PracticalDermatology

The elderly are the fastest growing age group in the US. By 2050, it is estimated that 23 percent of Americans will be over age 65, and of these about 25 percent will be older than 85. Moreover, from the start of this calendar year, more than 10,000 Baby Boomers reach age 65 every day, a trend that will continue for the next 19 years. According to Robert A. Norman, DO, MPH, Associate Professor of Dermatology at Nova Southeastern Medical School, these facts show the need for an increased emphasis on geriatric medicine, particularly in dermatology.

Dermatologists will see more elderly patients presenting with age-related dermatological conditions. Along with the common problems prevalent in an aging population, aging patients will also have new dermatological problems related to wear and tear, the effects of sun exposure, and pharmacologically induced problems arising from treating other conditions. Ahead, Dr. Norman answers questions about the state of care in geriatric dermatology.

What are pressing issues in geriatric dermatology?

Consideration of surgical and cosmetic concerns of the elderly is essential, Dr. Norman asserts. “Just as children are not merely ‘young adults,' elderly patients are not just ‘old adults,'” he says. Importantly, older people undergo psychological, physiologic, and anatomic changes that affect all organ systems, including the skin. In addition, older patients suffer from a variety of pre-existing conditions. “These include diabetes, heart disease, hypertension, clotting disorders, renal insufficiency, and the general debility of old age,” he says. Overall, one-third of geriatric patients have three or more preexisting diseases or conditions.

It is important to keep attuned to the unique needs and circumstances of these patients. Trends among older patients indicate that integrative therapies are becoming more popular, says Dr. Norman. “Patients take herbal medicines such as echinacea, garlic, ginkgo biloba, ginseng, St John's Wort, valerian, ephedra, and kava,” says Dr. Norman. “Like other medications, these supplements can have a significant effect on elderly patients,” he explains. Although these herbal medications are considered natural products that may have some benefits, adverse effects such as increased bleeding tendencies and drug interactions are associated with their use, Dr. Norman observes. Particularly during these tough economic times, Dr. Norman suggests, socioeconomic pressures and lack of insurance coverage for many prescriptions and procedures may encourage patients to pursue non-traditional interventions.

How may a clinician's interaction and treatment approaches differ with older patients?

The care of geriatric patient is often medically complicated. “The dermatologist should communicate with other providers and use a multidisciplinary approach, especially important in the frail elderly,” Dr. Norman explains. “Providing the patient and family with clear, slow and sufficient volume oral instructions and simple, legible, and large print written instructions are keys to patient compliance.”

Treatment depends on the patient and the patient's family, according to Dr. Norman. “I have encountered elderly patients in the nursing home with melanoma or invasive SCC and the patient and family choose to do no further diagnostic investigations or treatments,” he says. “When elderly patients have a skin cancer such as a BCC or SCC, I often prefer either doing ED&C's or superficial radiation therapy instead of more invasive procedures, but I leave the choice to the patient and family,” he observes. The autonomy and informed choice by the patient is key, he adds.

Discussing prevention with older patients is important. “Spend time discussing the zoster vaccine, smoking cessation, family dynamics and hobbies, sun protection, skin cancer detection, and issues important to quality of life,” says Dr. Norman.

Dr. Norman notes that a wide array of procedures and treatments are available to geriatric patients. “These interventions can enhance the appearance of patients and facilitate the removal of skin cancers or other lesions,” he says. He also explains that pre-existing medical conditions of geriatric patients must be comprehensively considered when selecting and performing cutaneous procedures. “Take a careful history and look for skin signs of systemic diseases or neurodermatitis, any indications of abuse, or symptoms of failing memory,” says Dr. Norman. He continues, “Many older patients suffer from a variety of diseases and take multiple medications; those over 65 years of age account for 25 percent of prescription use.” In addition, herbal supplements are often taken to ameliorate the consequences of diseases, and polypharmacy and drug interactions must be addressed.

Regarding surgery, Dr. Norman observes that skin surgery generally can be performed safely on even very old patients, provided precautions are followed. However, he notes that the biopsychosocial well-being and compassion for patients must take center stage. “If elderly patients are treated holistically and comprehensively, their experience can be enhanced and their health and appearance improved,” he says.

How do you best determine a patient's willingness or tolerability for a given treatment?

According to Dr. Norman, each group of diseases, including psychogenic dermatides, infections of the skin, purpura, vascular compromise and chronic venous insufficiency, and skin cancers have their associated treatment, and each person has an unique willingness and tolerability to undergo what it takes to resolve the problem. “Give your patient all the alternatives and help the person to choose,” he suggests. A discussion of the possible pros and cons of a treatment, pain tolerance, economic ability, and motivation are all key elements of a given treatment.

Are there particular conditions that may not be recognized or may be mistaken for something else?

Pruritus is a common condition that can provide a clue to many underlying problems, says Dr. Norman. Scabies in the elderly nursing home or ALF patient can go undetected unless the provider is aware of its common manifestations. Underlying diseases or metabolic conditions that can cause pruritis include renal failure, HIV, diabetes mellitus, thyroid disease, parathyroid disease, hypervitaminosis A, iron-deficiency anemia, neuropathy, liver disease, malignancy, and the use of certain medications.

In general, Dr. Norman notes that many skin diseases have an increased incidence in the elderly. Often there is a delay in referral from the primary care or emergency room providers and the patients may suffer as a result. “Bullous pemphigoid, mycosis fungoides, and other disorders can often go undetected without proper clinical understanding,” he says. “I have seen scurvy and other unusual diseases in my elderly patients, and the provider should be alert for skin signs of these diseases.”

When treating fungal infections, what are some of the factors that affect treatment selection?

Topical prescription antifungal agents offer some relief and may prevent further spread of the disease, according to Dr. Norman. Be wary about oral antifungals, however. “I am cautious about recommending oral therapy unless the patient suffers from pain on ambulation as a direct result of the infection or is quite emotionally distressed by the nail fungus,” he says. “Given the dangers of polypharmacy in the elderly and the inherent risk of any oral antifungal, I choose to reserve this therapy for only these exceptionally distressing situations,” he says.

Dr. Norman also suggests that toenail maintenance is essential in elderly patients. “Keeping toenails clean and trimmed is very important, to discourage fungus and bacteria from making a home under the toenail,” he notes. Patients should be told to avoid irritation to the toenails or skin around the toenails to avoid infection. “For those who have a salon pedicure, it is important to choose a reputable facility that understands the importance of sterilizing all equipment,” Dr. Norman observes. Additionally, toenail polish use should be avoided as it can trap moisture under the polish and encourage the growth of fungus.

When it comes to integrative therapy, Dr. Norman often recommends tea tree oil or Vicks Vapor Rub to help alleviate the problem of nail fungus; they are easy to use and less costly than many other products. “The active ingredient in tea tree oil is terpinen-4-ol, which has been proven to combat bacteria and fungi,” says Dr. Norman. Vaporub contains menthol, eucalyptus and camphor, all of which inhibit the growth of fungus. “If the patient chooses to use tea tree oil or Vicks Vaporub, I instruct him or her to apply it directly to the toenail, the cuticle, the underside of the nail, toes and feet,” says Dr. Norman.

What recent or future developments are changing how clinicians manage common dermatologic conditions in elderly patients?

“We have had many important advances, including our understanding the stratum corneum and barrier function, the skin as an immune system, advances in cosmetic and surgical techniques, genetics, and integrative medicine,” notes Dr. Norman. For example, he observes, pruritus secondary to xerosis is extremely common, and nonpharmacologic measures may be tried for mild pruritis, such as avoiding hot water and irritants such as fragrant or deodorant soaps, maintaining proper humidity, using cool water compresses, and trimming the nails to avoid scratch irritation and infections. Cooling lotions, such as with camphor and menthol, may also be used, he notes. “And now with our understanding of natural moisturizing factors and barrier functions, we have many products that include ceramides and other ingredients that bolster the skin's protective functions,” he adds.

In psoriatic disease in the elderly, Dr. Norman notes that biologic agents are now used regularly, which in part reflects a greater understanding of the immune system. “The ‘heartbreak of psoriasis' refers to the disease's physically and emotionally disabling effect on the patient, and new evidence has pointed to an actual increase in cardiac morbidity and mortality—true heartbreak-in those that suffer from this disease,” says Dr. Norman. He also predicts more advances dealing with broader use of the biologics, vaccines, and immune boosters on the horizon.

Recent advances in cosmetic and surgical techniques such as fillers, botulinum toxins, and Mohs surgery have allowed many seniors to undergo enhancements in a safe and effective manner, observes Dr. Norman. “Improvements in the elimination of multiple superficial actinic keratoses include treatment with d-aminolevulenic acid (ALA) followed by pulsed light laser therapy, photodynamic therapy or PDT,” he explains.

Other areas of advancement include the completion of the Human Genome Project mapping of 30,000 genes, according to Dr. Norman. Thus, genomic maps will be available to guide efforts to determine the genetic basis of disease. “We will be able to determine response to treatment and chart our senior patient's prognosis with greater efficiency,” says Dr. Norman. “The 21st will be the ‘genetic century' as we discover how mutations bring on skin disease and the multiple mechanisms surrounding their expression.”

However, in a general sense, Dr. Norman predicts that integrative medicine will play a significant role in geriatric dermatology going forward. “The future of integrative therapies in dermatology, in particular preventive medicine, botanicals including antioxidants, hypnosis, and behavioral modification will allow new detection and treatment options to help alleviate the problems of elderly skin conditions,” says Dr. Norman. “Based on research in integrative medicine, new educational and patient teaching options will be utilized in dermatology,” he continues.

Do you have any special recommendations for handling skin evaluations in elderly patients? How might they differ from skin exams in other patients?

“Be patient and listen carefully. When you can, take the time to listen to your elderly patients' stories,” Dr. Norman says. “Many want to talk and give advice or offer a glimpse into their past, and you provide a service to both you and your patient just by listening. These moments of conversation and exchange are part of what makes medicine a wonderful art.”

Take-Home Tips

Older people undergo psychological, physiologic, and anatomic changes that affect all organ systems, including the skin. In addition, older patients suffer from a variety of pre-existing conditions. Trends among older patients indicate that integrative therapies are becoming more popular. Attention to polypharmacy and possible drug/ supplement interactions is essential. Providing the patient and family with clear, slow and sufficient volume oral instructions and simple, legible, and large print written instructions are keys to patient compliance.

Robert Norman, DO is President and CEO of Dermatology and Skin Cancer Centers of Florida and is also the founder of the International Society of Geriatric Dermatology. His two most recent books are Preventive Dermatology and Diagnosis of Aging Skin Diseases, both available through Springer Publishing or on Amazon.com.