Atopic Dermatitis in the Elderly

A Review of Clinical and Pathophysiological Hallmarks

S. Williamson; J. Merritt; A. De Benedetto

Disclosures

The British Journal of Dermatology. 2020;182(1):47-54. 

In This Article

Abstract and Introduction

Abstract

Background: Atopic dermatitis (AD) is a multifactorial and complex disease, characterized by an impaired skin barrier function and abnormal immune response. Many elderly patients present with pruritus and xerosis to dermatology, allergy and primary care clinics, and there is a lack of information available to clinicians regarding the proper diagnosis and management of these patients. Although the elderly are described as having a distinct presentation of AD and important comorbidities, most investigations and clinical care guidelines pertaining to AD do not include patients aged 60 years and older as a separate group from younger adults.

Objectives: To summarize current information on pathophysiology, diagnosis and management of AD in the elderly population and identify areas of insufficient information to be explored in future investigations.

Methods: We carried out a systematic review of published literature, which assessed changes in the skin barrier and immune function with ageing and current information available for physicians to use in the diagnosis and treatment of AD in elderly patients.

Results: Many age-related changes overlap with key hallmarks observed in AD, most notably a decline in skin barrier function, dysregulation of the innate immune system, and skewing of adaptive immunity to a type-2 T helper cell response, in addition to increased Staphylococcus aureus infection.

Conclusions: While general physiological alterations with ageing overlap with key features of AD, a research gap exists regarding specific ageing-related changes in AD disease development. More knowledge about AD in the elderly is needed to establish firm diagnostic and treatment methodologies.

Introduction

Atopic dermatitis (AD) is the most common chronic inflammatory skin condition and leading cause of disease burden among nonlethal skin conditions.[1,2] AD is characterized by eczematous rash, diffuse xerosis, intense pruritus and recurrent Staphylococcus aureus infection.[3] Patients with AD often have atopy, including asthma, allergic rhinitis, and environmental and food allergies.[4] The clinical manifestations of AD tend to vary with age.[5] Three groups of patients with AD have been well established based on appearance and localization of eczematous lesions at different ages, i.e. infantile type, childhood type, and adolescent and adult type.[6] In infants (infantile type), AD typically presents as acute eczematous crusting plaques on the face, and scales on the scalp.[5] Childhood-type AD is characterized by acute and chronic lesions often involving the flexural aspects of limbs and around the mouth, nose and eyes,[5] while adult-type AD tends to present with diffuse lichenified plaques at the flexural surfaces, head and neck.[5] Elderly-type AD has recently been considered a fourth separate group, presenting more commonly with the reverse sign of lichenified eczema at the antecubital and popliteal fossae than with lesions localized to the creases of the folds, as is typical of adult-type AD.[5,7] Patients with elderly-type AD can be further subdivided by disease onset, i.e. infancy or childhood onset with recurrence or continuation of AD at age ≥ 60 years; initial onset in adolescence or adulthood with recurrence or continuation of AD at age ≥ 60 years; and primary onset of AD at age ≥ 60 years.[8]

This review presents the current information available regarding ageing-related AD pathophysiology, which is an evolving field of knowledge, as few articles have characterized AD in the elderly population.[7,9–12]

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