 1997; 30: 135–139.
Orthop Assoc 1999; 8: 181–187. 36 Pascarella L, Schonbein GW, Bergan JJ.
18 Mathus-Vliegen EMH. Old age, malnutrition and Microcirculation and venous ulcers: a review. Ann Vasc
pressure sores: an ill-fated alliance. J Gerontol A Biol Surg 2005; 19: 921–927.
Sci Med Sci 2004; 59: 355–360. 37 Gupta AK, Koven JD, Lester R, et al. Open label study
19 Stratton RJ, Ek A, Engfer M, et al. Enteral nutritional to evaluate the healing rate and safety of the profore
support in prevention and treatment of pressure ulcers: extra four-layer bandage system in patients with leg
a systematic review and meta-analysis. Aging Res Rev ulceration. J Cutan Med Surg 2000; 4: 8–11.
2005; 4: 422–450. 38 Kaur C, Sarkar R, Kanwar AJ, et al. An open trial of
20 White-Chu EF, Reddy M. Dry skin in the elderly: calcium dobesilate in patients with venous ulcers and
complexities of a common problem. Clin Dermatol stasis dermatitis. Int J Dermatol 2003; 42: 147–152.
2011; 29: 37–42. 39 Rimland D, Moanna A. Increasing incidence of herpes
21 Choi EH, Man MQ, Xu P, et al. Stratum corneum zoster among veterans. Clin Infect Dis 2010; 50: 1000–
acidification is impaired in moderately aged human 1005.

International Journal of Dermatology 2012, 51, 509–522 ª 2012 The International Society of Dermatology
Jafferany et al. Geriatric dermatoses Review 521

40 Kost RG, Sraus SE. Postherpetic neuralgia: pathogenesis, 59 Ward S. Eczema and dry skin in older people:
treatment and prevention. N Engl J Med 1996; 335: 32–42. identification and management. Br J Community Nurs
41 Whitley RJ, Weiss H, Gnann JW Jr, et al. Acyclovir 2005; 10: 453–456.
with and without prednisone for the treatment of herpes 60 Sandstrom Falk MH, Tengvall Linder M, Johansson
zoster. A randomized, placebo-controlled trial. The C, et al. The prevalence of Malassezia yeasts in
National Institute of Allergy and Infectious Diseases patients with atopic dermatitis, seborrhoeic dermatitis
Collaborative Antiviral Study Group. Ann Intern Med and healthy controls. Acta Derm Venereol 2005; 85:
1996; 125: 376–383. 17–23.
42 Chan N, Yang M, He L, et al. Corticosteroids for 61 Hedayati MT, Hajheydari Z, Hajjar F, et al.
preventing post herpetic neuralgia. Cochrane Database Identification of Malassezia species isolated from Iranian
Syst Rev 2010; 12: CD005582. seborrhoeic dermatitis patients. Eur Rev Med
43 Cadogan MP. Herpes zoster in older adults. J Gerontol Pharmacol Sci 2010; 14: 63–68.
Nurs 2010; 36: 10–14. 62 Fitzpatrick JE. Common inflammatory skin diseases of
44 Sanford M, Keating GM. Zoster vaccine (zostavax): a the elderly. Geriatrics 1989; 44: 40–46.
review of its use in preventing herpes zoster and post 63 Schwartz RA, Janusz CA, Janninger CK. Seborrheic
herpetic neuralgia in older adults. Drugs Aging 2010; dermatitis: an overview. Am Fam Physicians 2006; 74:
27: 159–176. 125–130.
45 Elgart ML. Skin infections and infestations. Clin Geriatr 64 Piacerico S, Larese F, Recchia GP, et al. Allergic contact
Med 2002; 18: 89–101. sensitivity in elderly patients. Aging Clin Exp Res 2004;
46 Dobson CB, Itzhake RF. Herpes Simplex virus type I 16: 21.
and Alzheimer’s disease. Neurobiol Aging 1999; 20: 65 Ghadially R, Brown BE, Sequeira-Martin SM, et al. The
457–465. aged epidermal permeability barrier: structural,
47 Mori I. Herpes simplex virus type I persists in the aged functional and lipid biochemical abnormalities in
brain through hypothetical expression of accessory humans and a senescent murine model. J Clin Invest
genes. J Neurovirol 2010; 16: 203–207. 1995; 95: 281–290.
48 Itzhaki RF, Wozniak MA. Herpes simplex type I in 66 Tavadia S, Bianchi J, Dawe S, et al. Allergic contact
Alzheimer’s disease: the enemy within. J Alzheimers Dis dermatitis in venous leg ulcer patients. Contact
2008; 13: 393–405. Dermatitis 2003; 48: 261–265.
49 Gur I. The epidemiology of molluscum contagiosum in 67 Jafferany M, Vander Stoep A, Dumitrescu A, Hornung
HIV seropositive patients: a unique entity or insignificant RL. The knowledge, awareness and practice patterns of
finding. Int J STD AIDS 2008; 19: 503–506. dermatologists towards psychodermatology: results of a
50 Scherer WP, McCreary JP, Hayes WW. The diagnosis of survey study. Int J Dermatol 2010; 49: 784–789.
onychomycosis in a geriatric population: a study of 450 68 Locala JA. Current concepts in psychodermatology.
cases in South Florida. J Am Podiatr Med Assoc 2001; Curr Psychiatry Rep 2009; 11: 211–218.
91: 456–464. 69 Martin-Brufau R, Corbalan-Berma J, Ramirez-Andreo
51 Acra E, Saracli MA, Akar A, et al. Polymerase chain A, et al. Personality differences between patients with
reaction in the diagnosis of onychomycosi. Eur J lichen simplex chronicus and normal population: a
Dermatol 2004; 14: 52–55. study of pruritus. Eur J Dermatol 2010; 20: 359–
52 Welsh O, Vera-Cabreva L, Welsh E. Onychomycosis. 363.
Clin Dermatol 2010; 28: 151–159. 70 Solak O, Kulac M, Yaman M, et al. Lichen simplex
53 Lopes-Martinez R. Candidosis, a new challenge. Clin chronicus as a symptom of neuropathy. Clin Exp
Dermatol 2010; 28: 178–184. Dermatol 2009; 34: 476–480.
54 Legge BS, Grady JF, Lacey AM. The incidence of tinea 71 Gencoglan G, Inanir I, Gunluz K. Therapeutic hotline:
pedis in diabetic versus non diabetic patients with treatment of prurigo nodularis and lichen simplex
interdigital macerations: a prospective study. J Am chronicus with gabapentin. Dermatol Ther 2010; 23:
Podiatr Med Assoc 2008; 98: 353–356. 194–198.
55 Hollness DL, DeKoven JG, Nethercott JR. Scabies in 72 Dazzi C, Erma D, Piccinno R, et al. Psychological
chronic healthcare institutions. Arch Dermatol 1992; factors involved in prurigo nodularis: a pilot study. J
128: 1257–1260. Dermatolog Treat 2011; 22: 211–214.
56 Tan HH, Goh CL. Parasitic skin infections in the 73 Dereli T, Karaca N, Inanir I, Ozturk G. Gabapentin for
elderly: recognition and treatment. Drugs Aging 2001; the treatment of recalcitrant chronic prurigo nodularis.
18: 165–176. Eur J Dermatol 2008; 18: 85–86.
57 Meinking TL. Infestations. Curr Probl Dermatol 1999; 74 Odlaug BL, Grant JE. Pathological skin picking. Am J
11: 73–120. Drug Alcohol Abuse 2010; 36: 296–303.
58 Chan LY, Tang WY, Ho HH. Crusted (Norwegian) 75 Odlaug BL, Grant JE. Clinical characteristics and
scabies in two old-age home residents. Hong Kong Med medical complications of pathological skin picking. Gen
J 2000; 6: 428–430. Hosp Psychiatry 2008; 30: 61–66.

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

76 Grant JE, Odlaug BL. Update on pathological skin 95 Schwartz RA. The actinic keratosis: a perspective and
picking. Curr Psychiatry Rep 2009; 11: 283–288. update. Dermatol Surg 1997; 23: 1009–1019.
77 Lepping P, Freudenmann RW. Delusional parasitosis: a 96 Calderone DC, Fenske NA. The clinical spectrum of
new pathway for diagnosis and treatment. Clin Exp actinic elastosis. J Am Acad Dermatol 1995; 32: 1016–
Dermatol 2008; 33: 113–117. 1024.
78 Lyell A. Delusional parasitosis (the Michelson lecture). 97 Sawicki J, Barankin B. Dermacase: Favre -Racouchot
Br J Dermatol 1983; 108: 485–499. syndrome. Can Fam Physician 2010; 56: 247–248.
79 Lee WR. Matchbox sign. Lancet 1983; 2: 457–458. 98 Dufresne RG Jr, Curlin MU. Actinic cheilitis: a
80 Boggild AK, Nicks BA, Yen L, et al. Delusional treatment review. Dermatol Surg 1997; 23: 15–21.
parasitosis: six year experience with 23 consecutive 99 Pageon H, Asselineau D. An in vitro approach to the
cases at an academic medical center. Int J Infect Dis chronological aging of skin by glycation of the collagen:
2010; 14: e317–e321. the biological effect of glycation on the reconstructed
81 Aw DC, Thong JY, Chan HL. Delusional parasitosis: skin model. Ann NY Acad Sci 2005; 1043: 529–532.
case series of 8 patients and review of the literature. 100 Danby FW. Nutrition and aging skin: sugar and
Ann Acad Med Singapore 2004; 33: 89–94. glycation. Clin Dermatol 2010; 28: 409–411.
82 Kenchaiah BK, Kumar SC, Tharyan P. Atypical 101 Natarajan VS, Ravindran S, Sivashanmugam.
antipsychotics in delusional parasitosis: a retrospective Assessment of nutrient intake and associated factors in
case series of 20 patients. Int J Dermatol 2010; 49: 95– elderly Indian population. Age Aging 1993; 22: 103–
100. 108.
83 Lepping P, Russell I, Freudemann RW. Antipsychotic 102 Chenoff R. Micronutrient requirements in older women.
treatment of primary delusional parasitosis. Br J Am J Clin Nutr 2005; 8: 1240S–1245S.
Psychiatry 2007; 191: 198–205. 103 Yancey KB. The pathophysiology of autoimmune
84 Freudenmann RW, Lepping P. Second generation blistering disorders. J Clin Invest 2005; 115: 825–828.
antipsychotics in primary delusional parasitosis: 104 Mutasim DF. Autoimmune bullous dermatoses in the
outcome and efficacy. J Clin Psychopharmacol 2008; elderly: diagnosis and management. Drugs Aging 2003;
28: 500–508. 20: 663–681.
85 Lee CS. Delusion of parasitosis. Dermatol Ther 2008; 105 Patricio P, Ferreira C, Gomes MM, et al. Autoimmune
21: 2–7. bullous dermatoses: a review. Ann NY Acad Sci 2009;
86 Naldi L, Conforti A, Venegoni M, et al. Cutaneous 1173: 203–210.
reaction to drugs: an analysis of spontaneous reports in 106 Walsh SRA, Hogg D, Mydlarski PR. Bullous
four Italian regions. Br J Clin Pharmacol 1999; 48: pemphigoid: from bench to bedside. Drugs 2005; 65:
839–846. 905–926.
87 Sullivan JR, Shear NH. Drug eruptions and other 107 Sollecito TP, Parisi E. Mucous membrane pemphigoid.
adverse drug effects in aged skin. Clin Geriatr Med Dent Clin North Am 2005; 49: 91–106.
2002; 18: 21–42. 108 Laforest C, Huilgol SC, Casson R, et al. Autoimmune
88 Nedorost ST, Stevens SR. Diagnosis and treatment of bullous diseases: ocular manifestations and
allergic skin disorders in the elderly. Drugs Aging 2001; management. Drugs 2005; 65: 1767–1779.
18: 827–835. 109 Smoker A. Skin care in old age. Nurs Stand 1999; 13:
89 Noiles K, Vender R. Are all seborrheic keratoses 47–53.
benign? Review of typical lesions and its variants J 110 Hodgkinson B, Nay R, Wilson J. A systematic review of
Cutan Med Surg 2008; 12: 203–210. topical skin care in aged care facilities. J Clin Nurs
90 Nanda A, Mamon HJ, Fuchs CS. Sign of Leser-Trélat in 2007; 16: 129–136.
newly diagnosed advanced gastric adenocarcinoma. J
Clin Oncol 2008; 26: 4992–4993. Answers
91 Testori A, Soteldo J, Sances D, et al. Cutaneous melanoma
in the elderly. Melanoma Res 2009; 19: 25–34. 1. a
92 Weedon DD, Malo J, Brooks D, Williamson R. 2. c
Squamous cell carcinoma arising in keratoacanthoma: a 3. c
neglected phenomenon in the elderly. Am J 4. d
Dermatopathol 2010; 32: 423–426. 5. b
93 Victor FC, Cohen DE, Soter NA. A 20-year analysis of
6. c&d
previous and emerging allergens that elicit photoallergic
7. a&d
contact dermatitis. J Am Acad Dermatol 2010; 62: 605–610.
8. a
94 Forsyth EL, Millard TP. Diagnosis and pharmacological
treatment of chronic actinic dermatitis in the elderly: an 9. c
update. Drugs Aging 2010; 27: 451–456. 10. c

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