|Year : 2022 | Volume
| Issue : 2 | Page : 73-77
Pattern of dermatoses in the elderly population attending the dermatology clinic at a Tertiary Care Center in South-East Rajasthan
Avinash Sharma1, Ramesh Kumar Kushwaha1, Vartika Kesarwani2, Suresh Kumar Jain1, Devendra Yadav1, Sonika Sharma3
1 Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, India
2 AIIMS, Jodhpur, India
3 SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||27-Feb-2022|
|Date of Decision||25-Mar-2022|
|Date of Acceptance||10-Apr-2022|
|Date of Web Publication||15-Jul-2022|
Suresh Kumar Jain
Department of Dermatology, Venereology and Leprology, Government Medical College, Kota - 324 005, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: The skin acts as the first line of defense for the body against external injuries. With aging, the architecture of the skin undergoes intrinsic changes that impair its capacity for repair. In addition, the aging skin is more susceptible to injury by external stimuli, including ultraviolet rays and environmental pollutants. The combination of these factors predisposes the elderly to a variety of dermatological disorders, including xerosis, pruritus, photoaging, eczematous disorders, and tumors. The elderly (>60 years of age) population in India accounted for 8.6% (104 million) in 2011, and the figure has been projected to increase to 19% by the year 2050. It is imperative to identify the pattern of cutaneous disorders in this population as skin care regimens aimed to improve epidermal function have been shown to be effective in the prevention and treatment of some of these aging-associated cutaneous disorders. Objectives: The objective of the study was to identify the pattern of dermatoses among the elderly population attending the dermatology clinic at a tertiary care hospital in South-east Rajasthan. Materials and Methods: We conducted a cross-sectional descriptive study of patients above the age of 60 years who attended the dermatology clinic at a tertiary care hospital in South-east Rajasthan from May 2018 to May 2020. A combination of history, physical examination, and clinical investigations (when appropriate) were used to establish the diagnosis. Results: A total of 210 patients were included in this study. Most patients were between the age group of 60–65 years (40.47%). One hundred and thirty-eight were male (65.71%) and 72 were female (34.28%), with a male to female ratio of 1.9:1. Our study demonstrated that xerosis was one of the most common diagnoses seen in 126 cases (60%), followed by eczematous skin conditions seen in 82 cases (39%). Conclusion: The elderly constitute an important part of the population. Cutaneous disorders in the elderly range from mild disorders such as cherry angiomas to dermatological malignancies. Therefore, it is important to recognize the pattern of dermatosis in this population so that appropriate therapeutic and preventive strategies could be implemented.
Keywords: Aging-associated dermatoses, geriatric, skin aging, South-east Rajasthan, xerosis
|How to cite this article:|
Sharma A, Kushwaha RK, Kesarwani V, Jain SK, Yadav D, Sharma S. Pattern of dermatoses in the elderly population attending the dermatology clinic at a Tertiary Care Center in South-East Rajasthan. J Indian Acad Geriatr 2022;18:73-7
|How to cite this URL:|
Sharma A, Kushwaha RK, Kesarwani V, Jain SK, Yadav D, Sharma S. Pattern of dermatoses in the elderly population attending the dermatology clinic at a Tertiary Care Center in South-East Rajasthan. J Indian Acad Geriatr [serial online] 2022 [cited 2022 Aug 18];18:73-7. Available from: http://www.jiag.com/text.asp?2022/18/2/73/351073
| Introduction|| |
The elderly population comprises people more than or equal to 60 years of age. The proportion of the elderly population is increasing rapidly worldwide. According to the World Health Organization, the global population of people aged more than or equal to 60 years old is currently 1 billion and is expected double by the year 2050. The increasing proportion of the geriatric population is leading to an increase in the burden of aging-associated disorders. Skin is a complex organ that protects its host from the external environment and, at the same time, allows interaction with its environment. It is a dynamic, complex and integrated system of cells, tissues, and matrix elements that protect the body from various infectious agents, physical factors, ultraviolet (UV) radiations, act as a physical permeability barrier, and give outward physical appearance. With aging the skin, like any other organ of the body, undergoes a progressive decrease in maximal functioning. In case of skin, this functional decline with aging is compounded and accelerated by chronic environmental insults, such as UV and infrared (IR) irradiation as well as environmental carcinogens present in polluted air. With aging skin, there are intrinsic (chronological) changes such as increased oxidative damage, cell senescence, defective amino acid racemization, nonenzymatic glycosylation of proteins and extrinsic changes (primarily due to photodamage) such as elastosis which is characterized by tangled masses of degraded elastic fibers, UV-induced DNA damage, collagen degradation, and increased reactive oxygen species (ROS). This makes the aging skin very susceptible and thereby predisposes to a wide spectrum of skin disorders ranging from mild dermatosis such as pruritus, xerosis, and eczema to severe conditions such as blistering disorders and skin cancers.
With rapidly increasing elderly population in developing countries such as India. It has become important that we recognize the diversity of skin problems faced by the elderly population so that proper health care could be provided to these patients. There are very few studies conducted about skin problems of the elderly in India. We conducted a study to evaluate both physiological and pathological skin changes with aging among the elderly population of Rajasthan.
| Materials and Methods|| |
We conducted a cross-sectional descriptive study at a tertiary care hospital in South-eastern Rajasthan from May 2018 to May 2020. We included 210 patients aged 60 years and above attending the dermatology clinic at our hospital. Participation was voluntary. Informed consent was obtained from all study subjects. Patients with a known history of genodermatosis, albinism, photosensitivity, DNA repair diseases, premature aging syndrome, or known internal malignancy were excluded from the study. A detailed history, including the duration of the disease, site of involvement, occupation, and demographic details, was obtained. This was followed by a thorough dermatological and systemic examination after obtaining informed consent. Relevant routine investigations such as hematology, biochemistry, and dermatology specific investigations, including potassium hydroxide mount, Tzanck smear, skin biopsy, and immunofluorescence, were performed when indicated or if a clinical diagnosis could not be established. The study had been duly approved by the Hospital Ethics Committee.
Data were tabulated in an Excel sheet. A systematic analysis was performed. The quantitative variables were presented as the mean ± standard deviation, and qualitative variables were presented as frequency and percentages.
| Results|| |
This study was conducted over a period of 2 years. A total of 210 patients were included with a mean age of 66.4 ± 8.4 years. Overall, 72 (34.28%) were females, and 138 (68.4%) were males, with a male to female ratio of 2:1. In the present study, most of the patients belonged to the 60–70 years age group (142 cases), comprising 68.56%. Among systemic diseases, hypertension was the most common associated disease seen in 70 cases (33.33%), followed by diabetes mellitus in 55 cases (26.19%).
Among physiological skin changes, xerosis was the most common in 126 cases (60%), followed by wrinkling in 96 cases (45.71%), Idiopathic guttate hypomelanosis (IGH) in 62 cases (29.52%), senile comedones in 12 cases (5.71%), and senile lentigines in 14 cases (6.66%) [Table 1].
The pathological skin changes were eczematous disorder in 82 cases (39.04%), followed by infections in 81 cases (38.57%) and generalized pruritus, which was seen in 60 cases (28.57%) [Table 2].
In eczematous conditions, chronic eczema was seen in 22 cases (26.82%), followed by asteatotic eczema in 16 cases (19.51%), stasis eczema was seen in 12 cases (14.63%), airborne contact dermatitis in 9 cases (10.97%), infectious eczematous dermatitis and contact dermatitis in 7 cases each (8.53), hand eczema in 3 cases (7.31%), nummular eczema in 2 cases (2.43%), and seborrheic dermatitis in 1 case (1.21%).
Generalized pruritus was seen in 60 cases in our study, of which xerosis was most commonly associated with generalized pruritus in 32 cases (53.33%), diabetes mellitus in 21 cases (35%), anemia in 3 cases (5%), kidney disease in 3 cases (5%), hypothyroidism in 1 case (1.6%), and liver disease in1 case (1.6%) [Table 3].
A total of 81 cases were found to have infectious dermatosis, of which fungal infections were the most common finding seen in 56 cases (71.79%). Bacterial infections were seen in 5 cases (6.41%), viral infections in 9 cases (11.53%), and parasitic infections in 8 cases (10.25%).
Among the 56 cases of fungal infections, dermatophytosis was seen in 52 cases (92.85%) and candidiasis in 4 cases (7.14%).
Among the five bacterial infections, folliculitis was seen in 3 cases (60%) and furuncle in 2 cases (40%). Among the viral infections, herpes zoster in 8 cases (88.88%) and viral warts in 1 case (11.11%). All 8 (10.25%) cases of parasitic infections had scabies.
Papulosquamous disorders were observed in 21 cases. Among them, psoriasis was seen in 16 cases (76.19%) and lichen planus in 5 cases (23.80%). Bullous pemphigoid was seen most frequently among the bullous disorders in 7 cases and pemphigus vulgaris in 5 cases.
Among the psychocutaneous disorders, lichen simplex chronicus in 18 cases (64.28%), delusional parasitosis was seen in 6 cases (21.42%), and prurigo nodularis in 4 cases (14.28%).
Among the 210 benign skin lesions seen in our study, the most common was seborrheic keratoses with 67 cases (30.90%), followed by cherry angiomas in 62 cases (29.52%), dermatosis papulosa nigra in 40 cases (19.04%), acrochordons in 39 cases (18.57%), sebaceous hyperplasia in 2 cases (0.95%); combined features of above findings were seen in some cases.
Among the premalignant conditions, 1 case of Bowen's disease was seen. The most common malignant condition seen in our study was basal cell carcinoma seen in 3 cases.
Among the 26 miscellaneous skin conditions, we have seen macular and lichen amyloidosis in 6 cases (23.07%), leg ulcer in 5 cases (19.23%), chronic urticaria in 5 cases (19.23%), acrokertoelastoidosis marginalis in 3 cases (11.53%), vitiligo, granuloma annulare, lichen sclerosus et atrophicus in 2 cases each (7.69%), and pyogenic granuloma in 1 case (3.84%).
Of 210 nail changes, loss of luster was the most common nail change seen in 97 cases (46.19%), followed by longitudinal ridging in 55 cases (26.19%), nail plate thickening in 26 cases (12.38%), subungual hyperkeratosis in 14 cases (6.66%), onychomycosis in 10 cases (4.76%), Beau's lines and pitting in 4 cases each (1.90%). In some of these cases, combinations of findings were seen [Table 4].
In our study, graying of hair was seen in all cases 210 (100%). Among 72 females, diffuse hair loss was seen in 42 cases (58.33%), and of 138 males, androgenetic alopecia was seen in 78 cases (62.31%).
| Discussion|| |
This cross-sectional clinical hospital-based study aimed to evaluate the demographic features, patterns, and frequency of various dermatological disorders among elderly patients attending dermatology venereology, and leprology clinics in southeastern Rajasthan.
Most of our study subjects were males with a male to female ratio of 1.9:1. Our findings are consistent with a study by Patange and Fernandez. In contrast to this Durai et al. showed female predominance with female to male ratio being 1.34:1.
The immune system has two major roles: defense against external insults and internal immunologic surveillance. With aging there is a decrease in T-cell memory, loss of the naïve T-cell population, defective humoral and cellular immunity. ROS within cells increases with aging, which leads to oxidative stress and contributes to low-grade inflammation. Chronic inflammatory state decreased immunity to exogenous antigens and increased autoreactivity compromise the ability to sustain environmental insults. In addition, ROS imbalance contributes to immune senescence, beginning with a decline in the innate immune response and culminating with impaired adaptive immune responses. All of these lead to an increased incidence of infections, eczematous conditions, and malignancies in the elderly.
In our study, the most common pathological disorder was eczema in 39.04% cases, followed by infections in 38% cases, generalized pruritus in 28.5% cases, and papulosquamous in 10% of the cases. In a study by Durai et al. The most common dermatoses were generalized pruritus in 49.6% cases, followed by infections in 46.8% cases and eczemas in 24.2% in cases. Kumar et al. reported the most common dermatoses being infections in 30%, followed by dermatitis in 29.6% and papulosquamous disease in 18.4% cases.
Eczematous conditions constituted the most disease burden in our study. Of these, asteatotic eczema was most common (19.51%), followed by stasis eczema (14.63%). A study by Agarwal et al. on 500 elderly patients in North India reported eczemas as the most common dermatosis with allergic CD in 30%, irritant CD in 11%, and asteatotic eczema in 10%. In our study, asteatotic eczema was most common; we believe the hot and dry climatic condition of the region is responsible for this variation.
In our study, among the fungal infections, dermatophytosis was seen in (24.76%), and candidiasis was seen in (1.90%). A higher prevalence of dermatophyte infection could be because of hot climatic conditions and poor hygiene maintenance in old age. Other contributory factors are poor glycemic control, poor microcirculation, peripheral vascular disease, peripheral neuropathy, and decreased immune response.
There are very few studies showing an association of generalized pruritus with specific systemic disease in geriatric population. Generalized pruritus was seen in 60 cases (28.57%) in our study, of which 32 cases (53.33%) had xerosis, 21 cases (35%) had diabetes mellitus, 3 cases (5%) had iron-deficiency anemia, kidney disease in 3 cases (5%) and hypothyroidism in 1 case (1.6%), liver disease in 1 case (1.6%). A study conducted by Syed et al. among the geriatric population in Telangana district and by Nair et al. on systemic diseases and their cutaneous manifestations in the elderly reported an association of generalized pruritus with diabetes mellitus in 34% and 33%, respectively.,
In the present study, we found 10% of the study population have a papulosquamous disorder, the most common being psoriasis (7.6%) followed by lichen planus (2.38%). Kumar et al., Cvitanovi et al., Sahoo et al., and Chopra reported psoriasis in 9.2%, 6.20%, 9%, and 5.6%, which were very similar to our study.,,,
Among dermatological disorders, blistering disorders constitute a significant cause of morbidity and mortality in this elderly population. With advancing age, the incidence of bullous disorders such as bullous pemphigoid is expected to rise. In our study, blistering disorders were seen in 12 (5.71%) cases, the most common disorder was bullous pemphigoid (3.33%), followed by pemphigus vulgaris (2.38%). Incidence of blistering disorder by us was higher than Yalcin et al. and Chopra who reported incidence of 1.5% and 2.9%, respectively, in their groups. Our results were comparable to Kumar et al. (6.4%).
Among nail changes, loss of luster was the most common finding in our study seen in 97 cases (46.19%), followed by longitudinal ridging in 26.19%, nail plate thickening in12.38% cases, and onychomycosis in 4.76%. In a study by Durai et al. the most common nail finding observed was the loss of luster in 254 (50.8%) individuals. Patange and Fernandez observed a loss of luster in 20.5%. Durai et al. found loss of luster in 50.8%, vertical ridging in 24%, and onychomycosis in 22.5%.
Aging is an inevitable and continuous process. In skin, however, this process is very much influenced by various physical, chemical, and mechanical insults. Aging skin has not only medical and cosmetic implications but also social ramifications. Various physiological signs of aging were observed in our study.
Xerosis was most common (60% n = 126) followed by wrinkling (45.7%), idiopathic guttate hypomelanosis (29.7%), senile lentigines 6.66%, and senile comedones (5.7%). while Agarwal et al. and Kumar et al., reported xerosis in 34% cases and 45% cases, respectively. Higher incidence in our study may be attributed to the dry and hot climate of the region.
Xerosis with aging is because of increased compaction of stratum corneum, increased thickness of granular cell layer, reduced epidermal thickness, and reduced epidermal mucin content.
The second most common physiological change was wrinkling in our study, observed in 96 patients (45.71%) of 210. This incidence was lower than what found in other studies. Agarwal et al. and Kumar et al. reported 97.8% and 98.8%, respectively. Idiopathic guttate hypomelanosis in our study was present in 29.7%, and most lesions were observed in nonsun exposed areas such as the chest and shins of the lower limb. Incidence was higher than what was reported by Patange and Fernandez (n = 49, 24.5%). Higher frequency was reported by Kumar et al. (51.2%) and Agarwal et al. (51.8%).
The intrinsically aged skin has atrophic, fine wrinkles; in contrast, prematurely photodamaged skin typically shows a thickened epidermis, mottled discoloration, deep wrinkles, laxity, dullness, and roughness.
In benign tumors of the skin, seborrheic keratosis was seen in 67 (31.90%) cases. Cherry angioma in 62 (29.52%) cases, dermatosis papulosa nigra in 40 (19.04%), and acrochordons in 39 (18.57%). Patange and Fernandez found seborrheic keratoses in 37.5%, cherry angioma in 46.5%, and acrochordons in 24.5% of cases. Durai et al. noticed seborrheic keratosis in 253 cases (50.6%), cherry angioma in 36 (7.2%) cases acrochordons in 49%, and sebaceous hyperplasia in 1.6% of cases.
Among the malignant conditions, there were 3 cases (1.42%) of basal cell carcinoma. Our results were comparable to the study conducted by Durai et al. who reported malignant tumors in 1% cases (n = 5). No malignant skin conditions were noted in a study by Raveendra and Agarwal et al. The incidence was lower than what was found in other studies outside India, which may be explained on the basis of genetic variability and darker skin types of Indians.
| Conclusion|| |
With a rapidly increasing proportion of the geriatric population in India, it is important to recognize various dermatoses affecting the geriatric population. In our study, we evaluated various dermatoses prevalent in the elderly population of Southeastern Rajasthan. However, since it was a hospital-based study, it may not reflect the true prevalence of disease burden in the general population. However, this study gives a fair idea about the pattern of dermatological diseases in the elderly population and would further help in the availability of medicines and tailoring age-specific treatment guidelines for elderly people.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Yaar M, Gilchrest BA. Aging of skin. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick's Dermatology in General Medicine. 8th
ed. New York: McGraw-Hill; 2012. p. 1213-26.
Patange VS, Fernandez RJ. A study of geriatric dermatoses. Indian J Dermatol Venereol Leprol 1995;61:206-8.
] [Full text]
Durai PC, Thappa DM, Kumari R, Malathi M. Aging in elderly: Chronological versus photoaging. Indian J Dermatol 2012;57:343-52.
] [Full text]
Kumar D, Das A, Bandyopadhyay D, Chowdhury SN, Das NK, Sharma P, et al
. Dermatoses in the elderly: Clinico-demographic profile of patients attending a tertiary care centre. Indian J Dermatol 2021;66:74-80. [Full text]
Agarwal R, Sharma L, Chopra A, Mitra D, Saraswat N. A cross-sectional observational study of geriatric dermatoses in a tertiary care hospital of northern India. Indian Dermatol Online J 2019;10:524-9.
] [Full text]
Syed Y, Sukumar G, Potluri S. A clinical study of dermatological manifestations in geriatric patients in Shadan Institure of Medical Sciences and Teaching Hospital and Research centre, Hyderabad. Indian J Dermatol 2017;3:24-8.
Nair P, Bodiwala N, Arora T, Patel S, Vora R. A study of geriatric dermatosis at a rural hospital in Gujarat. J Indian Acad Geriatr 2013;9:15-9.
Cvitanovi H, Eva EK, Kuljanac I, Jancic E. Skin disease in a geriatric patients group in outpatient dermatologic clinic Karlovac, Croatia. Coll Antropol 2010;34 Suppl 2:247-51.
Sahoo A, Singh PC, Pattnaik P, Panigrahi R. Geriatric dermatoses in southern Orissa. Indian J Dermatol 2000;45:66-8. [Full text]
Chopra A. Skin diseases in the elderly. Indian J Dermatol Venereol Leprol 1999;65:245-6.
] [Full text]
Yalçin B, Tamer E, Toy GG, Oztaş P, Hayran M, Alli N. The prevalence of skin diseases in the elderly: Analysis of 4099 geriatric patients. Int J Dermatol 2006;45:672-6.
Raveendra L. A clinical study of geriatric dermatoses. Our Dermatol Online 2014;5:235-9.
Liao YH, Chen KH, Tseng MP, Sun CC. Pattern of skin diseases in a geriatric patient group in Taiwan: A 7-year survey from the outpatient clinic of a University Medical Center. Dermatology 2001;203:308-13.
[Table 1], [Table 2], [Table 3], [Table 4]