|Year : 2021 | Volume
| Issue : 2 | Page : 51-55
Spectrum of skin diseases in the elderly age group: A hospital-based study
Mriganka Mehra1, Nitin Mishra1, Pratik Gahalaut1, Madhur Kant Rastogi1, Neni Agarwal2
1 Department of Dermatology, SRMS IMS, Bareilly, Uttar Pradesh, India
2 Department of Dermatology, GGSMCH, Baba Farid University of Health Sciences, Faridkot, Punjab, India
|Date of Submission||03-Jun-2021|
|Date of Decision||20-Jul-2021|
|Date of Acceptance||30-Aug-2021|
|Date of Web Publication||22-Oct-2021|
Dr. Mriganka Mehra
Department of Dermatology, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly - 243 202, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: The increasing average lifespan has led to an increase in an elderly patient encountered in day-to-day practice. Despite this, there is a lack of statistical data about dermatosis in the elderly. Objectives: This study has been performed with the objectives of studying the spectrum of skin diseases in the elderly and study associations of these with various demographic characteristics such as age, gender, and residence with clinical diagnosis. Methodology: This was a cross-sectional study based in a tertiary care teaching hospital, which included patients aged 60 years and above, presenting to the outpatient department of dermatology. Results: A total of 440 patients were enrolled. The mean age was 65.92 years, with maximum belonging to the 60–69 years' age group (73%) and a male preponderance (1.97:1). The most common systemic ailment was diabetes mellitus (18.2%). The most common physiological change was wrinkling (92.3%). Among pathological conditions, infections were the most common group (51.3%). Fungal infections were seen in 24.1% and leprosy in 6.8% of patients. Wrinkling, neoplasia, and nail changes were significantly higher in males. Metabolic dermatosis was significantly higher in diabetics. Generalized pruritus, neoplasia, and pigmentary disorders were significantly more common in urban residents, whereas infections were significantly higher in rural residents. Conclusion: The most common physiologic finding among the elderly was wrinkles while the most common dermatosis were infections. Dermatosis in the elderly has atypical presentations due to an interplay of physiological and pathological factors. With increasing average lifespan, dermatological demands of the aged are growing. Thus, it is important to study the problems of the aged individuals, so proper dermatological care can be provided to them.
Keywords: Cutaneous manifestations, dermatosis, geriatric, infections
|How to cite this article:|
Mehra M, Mishra N, Gahalaut P, Rastogi MK, Agarwal N. Spectrum of skin diseases in the elderly age group: A hospital-based study. J Indian Acad Geriatr 2021;17:51-5
|How to cite this URL:|
Mehra M, Mishra N, Gahalaut P, Rastogi MK, Agarwal N. Spectrum of skin diseases in the elderly age group: A hospital-based study. J Indian Acad Geriatr [serial online] 2021 [cited 2021 Nov 27];17:51-5. Available from: http://www.jiag.com/text.asp?2021/17/2/51/329016
| Introduction|| |
“Senior citizen” or “elderly” is a person who is of age 60 years or above as defined by the “National Policy on Older Persons” adopted by the Government of India in January 1999. A growth in the elderly population has been noted due to a substantial reduction in mortality owing to economic well-being, better health-care systems and advancements in the field of Medicine. This phenomenon, called population aging, is a dynamic demographic trend seen all over the world.
With the increasing average lifespan, the percentage of geriatric patients is bound to rise. Consequently, the dermatological demands of the aged will grow. This will alter the prevalence and pattern of skin diseases encountered in general dermatology practice. Thus, it is important to study in detail the problems of the aged, so that proper dermatological care can be provided to them.
Skin disorders found to be common in elderly in prior studies include xerosis, pruritus, photoaging (dermatoheliosis), benign tumors like acrochordons, seborrheic keratosis, cherry angiomas and infections like herpes zoster, dermatophytosis, and various eczematous conditions.
There is a lack of adequate statistical studies concerned with cutaneous diseases in the elderly. This study was undertaken to study the spectrum of cutaneous manifestations and prevalence of dermatological disorders in elderly patients.
| Methodology|| |
This was a cross-sectional study, which included patients aged 60 years and above presenting to the dermatology department of a tertiary care teaching hospital of Northern India from November 2017 to November 2018. All the participants consented to be enrolled, examined, and photographed. Data regarding basic demographic characteristics and complaints were self-reported, and general as well as cutaneous examination was performed and recorded. Diagnosis was clinical, and diagnostic tests were performed when necessary. The patients were divided into groups based on age: 60–69, 70–79, and ≥80 years. The modified B.G. Prasad scale was used to assess socioeconomic status. The findings were then tabulated and analyzed. Chi-square test was applied for comparison between variables. The results were considered statistically significant at P < 0.05.
| Results|| |
The mean age of patients in our study was 65.92 years, minimum age being 60 years and maximum being 100 years. In this study, majority of the patients were 60–69 years of age (73.18%), and the least were ≥80 years of age (3.18%). Among a total of 440 patients enrolled in the study, majority (66.4%) of patients were male. Male-to-female ratio was found to be 1.97:1. According to the Revised Modified B.G Prasad Socioeconomic Scale 2017, majority of patients were from lower class (33.2%), followed by lower middle (25.5%). The least number of patients belonged to the upper class (10.9%). Majority of the participants were unemployed (33.2%), followed by farmers (24.5%), skilled laborers (15.5%), and shop owners (15.5%). Other professions were <10% each. More than half of the patients were from rural area (63.2%) and the rest (36.8%) from urban residential areas, out of these 3.6% were from urban slum region.
Systemic ailments were noted in 250 patients, among which few had more than one condition. The most common systemic ailment was diabetes mellitus seen in 18.2%, followed by hypertension in 16.8% and coronary artery disease in 6.4%. Other illnesses were all <5%. 238 (54.1%) patients were on treatment for the above-mentioned systemic associations.
The most common physiological change was wrinkling in 406 (92.3%) cases, then xerosis in 164 (37.3%), idiopathic guttate hypomelanosis (IGH) in 264 (60%), senile comedones in 20 (4.5%), and senile lentigines in 10 (2.3%). In some of these cases, more than one of the above findings was seen.
Among pathological conditions, infections were found to be the most common group of dermatosis seen in 226 (51.3%) patients, followed by neoplasia in 120 (27.3%), eczematous conditions and vascular disorders in 68 (15.5%), papulosquamous diseases in 56 (12.7%), and metabolic and nutritional dermatosis in 30 (6.8%). Other groups were <5% [Table 1].
Out of the infections, fungal infections were the most common (24.1%). Bacterial infections were the second most common and were present in 10.5% (46) of total participants, followed by viral infections which presented in 10% (44 cases) and parasitic infestations in 6.8% (30 cases).
Among the 106 cases of fungal infections, dermatophytosis was seen in 74 (16.8%) cases, onychomycosis in 22 (5.0%), and candidiasis in 8 (1.8%). Of the bacterial infections, leprosy was seen in 30 (6.8%) cases, cellulitis in 6 (1.4%), folliculitis in 2 (0.5%), furuncle in 6 (1.4%), and impetigo in 2 (0.5%). Among the viral infections, herpes zoster was seen in 14 (3.2%) cases and postherpetic neuralgia in 16 (3.6%). Viral warts and molluscum contagiosum were seen in 6 (1.4%) cases each. Herpes labialis was seen in 2 (0.5%) cases.
The most common nail findings were ridging in 166 (37.7%) cases, followed by nail dystrophy in 44 (10%) and melanonychia in 30 (6.8%). Onycholysis and chromonychia were present in 22 (5%) cases, subungual hyperkeratosis in 18 (4.1%), and loss of luster in 14 (3.2%). Graying of hair was seen in 438 (99.1%) cases, diffuse hair loss in 80 (18.2%), and androgenetic alopecia in 140 (31.8%).
Between the genders, a significant difference was seen in the occurrence of wrinkling, wherein it was noted in 96.6% of males and 83.6% of females (P = 0.001). Significant differences were seen in the incidence of neoplasia: in 31.5% of males and in 16.2% of females [P = 0.015, [Table 2]]. A significant difference was seen in the occurrence of nail changes: in 74.3% of females and in 83.5% of males (P = 0.005).
Among diabetics, no difference in the incidence of physiological changes was seen. Significantly higher incidence of metabolic dermatosis was seen in diabetics: in 25% of diabetics and in 2.8% of nondiabetics (P < 0.001).
The most common dermatosis was found to be infections in all the subgroups, with regard to age. Significantly higher incidence of infections was noted in ≥80 years of age group, wherein 71.4% of patients presented with infections (P < 0.001). The most common physiological finding in all age groups was wrinkling. Senile comedones and lentigines were significantly higher in ≥80 years group (28.6%; P = 0.006 and P < 0.001, respectively).
Significant differences were not seen in physiological changes between patients belonging to rural and urban areas. Generalized pruritus, neoplasia, and pigmentary disorders were found to be more common in patients belonging to urban residence (P = 0.004, P = 0.030, and P = 0.026, respectively). Infections were seen more commonly in patients from rural areas (57.6%; P = 0.016).
| Discussion|| |
Skin, as the external most organ of the body, serves as a primary barrier against the environment. It also serves various other functions aside from protection. Aging is associated with the declining ability of the organism to carry out adaptive responses, thus decreasing ability to maintain homeostasis. This leads to an increased vulnerability to diseases.
In the present study, 440 patients were enrolled. The lowest age of participants was 60 years, while the oldest was 100 years of age. Among the 440 participants, 33.6% were female and maximum (66.4%) were male. Male-to-female ratio was found to be 1.97:1. Durai et al. studied 500 elderly patients in a hospital setting. They found a female-to-male ratio to be 1.34:1, wherein there were 213 (42.6%) males and 287 (57.4%) females.
Majority of patients, according to the Modified B.G. Prasad Scale, were from lower class (33.2%). In a study by Nayak et al., majority (47.1%) of patients presenting to the dermatology OPD belonged to upper middle class. This difference could due to the location of our center at the outskirts of Bareilly city, thus being in the vicinity of many villages and further the present study included only elderly patients.
More than half of the patients, in our study, were from rural areas (63.2%). Baur et al. conducted a 225-patient study, in which they found that out of overall attendees of skin OPD, 43.1% belonged to urban slums, 42.7% were from urban areas, and 14.2% belonged to rural areas. The pattern of residence of patients in our study is accounted for by the geographic location of our center, which is in proximity to many villages.
In our study, a total of 61.6% of patients had some systemic illness. The most common systemic ailment was diabetes mellitus (18.2%), followed by hypertension (16.8%). 54.1% of patients were on treatment for the above-mentioned systemic ailments. This is higher than that reported by Patange and Fernandez. They found systemic ailments in 35% of the total cases, out of which diabetes (9%) was the most common. This could be due to a higher referral rate to dermatology from other specialties, at our center.
Xerosis was noted in 37.3% in our study. Sahoo et al. noted a 12.5% incidence of xerosis, while Chopra et al. noticed it in 108 (50.8%) cases. The variation of incidence of xerosis could be due to seasonal variation as well as difference in use of emollients.
Static wrinkles were present in 92.3% in our study. This is comparable to older studies which report them in 94–95.6% of elderly., In our study, most of the wrinkling was observed on sun-exposed areas such as face, neck, forearms, and dorsa of the hands.
Idiopathic Guttate Hypomelanosis (IGH) was noted in 60% in our study. Previous studies report an incidence of in 24.4%. In our study, a higher incidence was noted, which could be due to genetic factors and greater sun exposure. As seen in previous literature, most lesions were present over distal extremities, neck, and upper chest due to greater sun exposure over these sites.
Infections were the most common presenting dermatosis (51.3%). Fungal infections were the most common (24.1%), followed by bacterial infections (10.5%), parasitic infestations (6.8%), and viral infections (10.0%).
A previous study reports incidence of infections and infestations of 46.8% and the most common was the fungal infections (34.4%).
In the present study, dermatophytic skin infections were present in 16.8%, onychomycosis in 5.0%, and candidiasis in 1.8% of cases. Johnson found a 12.7% incidence of dermatophytosis. Durai et al. noted the incidence of dermatophyte skin infections as 16%. Our study had a slightly higher incidence of dermatophytic skin infections than previous studies, which mirrors the present hyperendemic situation of dermatophytosis in India.
Among the bacterial infections, leprosy was seen in 6.8%; the incidence of leprosy was 1.5% in a study by Grover and Narasimhalu and as 6% by Raveendra. A higher incidence of leprosy (6.8%) in our study could be due to a referral bias as the study has been conducted at a tertiary medical center.
The most common nail findings were ridging in 37.7%, followed by nail dystrophy in 10% and melanonychia in 6.8%. Onycholysis and chromonychia were present in 5% each and subungual hyperkeratosis in 4.1%. Onychomycosis was noted in 5% and it most commonly presented with onycholysis.
The incidence of ridging in the elderly nail varies from 24% to 72.5%., The incidence of onychomycosis in the past studies was seen to vary from 5% to 22.2%.,
Graying of hair was present in 99.1%, which is comparable to the findings in previous literature. Durai et al. found graying in 97.2% of males and 90.9% of females. We noted diffuse hair loss in 18.2% and androgenetic alopecia in 31.8%. Previous studies report androgenetic alopecia in 20%–55.3% and diffuse hair thinning in 47%–67.2% of elderly patients., The incidence of androgenetic alopecia in our study is comparable to previous literature, whereas that of diffuse hair thinning is lower. This lower incidence could be due to differences in factors such as dietary, geographic, and genetic.
Significantly higher incidence of wrinkling was noted in males. This was likely due to more outdoor work and consequently greater sun exposure. Darjani et al. found no significant difference in physiological changes between genders. Significantly higher incidence of cutaneous neoplasia was seen in males (31.5%), compared to females (16.2%). Similar findings were noted by Darjani et al. in their study, wherein neoplasia were found in 20.3% of males and in 10.1% of females. This is a result of higher cumulative sun exposure among the males.
A significant difference was seen in the occurrence of all nail changes, which were noted in 74.3% of females and in 83.5% of males (P = 0.005). This could be due to greater work related trauma sustained by the nails, in case of men. Among the elderly, it has been previously noted that onychomycosis is more common in men than in women.
Significantly higher incidence of metabolic dermatosis (acrochordons, acanthosis nigricans, granuloma annulare, and diabetic bulla) was seen in diabetics (P < 0.001). Infections were seen to be higher in diabetics (62.5%) than in nondiabetics (48.9%), but no significant difference was noted (P = 0.119).
Metabolic dermatoses such as acanthosis nigricans and skin tags were found to be higher in elderly diabetics in previous studies. Previous studies have also shown infections to be more common in diabetics., However, in a study by Asokan and Binesh., they noted fungal infections to be equally common in elderly persons without diabetes mellitus. They concluded that it could be due to advancing age by itself being a predisposing factor for fungal infection.
The most common cutaneous morbidity was found to be infections in all 3 age groups, with significantly higher incidence occurring in ≥80 years of age. The most common dermatosis was found to be neoplasms in all age groups by Darjani et al. They also found infections to be the most common in ≥80 years' age group.
The most common finding in all age groups was wrinkling. Senile comedones and lentigines were highest (28.6%) in ≥80 years' age group (P = 0.006 and P < 0.001, respectively). Age-related changes such as senile lentigines were also found to be higher in ≥80 years' age group in a 440-patient study by Darjani et al.
Generalized pruritus, neoplasia, and pigmentary disorders were found to be more common in patients belonging to urban residence (P = 0.004, P = 0.030, and P = 0.026, respectively). Infections were seen more common (57.6%) in patients from rural areas (P = 0.016).
This is in accordance with Baur et al. who found that infections were greater in urban population.
No significant differences were seen in physiological changes between patients belonging to rural and urban areas. No such differences have been noted in prior literature.
| Conclusion|| |
A total of 440 patients were studied, among which the most common physiologic change was found to be wrinkling (92.3%). The most common dermatoses were infections and infestations (51.3%), out of which the most common were fungal infections (24.1%). Variations in the incidence of physiological changes and dermatosis were seen with regard to the gender, age, residence, and diabetic status of the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Statistics E. Central Statistics Office, Ministry of Statistics and Programme Implementation. Govt. of India, New Delhi (22nd
Issue); 2015. Available from: https://www.mospi.gov.in
. [Last accessed on 2020 Jan 20].
Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214-8.
] [Full text]
Jafferany M, Huynh TV, Silverman MA, Zaidi Z. Geriatric dermatoses: A clinical review of skin diseases in an aging population. Int J Dermatol 2012;51:509-22.
Chan HL. Leading article the skin in the elderly. Singapore Med J 1994;35:141-2.
Rajan SI, Sarma PS, Mishra US. Demography of Indian aging, 2001-2051. J Aging Soc Policy 2003;15:11-30.
Shaikh Z, Pathak R. Revised Kuppuswamy and BG Prasad socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9.
Lee SH, Jeong SK, Ahn SK. An update of the defensive barrier function of skin. Yonsei Med J 2006;47:293-306.
Pomatto LC, Davies KJ. The role of declining adaptive homeostasis in ageing. J Physiol 2017;595:7275-309.
Durai PC, Thappa DM, Kumari R, Malathi M. Aging in elderly: Chronological versus photoaging. Indian J Dermatol 2012;57:343-52.
] [Full text]
Nayak PB, Girisha BS, Noronha TM. Correlation between disease severity, family income, and quality of life in psoriasis: A Study from South India. Indian Dermatol Online J 2018;9:165-9.
] [Full text]
Baur B, Sarkar J, Manna N, Bandyopadhyay L. The pattern of dermatological disorders among patients attending the skin OPD of a tertiary care hospital in Kolkata, India. IDSR J Dent Med Sci 2013;3:4-9.
Patange VS, Fernandez RJ. A study of geriatric dermatoses. Indian J Dermatol Venereol Leprol 1995;61:206-8.
] [Full text]
Sahoo A, Singh PC, Pattnaik P, Panigrahi RK. Geriatric dermatoses in southern Orissa. Indian J Dermatol 2000;45:66.
Chopra A, Kullar J, Chopra D, Dhaliwal RS. Cutaneous physiological and pathological changes in elderly. Indian J Dermatol Venereol Leprol 2000;66:274.
] [Full text]
Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol 1987;123:1638-43.
Tindall JP, Smith JG Jr. Skin lesions of the aged and their association with internal changes. JAMA 1963;186:1039-42.
Johnson ML. Aging of the United States population. The dermatologic implications. Clin Geriatr Med 1989;5:41-51.
Verma S, Madhu R. The great Indian epidemic of superficial dermatophytosis: An appraisal. Indian J Dermatol 2017;62:227-36. [Full text]
Grover S, Narasimhalu CR. A clinical study of skin changes in geriatric population. Indian J Dermatol Venereol Leprol 2009;75:305-6.
] [Full text]
Raveendra L. A clinical study of geriatric dermatoses. Our Dermatol Online 2014;5:235-9.
Darjani A, Mohtasham-Amiri Z, Mohammad Amini K, Golchai J, Sadre-Eshkevari S, Alizade N. Skin disorders among elder patients in a referral center in northern Iran (2011). Dermatol Res Pract 2013;2013:193205.
Weinberg JM, Vafaie J, Scheinfeld NS. Skin infections in the elderly. Dermatol Clin 2004;22:51-61.
Asokan N, Binesh VG. Cutaneous problems in elderly diabetics: A population-based comparative cross-sectional survey. Indian J Dermatol Venereol Leprol 2017;83:205-11.
] [Full text]
Nigam PK, Pande S. Pattern of dermatoses in diabetics. Indian J Dermatol Venereol Leprol 2003;69:83-5.
] [Full text]
Timshina DK, Thappa DM, Agrawal A. A clinical study of dermatoses in diabetes to establish its markers. Indian J Dermatol 2012;57:20-5.
] [Full text]
[Table 1], [Table 2]