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Managing Cutaneous Disorders in Geriatric Patients

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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The goal of xerosis treatment is to break the xerotic cycle and prevent complications. Keratolytics, moisturizers, and steroids are the primary components of treatment used to achieve this goal. Dermatologists should also consider antipruritics if severe itching is present. Additional management suggestions include: reduce frequency of bathing with warm, not hot water, minimal use of nonirritant soaps, apply petrolatum or petrolatum-containing moisturizer (cream or ointment, not lotion) immediately after bathing, avoid topical alcohol (astringents) and high-concentration lactic acid (>5%), avoid harsh skin cleansers and friction from washcloths, rough clothing, and abrasives, and use of air humidification in dry environments.4,6

Bullous Pemphigoid

BP is a common, autoimmune blistering disease, which is characterized by tense blisters on normal or inflamed skin.7 It is one of the few autoimmune diseases in which incidence increases with age. In the geriatric population, BP is more prevalent, with studies showing the incidence in individuals older than 80 years range between 190 and 312 cases/million/year.8

BP presents primarily as nonspecific urticarial plaques with eczematous and herpetiformis-like lesions lasting for a few weeks to months followed by the development of blisters.8 Diagnosis is made through immunofluorescent staining of biopsy specimens showing linear pattern deposition of IgG and/or C3 along the epidermal basement membrane.7 Given that elderly patients often have multiple comorbidities, treatment should be aimed at attenuating the autoantibody inflammation and preventing complications. Clinicians should also consider whether BP is drug induced and discontinue treatment with the offending drug.8

Oral corticosteroids are the mainstay of treatment, but adverse effects (eg, hyperglycemia) can limit their use. Topical corticosteroids are the safest treatment; in geriatric patients, high-potency topical corticosteroids should be considered as first-line treatment. Systemic corticosteroids are generally effective and well tolerated. However, long-term use is associated with an increased risk of significant adverse effects including adrenal suppression, hyperlipidemia, and glaucoma. Therefore, careful monitoring in all patients is warranted, particularly when used at high doses for prolonged periods.8 

Issues in Geriatric Dermatology

Dermatologists treating geriatric patients need to be knowledgeable on skin diseases and conditions affecting this older population and understand that older people undergo psychologic, physiologic, and anatomic changes that affect all the organ systems, including the skin. Additionally, older patients present with a variety of preexisting conditions, with one-third of geriatric patients having 3 or more preexisting diseases or conditions.9 

Interactions and Treatment Approaches

Care of geriatric patients is often medically complicated, and the interaction and treatment approaches differ with geriatric vs younger patients. 

“Mobility issues are more common in the geriatric population. Therefore, rides to clinic for follow-up may need to be coordinated with family members or caregivers, making frequent follow-up difficult for some patients,” said Lauren Ploch, MD, MEd, FAAD, a board-certified dermatologist and fellow of the American Academy of Dermatology (AAD), in an email interview with The Dermatologist. “Some systemic options may not be good in people with underlying kidney disease, liver disease, and/or for people on certain medications. It’s important to know our patients and formulate treatment regimens for them personally vs based on age.”

Dermatologists also need to consider a patient’s willingness and tolerability for a given treatment. “A patient partners with their dermatologist to decide on the best treatment strategies to address their dermatologic needs,” said Meghan Feely, MD, FAAD, a board-certified dermatologist practicing in New York City and New Jersey.

Dr Ploch, who is also in private practice with Georgia Dermatology and Skin Cancer Center, added, “All options should be presented and discussed in detail because the functional status of all patients regardless of age is different,” noting that some of her geriatric patients are very mobile and still drive.

Dermatologists also need to consider the unique characteristics of older individuals such as life expectancy, polypharmacy, function, cognition, mobility, social support, and patient preference before prescribing treatment.2

“Polypharmacy and adverse effects should always be discussed with patients and caregivers. I discuss life expectancy when discussing the treatment of nonmelanoma skin cancer. However, I have several patients age 100+, so I think that these discussions are happening at higher ages than ever and that we need to take functional status into account,” explained Dr Ploch. “It is important for us as dermatologists to truly know and be familiar with all of our patients, especially patients over the age of 80.”

For example, she recently saw an 85-year-old patient who asked if it was “worth treating” her basal cell carcinoma. “While basal cell carcinoma is often less aggressive than other skin cancers, it can still grow and become symptomatic. I suggested that we treat this because she’s a young 85 and still has many years to enjoy her life,” shared Dr Ploch.

Dr Feely, who also serves as a media expert for the AAD and is an attending physician at Mount Sinai’s department of dermatology, underscored the importance of patient education. “Patient education is pivotal to ensure patients and their families understand their treatment options and the risks, benefits, and alternatives of therapeutic interventions.”

When it comes to skin evaluations in geriatric patients, Dr Feely said, “Be attentive to other health comorbidities, which can impair wound healing, and be cognizant of the patient’s medications, mobility issues, nutritional status, and other issues that can impact a patient’s skin.”

Dr Ploch modifies her skin exam with patients who have mobility issues, often relying on caregivers and nurses to help with repositioning during the exam. “We need to address social issues and often have to counsel caregivers more than patients. If a patient requires daily bathing and twice-daily application of medicines, but is only getting a bath once per week and no one is applying medications, that needs to be addressed. Sometimes the conversations may be difficult but need to be had.”

Future Developments

Important advances, including understanding the stratum corneum and barrier function and the skin as an immune system, are changing how clinicians manage common dermatologic conditions in geriatric patients.9 

“Diabetes, congestive heart failure, and atherosclerosis, among other health issues, can impair our vasculature and impede wound healing. Strides to address these and other disorders with a multidisciplinary approach will improve our patients’ overall health and the health of their skin,” said Dr Feely.

“Some of the newer medications for psoriasis and atopic dermatitis that have less medication interactions and/or less effect on the hepatic and renal systems are game-changers,” noted Dr Ploch. “Also, ceramide-containing moisturizers with ammonium lactate are great for pruritus due to xerosis in the elderly. I find that my older patients are tolerating Mohs surgery better than ever and developments in Mohs for melanocytic lesions have allowed several of my patients to have large melanoma-in-situs treated without the risk of systemic sedation.” 

References

1. Cao T, Tey HL, Yosipovitch G. Chronic pruritis in the geriatric population. Dermatol Clin. 2018;36(3):199-211.

2. Linos E, Chren MM, Covinsky K. Geriatric dermatology—a framework for caring for older patients with skin disease. JAMA Dermatol. 2018;154(7):757-758.

3. Rui P, Hing E, Okeyode T. National ambulatory medical care survey: 2014 state and national summary tables. National Center for Health Statistics. 2014. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2014_namcs_web_tables.pdf. Accessed September 17, 2018. 

4. Berger TG, Shive M, Harper MD. Pruritus in the older patient: a clinical review. JAMA. 2013;310(22):2443-2450.

5. Pereira MP, Ständer S. Therapy for pruritis in the elderly: a review of treatment developments. Expert Opin Pharmacother. 2018;19(5):443-450.

6. Norman R. Common skin conditions in dermatology. Ann Long-Term Care. 2008;16(6):40-45.

7. Na CR, Wang S, Kirsner RS, Federman DG. Elderly adults and skin disorders: common problems for nondermatologists. South Med J. 2012;105(11):600-606.

8. Kim M, Borradori L, Murrell DF. Autoimmune blistering diseases in the elderly: clinical presentations and management. Drugs Aging. 2016;33(10):711-723.

9. Norman R. Effectively manage older patients with skin diseases. Practical Dermatology. http://practicaldermatology.com/2011/09/effectively-manage-older-patients-with-skin-diseases/. Published September 2011. Accessed September 17, 2018.

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