How Do I Differentiate Normal Aging of the Skin From Pathologic Conditions?

Theodore D. Scott, RN, MSN, FNP-C, DCNP

Disclosures

June 10, 2008

Question
As a newly graduating adult nurse practitioner, I want to know which skin conditions to expect most commonly in the elderly patient population. How do I distinguish normal aging of the skin from pathologic conditions?

Response from Theodore D. Scott, RN, MSN, FNP-C, DCNP
Clinical Preceptor, University of San Diego, San Diego, California; Nurse Practitioner, Southern California Permanente Medical Group, San Marcos, California

This is an excellent question. Entire textbooks have been written about this subject. In my dermatology practice, almost 50% of my encounters are with geriatric patients. There are, indeed, a number of expected skin changes in elderly individuals that are consequences of aging and years of sun damage. I will briefly cover a select few of the skin conditions most likely to be encountered in geriatric patients.

Xerosis

Sebum production declines over time because of many factors, both genetic and environmental. Many seniors will experience the dryness known as xerosis first on the lower legs and arms, becoming more generalized over time (Figure 1). Some patients may even have problems with sebum overproduction on the scalp and face, but their skin is dry everywhere else. Dryness can lead to problems like "winter itch" as low sebum production and dry warm air in the home combine to produce considerable pruritus. Patients may scratch dry skin to the point of skin breakdown, with the risk for secondary infection. Dry skin and poor peripheral circulation can also lead to conditions such as stasis dermatitis.

Figure 1.

Xerosis of the lower leg and stasis dermatitis. Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Rhytides

These wrinkles, first noticeable on sun-exposed skin of the posterior neck and forehead and progressing to the face and arms, are known as rhytides. Rhytides are caused by sun damage that both decreases the production of collagen in the skin and thins the skin (Figure 2).

Rhytides on the neck. Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Rhytides on the neck. Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Solar Lentigos

Solar lentigos are tan to brown irregular macules on the sun-exposed parts of the face, arms, upper chest, and upper back, commonly called "liver spots" or "age spots" (Figure 3). In reality, these spots represent areas of melanin overproduction in the skin from chronic sun exposure. Your patients may protest that they do not go out in the sun anymore, but solar lentigos do not indicate recent sun exposure; rather, they are the result of a lifetime of chronic sun exposure. Patients often don't realize that they don't need to be lying on the beach holding a frosty beverage to get sun exposure. Driving the car, walking to the mail box, or working in the garden all provides opportunities for sun exposure.

Solar lentigos often referred to as "liver spots" or "age spots" (3 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Solar lentigos often referred to as "liver spots" or "age spots" (3 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Solar lentigos often referred to as "liver spots" or "age spots" (3 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Senile Purpura

Hemorrhages below the epidermis in the papillary dermis, visible as red to purple macules, are senile purpura (Figure 4). These usually occur in the most sun-damaged areas of the forearms, where the skin has thinned and the blood vessels are more brittle than they are in younger skin. Very little shearing force is required to produce a hemorrhage. If the patient is taking an anticoagulant medication (aspirin, warfarin, or clopidogrel), the hemorrhage will be more extensive. Upon resolution, senile purpuras leave a permanent bronze discoloration of the skin, caused by a hemosiderin (iron oxide), a pigment that cannot be reabsorbed into the circulation.

Multiple senile purpuras. Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Seborrheic Keratoses

Seborrheic keratoses are tan, brown-black, or gray, waxy to verrucoid papules and plaques (Figure 5). These lesions usually have the appearance of wax that has dripped on the skin and dried. The diagnostic features of seborrheic keratoses are their stuck-on appearance and the presence of dark cysts within the lesions called "pseudo horn cysts." Although the patient can have literally hundreds of these lesions, seborrheic keratoses are benign and can be removed by cryotherapy, curettage, or shave excision. Of note, however, is the sign of Leser-Trélat, manifested by the sudden eruption of multiple seborrheic keratoses that rapidly increase in size and number. The sign of Leser-Trélat can indicate an internal malignancy.

Seborrheic keratosis (4 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Seborrheic keratosis (4 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Seborrheic keratosis (4 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

Seborrheic keratosis (4 examples). Photograph courtesy of Theodore D. Scott, RN, MSN, FNP-C, DCNP. Used with permission.

In a future Ask the Expert response, I will review some of the most common malignant conditions you may encounter in your elderly patients.

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