Dry skin and asteatotic eczema

Dryness with itching is common in elderly skin. It may be a mild roughness and scaling, or more severe, with fissuring and inflammation (asteatotic eczema, p. 38). The changes often occur on the legs and are aggravated by low humidity, central heating and excessive washing. Emollients, sometimes with a mild or moderate potency topical steroid ointment, usually help.

Seborrhoeic dermatitis (p. 38) in the elderly (Fig. 1) may be flexural and resemble psoriasis, candidiasis or erythrasma. In old people, allergic contact dermatitis (p. 34) to allergens in topical medicaments or toiletries, e.g. lanolin, neomycin, fragrances and local anaesthetics, particularly needs to be considered.

Fig. 1 Flexural seborrhoeic dermatitis affecting the scrotum and penis.

Pruritus

Itch in old age can be severe and unrelenting. Examination will usually show asteatotic eczema, scabies, urticaria or the prebullous phase of pemphigoid (p. 78), or investigations may reveal renal or liver disease or underlying malignancy (p. 88). The small group of patients in whom no cause is found have ‘senile pruritus’. Topical treatments and sedating antihistamines are often ineffective.

Psoriasis

Psoriasis has its peak onset in the teens with a second peak in the sixth decade. In the elderly patient, it is frequently flexural (p. 28), but all patterns, except guttate, are seen. Management can be difficult due to inability to apply topical therapy, attend hospital or stand for ultraviolet treatment. Methotrexate is used quite often and is mostly well tolerated.

Infections and infestations

Herpes zoster (p. 54) at some time affects 25% of people over 65. Post-herpetic neuralgia increases with age, occurring in 75% of shingles victims over 70. Early treatment with antivirals (e.g. aciclovir) together with amitriptyline or gabapentin makes neuralgia less likely.

Infection with Candida albicans (p. 58) is common in the flexures of obese elderly women. Onychomycosis (p. 68) is a frequent incidental finding in old people, especially men. Treatment is not always needed unless the nail produces pain.

Scabies epidemics are a problem in old people’s homes and are difficult to control (p. 62). Any itchy old person should be examined carefully, as burrows are easily missed. Elderly patients who are debilitated, paralysed, immunosuppressed or who cannot scratch may develop crusted ‘Norwegian’ scabies (Fig. 2), which is highly contagious due to the thousands of mites present.

Fig. 2 Crusted ‘Norwegian’ scabies.

Photodamage and skin tumours

Most benign and malignant skin tumours are more common in the elderly (Table 1). Many are related to sun exposure (p. 107). Specific disorders of photodamage include:

Fig. 3 Actinic keratoses.

Histologically, they show hyperkeratosis, abnormal keratinocytes with loss of maturation and dermal elastosis. Actinic keratoses may regress spontaneously. However, they can progress to squamous cell carcinoma, although this is relatively uncommon. Treatment is normally by cryosurgery, but certain lesions may be best treated with curettage, excision or by applying 5% fluorouracil cream (Efudix) once or twice daily for 3–4 weeks, 3% diclofenac gel (Solaraze) twice daily for 60–90 days or imiquimod (Aldara). Photodynamic therapy is a useful option in widespread (‘field’) actinic damage (p. 113).

A cutaneous horn may occasionally develop in an actinic keratosis (Fig. 4). It is best treated by excision.

Fig. 4 A cutaneous horn.

Fig. 5 Actinic elastosis.

The characteristic rhomboid pattern is seen on the neck, associated with senile comedones. A history of chronic sun exposure, often occupational, is invariably obtained.

Fig. 6 Chrondrodermatitis nodularis.

Ulceration

Fig. 7 Pressure ulcer over the sacrum.

Pressure ulcers mainly occur in the elderly who are recumbent and immobile, e.g. due to a fractured femur, arthritis, unconsciousness or paraplegia. Malnutrition, reduced cutaneous sensation and arterial disease predispose to tissue breakdown.

Prevention is possible if at-risk patients are identified. Regular repositioning, the use of an antipressure mattress and attention to diet and to the patient’s general condition help in prevention and treatment. A necrotic eschar separates by itself in 2–4 weeks. The resulting ulcer can be covered by a semipermeable dressing, e.g. Opsite. Proteolytic enzymes (Varidase) may be used to debride heel lesions. Pain relief is vital. Surgical excision and flap repair are possible provided the patient’s general condition is satisfactory.