The structure of the skin changes with age, and epidermal cell replacement and collagen formation begin to reduce throughout later life, resulting in a more fragile skin, which is thinner and more wrinkled, and therefore more susceptible to breakdown and ulceration (Ersser, 2010). These skin changes that occur in later life lead to conditions such as dermatitis. The term ‘dermatitis’ refers to a range of inflammatory skin conditions that vary in aetiology, with common manifestations including erythema, scaling, vesicles, itching and lichenification where there is chronic inflammation (British Medical Journal, 2018). It can be difficult to differentiate between each type of dermatitis as they can appear similar, but do have distinct signs and symptoms to look out for.
The outer layer of the skin, otherwise known as the stratum corneum, is involved in the skin's barrier function, through its component lipids, namely, cholesterol, free fatty acids, and ceramids (van Smeden and Bouwstra 2016), and this layer is impaired in older people. Therefore, moisture is lost, which leads to dryness. Without barrier lipids to protect the skin's barrier function, the skin becomes dry, scaly and itchy, and its defence against bacteria, chemicals and fungi is hampered (National Eczema Society (NES), 2019). The thin, dry nature of the older person's skin means it is susceptible to tearing, an aspect that needs to be considered carefully when dressing changes for wound care are made, especially in terms of choice, application and removal of the dressing.
Other intrinsic factors are also involved in an older person's susceptibility to eczema. The presence of comorbidities, such as diabetes, renal failure and thyroid disease, can lead to a higher risk of eczema, and these conditions are more common in later life. A poor diet and fluid intake as well as medications or incontinence can also affect the skin's barrier function. Additionally, the presence of cognitive decline or mental health conditions can alter the mental state and may affect the skin due to the secondary effect of poor personal hygiene. Sometimes, eczema can occur after a particularly stressful event or period, such as following a bereavement (NES, 2019).
Eczema
Eczema consists of dry, pruritic skin with typical manifestations alongside this of erythema, scaling or vesicles, and lichenification in skin flexures where chronic inflammation is present (British Medical Journal, 2018). Patients often have a familial history of other atopic diseases, such as asthma and allergic rhinitis. First-line treatment for eczema consists of emollients and topical corticosteroids, for example:
- Doublebase Gel (Dermal Laboratories)
- Cetaphil (Galderma)
- QV Cream and QV Skin Ointment (Crawford)
- Hydromol ointment (Alliance)
- EPIMAX Original Cream and EPIMAX Isomol Gel (Aspire Pharma)
- Dermalex (Perrigo)
- Oilatum and Cetraben (Thornton & Ross)
If these fail to work, other options include topical calcineurin inhibitors, phototherapy and immunosuppressive agents (British Medical Journal, 2018).
Contact dermatitis
Irritant contact dermatitis results from direct toxicity, occurring in any person without any prior sensitisation, while allergic contact dermatitis is a delayed hypersensitivity reaction requiring prior sensitisation (British Medical Journal, 2018). Both conditions show presentations of localised burning, stinging, itching, blistering, erythema and swelling following contact with an allergen or irritant, such as pollen and laundry detergent. Hyperpigmentation, fissuring and scaling may also occur. When the allergen or irritant is identified, the main goals of treatment would be to avoid future exposure and also to resolve the existing dermatitis. For irritant contact dermatitis, exposure reduction and moisturisers are recommended (British Medical Journal, 2018), in addition to exposure elimination in combination with topical corticosteroids or topical calcineurin inhibitors for allergic contact dermatitis. Where the allergic contact dermatitis is severe, oral corticosteroids may be required.
Dyshidrotic dermatitis
Dyshidrotic dermatitis involves recurrent crops of 1- to 2-mm vesicles, with pruritus on the palms, soles and/or lateral aspects of the fingers (British Medical Journal, 2018). The condition known as pompholyx is more acute and involves severe eruptions of large bullae on the hands and feet. The significant exacerbating factor is irritation, often present with frequent hand washing, hyperhidrosis and stress, although the underlying aetiology is unknown. In the present circumstances of the COVID-19 pandemic, where people are being advised to wash their hands often, and the pandemic is causing heightened stress, special attention must be directed to this condition, as increasing numbers of people are likely to develop it.
The main goal in treating dyshidrotic dermatitis would be in its identification and the avoidance of exacerbating factors. Therefore, patients should be taught how to maintain effective skin barrier mechanisms, such as through the use of emollients and the avoidance of irritants. Where these lifestyle measures are changed but the patient is not responsive, topical corticosteroids or immunomodulators would be used. Some cases are more severe with eruptive bullae on the palms and soles, for which oral corticosteroids are useful. For particularly recalcitrant cases, many other options are available, including phototherapy, oral immunosuppressants or nickel-directed therapy (British Medical Journal, 2018).
Seborrhoeic dermatitis
Seborrhoeic dermatitis is characterised by erythematous and greasy, scaly patches on the scalp, glabella, nasolabial fold, posterior auricular skin and anterior chest (British Medical Journal, 2018). Another feature of this chronic condition is dandruff. It is unclear what exactly causes this condition in older adults specifically, despite how common the condition is, but it is thought that seborrheic dermatitis is triggered by an overgrowth of a harmless yeast that is part of the skin's normal flora, Malassezia. It is believed to be an over-reaction of the immune system to this yeast (British Association of Dermatologists 2018). The condition appears to be common in people with Parkinson's disease (British Association of Dermatologists, 2018). Tiredness and stress can also trigger a flare up of seborrhoeic dermatitis, which may be common in older people, and it is more common in colder weather (British Association of Dermatologists, 2018).
The main aim of treatment would be to control symptoms, through the administration of topical corticosteroids, coal tar, calcineurin inhibitors and antifungals (British Medical Journal, 2018). Shampoos and scalp preparations also are useful specifically for this condition (e.g. Neutrogena T/Gel (Johnson & Johnson) and Polytar (Thornton & Ross). Systemic antifungals should be reserved for severe cases.
Lichen simplex chronicus
Lichen simplex chronicus is identified by the following trademark symptoms: lichenified erythematous, often hyperpigmented, cutaneous plaques that occur mostly on the scalp, neck, forearms, ankles and genitalia as a result of chronic scratching and rubbing (British Medical Journal, 2018). There may be just a single or multiple patches or plaques of lichen simplex chronicus on skin affected by an underlying dermatosis, for example, due to atopic dermatitis, allergic contact dermatitis, stasis dermatitis, superficial fungal (tinea and candidiasis) and dermatophyte infections, lichen sclerosis, viral warts, scabies, lice, arthropod bites or cutaneous neoplasia (British Medical Journal, 2018).
Lichen simplex chronicus is a very difficult condition to treat, with the main goals being to remove any triggering and exacerbating environmental factors, repair the barrier function of the skin and identify and treat the underlying dermatological or systemic condition that might be causing the condition in the case of secondary disease (British Medical Journal, 2018). It is crucial to disrupt the itch–scratch cycle characteristic of lichen simplex chronicus by reducing the degree of skin inflammation and controlling nocturnal pruritus. Therefore, treatment of lichen simplex chronicus should be tailored closely to the individual and may require a topical corticosteroid (e.g. Canesten hydrocortisone cream (Bayer)), emollients and lifestyle modifications, such as distraction techniques, psychological input such as mindfulness practices to take the focus away and changes in clothes to help lessen the severity of the itch–scratch cycle; itch relief creams, such as Diprobase (Bayer) and Eucerin AtoControl Acute Care Cream (Beiersdorf), may also be used. Additionally, nocturnal pruritus may be treated with an older-generation sedating antihistamine (British Medical Journal, 2018).
Assessing pruritus
Generally, the most common symptom of dermatitis, dermatologically speaking is itching, which might appear with or without lesions of the skin. Therefore, to evaluate pruritus, a thorough history and complete physical examination are essential. It is important to think about and identify the possible causes or potential diseases present while examining the skin, as well as determining the intensity of and duration since onset of the pruritus.
Research on prevalence of skin conditions in older adults
A multicentre prevalence study was carried out in 2017 that measured the prevalence of skin diseases in older residents of nursing homes (Hahnel et al, 2017). It explored the possible associations with demographic and medical characteristics. The research was carried out in a random sample of 10 institutional long-term care facilities in the federal state of Berlin, Germany, and a total of 223 residents were included in the study. Some 60 dermatological diseases were diagnosed, with the most frequently diagnosed skin disease being xerosis cutis (99.1%) followed by tinea ungium (62.3%) and seborrheic keratosis (56.5%) (Hahnel et al, 2017). The study results indicated that nearly every resident in residential care facilities has at least one dermatological condition. Dermatological findings showed a range of diagnoses, from highly prevalent xerosis and cutaneous infection, to skin cancer. The researchers identified that not all conditions would require immediate dermatological treatment and could be managed by targeted skin care interventions. It is important that the person caring for the patient or resident has the knowledge and diagnostic skills to make appropriate clinical decisions, or knows what to look out for and when to refer the patient to a doctor for a dermatology referral. This is because older people who require care due to cognitive disease such as dementia may not be able to notice, due to the constraints of their cognitive impairment, the signs of even a severe skin condition, despite the presentation of symptoms such as itching. The researchers determined that it is unlikely that specialised dermatological care would be delivered widely in the growing long-term care sector (Hahnel et al, 2017).
A positive aspect of the study by Hahnel et al (2017) is its sample size. It is the largest randomly selected sample of long-term care residents over the ages of 65 years old undergoing head-to-toe skin examinations by board-certified dermatologists. Skin diseases, medications and concomitant diseases were classified according to international definitions, and functional assessments were carried out in accordance with established methods, which further supports the generalisability of results. The sample would have been bigger if it were possible, and, despite inclusion of three large care facilities, the intended sample size of 280 was not achieved. Additionally, a limitation of the study was that the systemic diseases were not specified and laboratory and histology data were not available.
The main point to take away from the study by Hahnel et al (2017) was that it showed that almost every resident in institutional long-term care is likely to be affected by at least one dermatological diagnosis, and that 60 dermatological diseases were diagnosed, which was unexpectedly high, showing the vast array of dermatological diseases on the spectrum of diagnoses that may affect older care residents. Notably, xerosis cutis was the most prevalent condition, followed by tinea unguium, seborrheic keratosis, androgenetic alopecia, incontinence-associated dermatitis (IAD) and tinea pedis (Hahnel et al, 2017). The researchers detected very few bivariate associations between skin diseases and demographic and other characteristics, with the majority indicating that the strengths of associations were small. The study found that male sex was strongly associated with androgenetic alopecia, tinea pedis and actinic keratosis, a university qualification may be protective against xerosis cutis, and that increasing age leads to increased risks of seborrheic keratosis and intertrigo and to decreased risks of seborrheic dermatitis (Hahnel et al, 2017). The researchers stated that the Barthel index and the duration of residency appeared to be unrelated to the occurrence of skin diseases in this population.
Conclusion
In summary, there is a wide spectrum of dermatological diseases commonly found among older adults in community settings. These conditions include a range of allergic dermatological conditions. Awareness of the signs and symptoms of various skin conditions is important, so the skin can be assessed and the patient can be referred to a specialist depending on the need for intervention, as well as to ensure that treatment is optimal. It is important for health practitioners in the community to be aware of underlying conditions or contact with substances that may have led to the secondary development of the dermatological condition. Treatment mainly involves symptom management and treating underlying conditions, although medical management may be required, including topical corticosteroids or oral medications. Any treatment should be individually tailored, depending on patient diagnosis and need. Lastly, not all patients respond the same way, so it is important to be aware of first- and second-line options once a diagnosis has been determined.
KEY POINTS
- Older adults in the community present a wide variety of skin conditions
- These include atopic dermatitis, allergic and contact dermatitis, dyshidrotic dermatitis and eczema
- Treatment involves eliminating the allergen or irritant, resolution of any symptoms as well as resolution of underlying systemic conditions that might exacerbate the skin condition
- It is important for community nurses to be aware of the signs and symptoms of common dermatological diagnoses in older adults, and known when to refer a patient to specialist services
CPD REFLECTIVE QUESTIONS
- Think about patients on your caseload and how their skin might have presented—was there anything you noticed when assisting with a wash? Did they appear to be itching any area of skin? Was a referral for review about this matter in place?
- What are the various allergens or irritants than might cause allergic contact dermatitis?
- Why are older adults particularly susceptible to skin conditions, especially in present circumstances?