Managing Cutaneous Disorders in Geriatric Patients

geriatric care

The population of individuals older than 65 years is growing at a rate of about 3% per year.1 By 2030, 20% of all Americans will be older than 65 years, making the geriatric population the same size as the pediatric population. Furthermore, the 85 years and older population is the fastest growing segment of the US population, expected to reach 20 million by 2060.2 A 2014 report from the National Center for Health Statistics found that the incidence of dermatologic conditions is also rising, with more than 27 million visits to dermatologists and more than 5 million new skin cancers each year, most in older adults.2,3

Thus, dermatologists will see more geriatric patients presenting with age-related dermatologic conditions, along with common problems prevalent in this patient population. A recent viewpoint article from Linos and colleagues2 underscored that the practice of dermatology would benefit from including provisions for older patients. “We need to explicitly incorporate principles of geriatrics in the practice of dermatology in the same way that principles of pediatrics have been incorporated into dermatology for decades,” they wrote.

Common Skin Disorders

Pruritus, xerosis, and bullous pemphigoid (BP) are a few of the common skin diseases diagnosed in geriatric adults (Table 1). 

table 1

Pruritus

Chronic pruritus in the geriatric population, as defined by pruritus that persists for more than 6 weeks experienced by individuals aged 65 and older, is a growing health care problem.1 Underlying diseases or metabolic conditions that can cause pruritis are shown in Table 2. A combination of 3 age-related biological processes contribute to pruritis: loss of barrier function, immunosenescence, and neuropathy. Given the high rate of comorbidities and polypharmacy in this age group, the clinical management of these patients is challenging.4,5

The goal of pruritis therapy is to optimize treatment efficacy by tailoring the treatment to the underlying etiology, which is varied. Mild pruritus may respond to nonpharmacologic measures such as avoiding hot water and irritants, maintaining proper humidity, and trimming the nails.6 For multimorbid patients, emollients, topical substances, and phototherapy constitute the best initial options. However, dermatologists should consider comorbid disease and drug interactions when prescribing systemic treatments. If systemic drugs are needed, the potential adverse effects need to be closely monitored.5 

table 2

Antihistamines, for example, should be used with caution. While first- and second-generation antihistamines can treat pruritus, second-generation antihistamines are preferred in the geriatric population. Because of the sedating and anticholinergic adverse effects associated with first-generation antihistamines, including confusion, constipation, blurred vision, dry mouth, and reduced clearance in advanced age, they are listed on the Beers Criteria of potentially inappropriate medications in older adults.1,2 

Novel medication such as neurokinin-1 receptor antagonists and opioid-targeting drugs have shown promising results for refractory chronic pruritus in clinical trials. These agents may offer another treatment option for geriatric patients who cannot tolerate conventional systemic agents.5

Xerosis

Xerosis is a common dermatologic condition characterized by pruritic, dry, cracked, and fissured skin with scaling, affecting more than 50% of those aged 65 and older. Additionally, preexisting diseases, therapies, and medications make elderly patients more susceptible to xerosis.4,6 Xerotic skin appears like a pattern of cracked porcelain and is caused by diminished natural moisturizing factors, sebum, and lipid production. Pruritus leads to secondary lesions. Xerosis is most often found on the legs of geriatric patients but may also be present on the hands and trunk.6 

Deficits in both skin hydration and lipid content play an important role in xerosis. As a result, the skin’s inability to retain moisture and provide an effective barrier directly impacts the development of xerosis in aged skin. Once the stage is set for xerosis development, flaking, fissuring, inflammation, dermatitis, and infection can develop.6

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