The High Prevalence of Skin Diseases in Adults Aged 70 and Older

Suvi-Päivikki Sinikumpu, MD, PhD; Jari Jokelainen, MSc; Anna K. Haarala, MD; Maija-Helena Keränen, MD; Sirkka Keinänen-Kiukaanniemi, MD, PhD; Laura Huilaja, MD, PhD

Disclosures

J Am Geriatr Soc. 2020;68(11):2565-2571. 

In This Article

Discussion

To the best of our knowledge, ours is the largest study to date in the field of geriatric dermatology to be based on a whole-body skin examination. A previous German study of 223 persons aged 65 and older found that skin diseases were common, and almost every participant had at least one dermatological diagnosis, with xerosis the most common.[18] In our study, as many as 80% of participants had a skin disease requiring treatment, but rather than dry skin, the most common dermatological conditions were fungal skin infections, rosacea, actinic keratosis, and asteatotic eczema. This difference in findings could be explained by the fact that the German study assessed residents of nursing homes, whereas ours was a general population of older people. Furthermore, the mean age of our population (78.4 years) was lower than that of the population of the German study (83.6 years). One of the largest epidemiological studies in geriatric dermatology (n = 4,099) was conducted in Turkey in 2006.[6] The study data were register based and collected from dermatological clinics, which may have caused selection bias. Furthermore, rather than reporting the exact incidences of individual skin conditions, the study grouped the conditions and reported the incidence of each category, making it impossible to compare the results with those of other studies.

We report a high frequency of tinea pedis (49%) and onychomycosis (30%). Our data support earlier findings that fungal skin infections are particularly common in older populations.[6,8,18] The increased susceptibility of older individuals to infections, including dermatological infections, probably arises from functional changes driven by the aging process of the immune system, known as immunosenescence.[19] This is noteworthy from a clinical point of view because tinea pedis is a known risk factor for severe bacterial infections such as cellulitis.[20] Previous studies found that fungal skin infections were also common in the NFBC1966 study (composed of the individuals born in 1966).[21]

The most common eczema in the present study was asteatotic eczema, seen principally in the geriatric population. The development of asteatotic eczema is driven by the depletion of lipids and free fatty acids in the epidermis that is seen as part of the aging process.[22] It is characterized by dry fissured skin, most often on the limbs and worsened by excessive bathing with soaps. The prevalence of asteatotic eczema was reported to be approximately 15% in patients aged 60 and older.[23,24] The other common eczema noted in the present study was seborrheic dermatitis (10%), a particular source of morbidity in older individuals.[10] Seborrheic dermatitis affects the areas of the body that are rich in sebaceous glands, such as the face and trunk. Sebocyte activity diminishes with advanced age, and in light of this, that seborrheic dermatitis is common in older persons may be an unexpected finding.[25] Previous reports suggested that the incidence of atopic dermatitis is increasing in the geriatric population,[26] but we were unable to confirm this, with the condition diagnosed in only .36% of subjects. However, other eczemas (i.e., nummular eczema) that may partially overlap with atopic dermatitis were more common.

MASD conditions are common in older people, whose skin barrier function is weakened and easily irritated by several factors including chemical irritants, moisture in the environment, mechanical friction, and microorganisms such as Candida albicans. In geriatric care, incontinence-associated dermatitis is a particularly common finding in the geriatric care setting, affecting up to 50% of patients.[27,28] In our study population, MASD was diagnosed in 9%. The lower prevalence reflects the fact that most of the individuals in our were still in relatively good health, lived at home, and had no major mobility issues.

Rosacea affected 25% of the population, a far greater proportion than the 2% to 8% found in previous studies in older populations.[29,30] However, the high rate of rosacea in the present study reflects the 15% found by a previous study of NFBC1966.[21] These high rates in a predominantly ethnic Finnish population may be explained by the association of rosacea with fair skin types.[31] It is known that in men, rosacea is uncommon before age 50 and reaches its peak prevalence between age 75 and 80. This peak occurs at an earlier age in women.[30] Rosacea has several deleterious effects on the patient's life: it can cause embarrassment, decreased self-esteem, and isolation from society because of the visibility of facial symptoms.[32] Prevalence of ocular rosacea was surprisingly low (.72%) in our study. This may reflect the fact that most study participants had erythematotelangiectatic rosacea and thus milder disease. However, it is currently unclear how ocular rosacea is associated with other rosacea types.[33] In our opinion, the epidemiology of rosacea in older people and its effects on patients' everyday lives require further study.

The finding of previously undiagnosed actinic keratosis or skin cancer in 22.3% of our subjects was surprising, even in light of the rapid worldwide increase of the prevalence of nonmelanoma skin cancers.[34] The rate of benign skin tumors also increases with advanced age,[11,18,29,35] and therefore the recognition of premalignant and malignant skin findings may be challenging for individuals and for physicians. In our study, benign tumors were very common, seen in 70% to 80% of subjects. With the exception of melanocytic nevi, the rates of these tumors were higher in the present population than in the NFBC1966 study[21] One-half of the study cases in this cohort of parents had at least one melanocytic nevus, but only 7% had more than 50. This is consistent with the fact that at the individual level, the number of melanocytic nevi increases with age in childhood, but the rate at which new nevi appear begins to decrease after middle age.[36]

We found several differences in the prevalence of skin diseases between the sexes. A higher proportion of men had fungal skin infections and women had more benign tumors, which matches previous epidemiological studies.[21,24,37,38] In our population, men were also more likely than women to be affected by seborrheic dermatitis and nummular eczema, actinic keratosis, and folliculitis. The male predominance in some skin diseases may partly be explained by hormonal differences between men and women. For example, seborrheic dermatitis is associated with androgen levels. Its incidence in men peaks during puberty when androgen levels are high.[39] In addition, sex differences in the use of cosmetics can influence the appearance of skin diseases because cosmetics may alter cutaneous pH and further change microbial colonization and barrier integrity.[40]

The associations between SES and skin diseases are poorly studied. In general, people with a lower SES have an increased risk of general morbidity,[41] but when it comes to skin diseases, findings vary.[42–44] Skin infections, widespread nummular eczema ("eczema infectiosum"), and folliculitis were previously reported as more common among people with low SES.[21] According to our present findings, the influence of SES on the presence of skin diseases diminishes with advanced age. However, this finding may be partially explained by the Finnish national health insurance system that covers every Finnish citizen. We found only weak associations: psoriasis and urticaria affected more subjects with low SES than those with high SES, but the numbers of study cases in these disease groups was low, and the results cannot be generalized. To our knowledge, the association between SES and skin diseases in older persons was previously studied in only one multicenter clinical study that revealed no association.[18] However, this German study population consisted only of residents of long-term care facilities, in which setting the effect of SES might be considered meaningless.

The primary strength of the present study is its population. In comparison, previous studies focused on narrower, more selected populations, such as patients at dermatological clinics or tertiary care centers, approaches that may have been prone to selection bias.[6,8] The present study also benefited from the whole-body clinical skin examination performed by experienced dermatologists on all subjects. Interobserver reliability was tested between the two main researchers (S.P.S. and L.H.), and its degree was high.[45] Furthermore, we comprehensively analyzed the prevalence of all the most common skin diseases in population subgroups based on the need for further treatment. Although all population candidates were invited to participate in the study, not all did. This must be acknowledged as a potential source of sample selection bias and therefore as a weakness. Due to the study setting, only point prevalences were determined, which can be considered a limitation. The fact that all our study subjects were white may limit the generalizability of our results to those with skin of color.

In conclusion, this study provides new data about the epidemiology of skin diseases in older people. Our principal finding is that dermatological disorders are extremely common in older individuals and should be considered by physicians treating geriatric patients. A whole-body clinical skin examination should be encouraged because it may reveal hidden cutaneous symptoms and it ensures timely diagnoses and appropriate treatment.

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