European Journal of Cardiovascular Medicine

A series of molecular changes over time cause a biological phenomenon called ageing, which is characterized by increasing functional deterioration. Due to the structural and physiological changes brought on by intrinsic and extrinsic ageing, human skin, like all other organs, ages chronologically and is prone to skin conditions. ¹ As people age, their skin loses its ability to perform its usual functions, most notably its ability to heal wounds and respond to infections. The dermo-epidermal junction flattens with age, the number of interdigitating declines, and the number of melanocytes drops by 20%, giving the skin and hair a pale appearance. ² The dermis loses volume and an excess of the brown pigment lipofuscin, a sign of cell injury, accumulates.³

Diseases are becoming more prevalent among the elderly population as a result of an increase in life expectancy.The normal result of skin ageing is the development of minor dermatoses including pruritus, eczema, xerosis, etc. ⁴ However, many dermatological disorders, such as skin cancer, can be deadly and cause serious morbidity and a reduction in quality of life. ⁵

India, a developing country, joined the group of ageing nations in 2001 when the percentage of people 60 and older exceeded 7%. In addition, by 2026, the population of elderly people is predicted to increase. There have been suggestions that this is due to both a rise in life expectancy and a decrease in birth rates. A growing portion of the Indian population is elderly, which has raised concerns across the globe. As a result, these patients must receive quality medical treatment and services. In India, there isn'tmuch research on the skin issues that older people face.

The clinical manifestations of skin disorders may differ and may not present as classically as in the younger population ⁶. This has led to greater interest in the diseases of the aged, and there is a need to evaluate various cutaneous disorders in the growing geriatric population.

This study was conducted to assess the range of physiological and pathological skin changes in the elderly patients of a tertiary care hospital in southern India. To assess health status and healthcare needs related to the skin for better resource allocation, distribution of material and manpower, and help healthcare providers in better decision-making resulting in higher patient satisfaction, it is essential to have a thorough understanding of the epidemiology as well as gender distribution of dermatological diseases in the geriatric population in this tertiary care hospital.

OBJECTIVES:

1. To describe the clinical pattern and frequency of skin changes in the elderly.

ii.To describe the epidemiological profile of cutaneous diseases in the elderly.

1. To describe the clinical pattern and frequency of pathological skin diseases in the elderly.

Study Design: Prospective hospital-based observational study.

Study area:The study was conducted in the Department of Dermatology, Subbaiah Institute of Medical Sciences, Shimoga, Karnataka.

Study Period: April 2022 – March 2023.

Study population: Patients above 60 years of age with dermatological complaints attending the outpatient department of

DVL,Subbaiah Institute of Medical Sciences, Shimoga, Karnataka.

Sample size:The study consisted of a total of 200 subjects.

Sampling method: Simple Random sampling method.

Inclusion criteria: Patients above 60 years of age attending the outpatient department of DVL.

Exclusion criteria:

1. Patients under chemoradiation therapy.
2. Patients who are not willing to participate in the study.
3. Patients with psychiatric diseases.

Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.

Study tools and Data collection procedure: A detailed history, clinical examination and relevant investigations will be

undertaken to arrive at a diagnosis.

Statistical analysis:

Data entry was done in Microsoft Excel software. Data analysis was done in Statistical Product and Service Solutions (SPSS). Continued variables were analysed by mean, standard deviation, median, mode, minimum and maximum. Qualitative variables were described by percentage distribution among groups.

A total of 200 cases with ages above 60 years attending Dermatology, Venereology and Leprology OPD of Subbaiah Medical College were included in the study.

Table No:1AGE DISTRIBUTION

The maximum number of patients in this study is 61- 65 years (35%), followed by 66- 70 years (34.5%). The least number of patients belongs to the age group of >80 (3.5%). In this study, the youngest patient is 61 years, and the oldest patient is 94 years. The mean age in this study is 68.52 years.

Table No: 2SEX DISTRIBUTION

In this study, among 200 patients, there were 103 males (51.5%) and 97 females (48.5%). Male: Female ratio is 1.06:1.

This study's maximum number of patients belonged to the agricultural occupation (38%), followed by housewives (24%). The least number of patients is in a group of businesses (9%).

In this study, among 200 patients 76 were farmers (38%) of which 52 were males, and 24 were females, 48 (24%) were housewives, 33 were retired (16.5%) of which 27 were males, and 6 were females, 25 were labourers (12.5%) of which 14 were males, and 11 were females, 18 were businessmen (9%) of which 10 were males, and 8 were females.

Table No: 3ASSOCIATED DISEASES

In this study of 200 patients, 125 patients have associated systemic diseases. Of these, the most common association is diabetes mellitus (25%) found in 50 cases, followed by hypertension (24%) found in 48 patients. Chronic kidney disease (4.5%) in 9 cases, ischemic heart disease (3%) in 6 cases, hypothyroidism (2%) in 4 cases, chronic obstructive lung disease (1%) in 2 cases, cerebrovascular accident (0.5%) in 1 case, epilepsy (0.5%) in 1 case, post cricoid carcinoma (0.5%) in 1 case and rheumatic heart disease (0.5%) in 1 case.

In this study, generalized pruritus is seen in 39 (19.5%) patients, of which xerosis is associated in 34 (17%) cases, diabetes mellitus in 6 (3%) cases, CKD in 2 (1%) cases, and hypothyroidism in 1 (0.5%) cases. Generalized pruritus is most commonly associated with xerosis in this study.

Table No: 4 SKIN CHANGES WITH AGING

In this study, among skin changes with ageingxerosis is predominant, which is seen in 105 (52.5%) cases, followed by wrinkles in 70 (35%) cases, idiopathic guttatehypomelanosis in 24 (12%) cases, senile comedones in 12 (6%) cases and senile lentigines in 7 (3.5%) cases.

Table No: 5PATHOLOGICAL SKIN CHANGES

Among various pathological skin changes benign cutaneous proliferations are the most common findings, seen in 172 cases (86%), followed by infections in 55 cases (27.5%), eczematous conditions in 25 cases (12.5%), papulosquamous disorders in 25 cases (12.5%), bullous disorders in 10 cases (5%), pigmentary disorders in 7 cases (3.5%), vascular disorders in 6 cases (3%), connective tissue diseases in 4cases (2%), keratinization disorders in 3 cases (1.5%), drug reactions in 2 cases(1%), malignant tumors in 1 case (0.5%), cutaneous cysts in 1 case (0.5%), paraneoplastic manifestation in 1 case (0.5%) and miscellaneous conditions seen in 54 cases (27%).

Table No: 6INFECTIVE CONDITIONS

In this study, among 200 patients, infections are seen in 55 patients. Of these, maximum infections are fungal, seen in 31 cases (15.5%). Among fungal infections, dermatophytosis is seen in 21 cases (10.5%), candidiasis in 8 cases (4%), and pityriasiscapitis in 2 cases (1%). Bacterial infections are seen in 20 cases (10%), of which maximum is furuncles with 6 cases (3%), leprosy is seen in 2 cases (1%), cellulitis in 3 cases (1.5%), furunculosis in 3 cases (1.5%), paronychia in 4 cases (2%), erysipelas in 1 case (0.5%) and erythrasma in 1 case (0.5%). Viral infections are seen in 5 cases (2.5%), of which herpes zoster is seen in 2 cases (1%), warts in 2 cases (1%), and pityriasisrosea in 1 case (0.5%). Among arthropod infections, scabies is seen in 2 cases (1%).

In this study, among 200 patients, benign tumours are seen in 172 cases (86%). Of these, acrochordons are the most common and are seen in 63 cases (31.5%), followed by seborrhoeic keratosis in 54 cases (27%), dermatosis papulosanigra in 34 cases (17%), cherry angiomas in 20 cases (10%), lipomas in 1 case (0.5%).

In this study of 200 patients, papulosquamous disorders are seen in 25 cases (12.5%). Among these psoriasis is seen in 20 cases (10%) and lichen planus in 5 cases (2.5%). Among psoriasis, psoriasis vulgaris is seen in 17 cases (8.5%), palmoplantar psoriasis in 1 case (0.5%), and plantar psoriasis in 2 cases (1%). Among lichen planus, classical lichen planus is seen in 2 cases (1%), hypertrophic lichen planus in 3 cases (1.5%).

Pigmentary disorders are seen in 7 cases (3.5%), of which vitiligo vulgaris is seen in 5 cases (2.5%), melasma in 1 case (0.5%), and post-inflammatory hyperpigmentation in 1 case (0.5%).

Table No: 7 KERATINIZATION DISORDERS

Keratinization disorders are seen in 3 cases, of which Darier’s disease is most common and seen in 2 cases (1%). Among Darter’s disease, unilateral Darier’s disease is seen in 1 case (0.5%), linear Darier’s disease in 1 case (0.5%) and ichthyosis vulgaris is seen in 1 case (0.5%).

Table No: 8MISCELLANEOUS DISORDERS

In this study of 200 patients, miscellaneous disorders are seen in 54 cases (27%). Among these, the most common finding is chronic non-healing ulcers seen in 8 cases (4%) followed by urticaria, which is seen in 7 cases (3.5%). Miliariarubra in 6 cases (3%), lichen simplex chronicus in 6 cases (3%), postherpetic neuralgia in 4 cases (2%), chronic actinic dermatitis in 3 cases (1.5%), erythroderma in 3 cases (1.5%), keloid in 3 cases (1.5%), lichen amyloidosis in 2 cases (1%), prurigonodularis in 2 cases (1%), sweat dermatitis in 2 cases (1%), chronic gout in 1 case (0.5%), callosity in 1 case (0.5%), cutaneous horn in 1 case (0.5%), acquired ichthyosis in 1 case (0.5%), angiolymphoid hyperplasia with eosinophilia in 1 case (0.5%), photodermatitis in 1 case (0.5%), irritated seborrhoeic keratosis in 1 case (0.5%) and perforating disorder in 1 case (0.5%).

In this study of 200 patients, nail changes are seen in 147 cases (73.5%). Of these, thickening is seen in 25 cases (12.5%), onychomycosis in 23 cases (11.5%), verticalridging in 18 cases (9%), subungual hyperkeratosis in 17 cases (8.5%), nail platedystrophy in 15 cases (7.5%), pitting in 11 cases (5.5%), shiny in 11 cases (5.5%), beau’s lines in 6 cases (3%), longitudinal melanonychia in 6 cases (3%), thinning of the nail plate in 4 cases (2%), paronychia in 4 cases (2%), pterygium in 2 cases (1%),koilonychia in 2 cases (1%), clubbing in 1 case (0.5%), leukonychia in 1 case (0.5%),splinter haemorrhage in 1 case (0.5%).

Ageing is the progressive, time-dependent deterioration of an organism's structural or functional integrity and may reflect in the ability of the organism to interact with and respond to its environment. Both intrinsic (genetic, chronological ageing) and extrinsic ageing (environmental, photoaging) contribute to cutaneous ageing. Ageing skin has a susceptibility to dermatological disorders due to the structural and physiological changes that occur as a consequence of intrinsic and extrinsic ageing.

In our study, a total of 200 patients varying in age from 61 - 94 years were examined. The youngest patient was 61 years old, and the oldest patient was 94 years old. The mean age is 68. 5 years.Out of 200 patients, 70 (35%) patients belonged to the age group of 61 – 65 years closely followed by 69 (34.5%) patients in the age group of 66- 70. The least number of patients, 7 (3.5%) are seen in the age group of >80 years. 103 patients (51.5%) were males, and 97 patients (48.5%) were females with a male-to-female ratio of 1.06:1.

In a study by Agarwal et al., 68.4% were in the age group of 60 – 69 years and 58.4% (292 patients) were males, and 41.6% (208 patients) were females⁷. In a study by Durai PC, Thappa DM et al., out of 500 patients 213 (42.6%) were males, and 287 (57.4%) were females. The mean age in their study was 67.98 in males and 58.93 in females.⁸

In another study by Patange SV et al., out of 200 patients, 126 (63%) were males, and 74 (37%) were females. 132 patients (66%) patients belonged to the 55-64 years age group, 51 patients (25.5%) belonged to the 65-75 age group, and only 17 patients (8.5%) were above 75 years of age. The oldest patient was 85 years old.⁹In another study by Cvitanovic H et al., of total 822 patients, 356 (43.3%) were males, and 466 (56.7%) were females with a male: female ratio of 0.76:1.¹⁰ In another study by Ankur Ghosh, out of 500 patients, 346 (69.2%) were males, and 154 (30.8%) were females with a male: female ratio of 2.2:1.¹¹

Out of 200 patients, 125 (62.5%) patients had associated diseases. Of these, the most common association was diabetes mellitus seen in 50 (25%) patients, closely followed by hypertension was seen in 48 (24%) patients. Chronic kidney disease was seen in 9 (4.5%) cases, ischemic heart disease in 6 (3%) cases, hypothyroidism in 4 (2%) cases, COPD and bronchial asthma in 2 (1%) cases each and CVA, epilepsy, post cricoid carcinoma, RHD in 1 (0.5%) case each.

In a study by Kshetrimayum S et al., out of 250 patients, the most common associated conditions were hypertension in 41 (16.4%) cases and diabetes mellitus in 17 (6.8%) cases.¹²In a study by Raveendra L, out of 200 patients, 108 (54%) patients had associated illnesses.⁵In another study by Pavithra S et al., the most commonly associated diseases were diabetes mellitus seen in 16.8% of cases and hypertension in 9.2% of cases. Both diabetes and hypertension were seen in 3.6% of patients.¹³

Among skin changes with ageing, 105 (52.5%) patients have xerosis, wrinkles in 70 (35%) patients, idiopathic guttatehypomelanosis in 24 (12%) cases, senile lentigines in 7 (3.5%) cases, and senile comedones in 12 (6%) cases.

Xerosis means dry skin. When associated with eczematous changes, it is called asteatotic eczema. In our study, it is seen in 52.5% of cases. In a study by RaveendraL., xerosis was seen in 70% of cases.⁵ In Pavithra S et al. study, xerosis was seen in 6.6% of cases.68 Agarwal R et al., noted xerosis in 34% of cases.⁷IAnkur Ghosh, noted xerosis in 7.6% of cases.¹¹In this study, wrinkling was seen in 70 (35%) cases. In a study by RaveendraL., wrinkling was seen in 88% of cases.5 In the Durai PC et al. study, it is seen in 99% of cases.⁸In our study, IGH is seen in 24 (12%) cases. This finding is lower in comparison with other studies. Ankur Ghosh found it in 23 (4.6%) cases,¹¹Durai PC et al. found it in 130 (26%) cases,⁸ Agarwal R et al. found it in 259 (51.8%) cases,⁷Raveendra et al. found it in 66(33%) cases,5 Patange SV et al. noted it in 25% cases.⁹

In a Turkish study by Kilic A et al, fungal infections were the most common dermatoses in 49.7% of cases.¹⁴ In a study conducted in Singapore by Yap BK et al, asteatotic eczema was the most common dermatosis followed by scabies, bacterial infections and other eczematous disorders. Fungal and viral infections were less common.¹⁵ In a Taiwan study conducted by Liao YH et al, eczematous dermatitis was most common followed by fungal infections, benign tumours and viral infections.¹⁶ In a Tunisian study conducted by Souissi A et al, fungal infections were most common, followed by benign tumours, eczematous dermatitis, keratinization disorders, bacterial infections and viral infections.¹⁷ In another study conducted by Scherer WP et al, fungal infections were found to be more common.¹⁸

In another study by Raveendra L, benign tumours were the most common dermatoses followed by infections and infestations in 64 (32%) cases, eczematous disorders in 62 (31%) cases, pigmentary disorders in 28 (14%) cases, papulosquamous disorders in 24 (12%) cases, bullous disorders in 3 cases (1.5%) similar to our study.⁵

In a study conducted by Pavithra S et al, benign neoplasms were the most common dermatoses and were found in 80.5% of cases, followed by fungal infections in 20.7% of cases, eczemas in 19.2% cases, papulosquamous disorders in 12.3% cases, leg ulcers in 6.6% cases, pigmentary disorders in 5.8% cases, infestations in 4.9% cases, bullous disorders in 4.4% cases, bacterial infections in 3.9% cases, viral infections in 3.4% cases, pressure sores in 2.9% cases, drug rash in 1.2% cases and Hansen’s disease in 0.7% cases.¹³

In a study by Thapa DP et al, eczemas were the most common dermatoses encountered in 35.8% of cases, of which seborrhoeic dermatitis was the most common followed by asteatotic eczema in 31.3% of cases. The second most common dermatoses were infections, of which fungal infections were most common in 13.6% of cases, viral infections in 7% of cases and bacterial infections in 2.1% of cases, scabies in 4.5% cases, papulosquamous disorders in 3.3% cases, bullous disorders in 1.8% cases, Hansen’s disease in 7.6% cases, drug rash in 1.9% cases, pigmentary disorders in 0.6% cases.¹⁹ In a Croatian study conducted by Cvitanovic H et al, eczematous dermatoseswere found in lower frequency.¹⁰

In Ankur Ghosh's study, infections were the most common dermatoses observed, fungal infections being most common among them in 149cases (29.8%), scabies in 51 (10.2%) cases, bacterial infections in 17 (3.4%) cases, viral infections in 29 (5.8%) cases. Eczemas in 31(6.2%) cases, of these allergic contact dermatitis was the most common. ACD is seen in 15 (3%) cases. Vitiligo is seen in 19 (3.8%) cases. Papulosquamous disorders in 25 (5%) cases. Adverse drug reactions in 11 (2.2%) cases. Benign tumours in 48 (9.6%) cases. Ulcers in 19 (3.8%) cases, urticaria in 15 (3%) cases, and post-herpetic neuralgia in 11 (2.2%) cases.¹¹

Nail changes are seen in 147 cases out of 200. The most common nail change observed is a thickening of the nail plate with loss of lustre in 25 (12.5%) cases. The second most common finding is onychomycosis seen in 23 (11.5%) cases.

In a study by Pavithra S et al, among nail changes, beau’s lines were seen in 1.9% of cases and lusterlessnails were seen in 1.9% of cases.¹³ PatangeSv et al found subungual hyperkeratosis in 7% of cases, and nail plate discolouration in 16% of cases.⁹

Durai PC et al found onychomycosis in 106 cases (21.2%), flattening in 6 (1.2%) cases, and blackish discolouration in 5 (1%) cases. Thickening, shininess and splitting in 3 (0.6%) cases each. Longitudinal melanonychia, median canalicular dystrophy and pitting in 2 (0.4%) cases each. Beau’s lines, leukonychia, paronychia, pallor, onycholysis and splinter haemorrhages were seen in 1 case (0.2%) each.¹

The skin plays an important role in permeability, transport of metabolites, barrier to penetration of microorganisms and chemicals, UV radiation, regulation of body temperature, and social and sexual communication. Due to degenerative and metabolic changes occurring in skin layers owing to ageing, elderly people are more prone to various dermatological disorders. Ageing occurs due to both intrinsic and extrinsic factors. The most common extrinsic factor is the ultraviolet radiation. The UV light also accelerates the intrinsic ageing in the sun-exposed areas of the body.

1. Durai PC, Thappa DM, Kumari R, Malathi M. Aging in elderly: Chronological versus photoaging. Indian J Dermatol. 2012; 57:343–52.