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ORIGINAL ARTICLE
Year : 2021  |  Volume : 66  |  Issue : 1  |  Page : 74-80
Dermatoses in the elderly: Clinico-demographic profile of patients attending a tertiary care centre


1 Consultant Dermatologist, Dermawave, Patna, Bihar, India
2 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
3 Department of Dermatology, Medical College and Hospital, Kolkata, West Bengal, India
4 Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
5 Department of Dermatology, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal, India
6 Department of Dermatology, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication1-Feb-2021

Correspondence Address:
Anupam Das
Building “Prerana” 19 Phoolbagan, Kolkata, West Bengal - 700 086
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_245_20

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   Abstract 


Background: Elderly population is vulnerable to develop a multitude of dermatological diseases, owing to comorbidities and polypharmacies. Objective: To know the prevalence of dermatological conditions in elderly patients attending outpatient department, determine the pattern and relative frequency of skin diseases, and find the relation with associated comorbidities. Materials and Methods: We performed a cross-sectional study on 250 patients, aged ≥60 years. Clinical diagnosis was done, followed by appropriate investigations when required. Descriptive data was analyzed on the parameters of range, mean ± S.D., frequencies, etc., Continuous variables were analyzed using unpaired t-test/Mann–Whitney U test and categorical data by Fisher's exact test/Chi-square test. Statistical software Medcalc version 10.2.0.0 for Windows vista was used. P value =0.05 was considered statistically significant. Results: 250 patients were evaluated, 164 males (65.5%) and 86 females (34.4%). Mean age was 67.87 ± 7.29 years. Commonest disease category was infection (30%), followed by dermatitis (29.6%), papulo-squamous (18.4%), and immunobullous (6.4%). Difference in acute and chronic disease was significant (P = 0.0001). 30% had infections; fungal (50.66%), bacterial (32%), and viral (17.33%). 74 patients had dermatitis (29.6% of study population). Commonest systemic disease was hypertension (23.2%), followed by diabetes mellitus (19.6%). Association of diabetes mellitus was significant (P = 0.0014), more in infective dermatoses (P = 0.0007). All had signs of aging; idiopathic guttate hypomelanosis (51.2%), xerosis (45.2%), seborrheic keratosis (42.6%), cherry angioma (33.2%), senile acne (6.6%). Photoaging was noted as wrinkling (98.8%), freckles (35.6%), purpura (10.8%), telangiectasia (5.6%). People involved in outdoor activity had higher Glogau scale (3.01 ± 0.69) compared to those indoors (2.44 ± 0.74), statistically significant difference (P = 0.001). Conclusion: Our study is the first of its kind, in Eastern India, where we evaluated and explored the disease pattern and extent of geriatric dermatoses among patients attending dermatology OPD of a tertiary care hospital.


Keywords: Dermatitis, dermatosis, elderly, idiopathic guttate hypomelanosis, infection, photoageing


How to cite this article:
Kumar D, Das A, Bandyopadhyay D, Chowdhury SN, Das NK, Sharma P, Kumar A. Dermatoses in the elderly: Clinico-demographic profile of patients attending a tertiary care centre. Indian J Dermatol 2021;66:74-80

How to cite this URL:
Kumar D, Das A, Bandyopadhyay D, Chowdhury SN, Das NK, Sharma P, Kumar A. Dermatoses in the elderly: Clinico-demographic profile of patients attending a tertiary care centre. Indian J Dermatol [serial online] 2021 [cited 2021 Feb 28];66:74-80. Available from: https://www.e-ijd.org/text.asp?2021/66/1/74/308492





   Introduction Top


During the last few decades and so, quality of life improved in different parts of world as well as our country, as a result more old people are alive nowadays.[1] By 2025, the world will host around 1.2 billion people aged 60 years and above and rising to 1.9 billion in 2050.[2] The health problems are usually multiple and are often masked by sensory and cognitive impairments, so these factors contribute to a worsening of morbidity and mortality.[3],[4]

Cutaneous aging includes two distinct phenomena: True aging (intrinsic aging) is a universal, presumably inevitable change attributable to the passage of time alone. Photoaging is the superimposition of effects of chronic sun exposure, on intrinsic aging, neither universal nor inevitable. The former is manifested primarily by physiologic alteration with subtle but undoubtedly important consequences on both healthy and diseased skin, the later has major morphologic as well as physiologic manifestations and corresponds more closely to the popular notion of “old skin.”[5],[6],[7]

With this background, we attempted to determine the frequency as well as the age and gender distributions of dermatological diseases in geriatric population. We also tried to differentiate chronological aging and photoaging by using Glogau scale and association of different dermatoses with systemic diseases in geriatric patients who attended dermatologic center of a tertiary care hospital in the eastern India.


   Materials and Methods Top


The study was an institution-based cross-sectional descriptive study. All the patients attending Dermatology Outpatient Department were examined and those consenting patients who were aged 60 years and above, were included. Detailed history was taken and thorough clinical examination was done. Clinical photographs were taken and recorded. The diagnosis was made clinically. However, in doubtful cases, appropriate investigations such as Wood's lamp examination, KOH mount, skin biopsy as guided by history and clinical examination, were done. Data was analyzed using Statistica version 6 (StatSoft Inc., 2001, Tulsa, Oklahoma, USA) and SPSS statistics version 17 (SPSS Inc., 2008, Illinois, Chicago, USA).


   Results Top


This study was conducted over a period of 12 months. During this period, dermatology outdoor patient department served around 49,241 people mostly of eastern region of India which includes West Bengal, Bihar, Jharkhand, Odisha. A total of 1,052 patients (713 male and 349 female) who were older than 60 years, attended the OPD (including both new and old patients). Thus, the overall share of geriatric patients was 2.13%. A total of 250 patients were finally enlisted and evaluated. Simple random sampling technique was adopted, by generating a random number sequence of 250 sample size among 1,000 population (the value obtained from previous year's data of OPD attendance of geriatric population). The demographic profile of the entire study population and the different subgroups is enlisted in [Table 1]. Mean age at presentation was 67.87 ± 7.29 years and there was no significant difference (P = 0.86, Kruskal–Wallis test). 164 (65.6%) were males and 86 (34.4%) were females. Commonest disease category was infection (75, 30%) followed by dermatitis (74, 29.6%), papulo-squamous diseases (46, 18.4%), and immunobullous disorders (16, 6.4%). Miscellaneous disease categories including malignancy, pigmentary anomalies, seborrheic keratosis, scabies, etc., had a share of 19% (51 patients).
Table 1: Demographic profile of geriatric patients

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Based on disease presentation, we have classified all major disease groups into acute (=6 weeks) and chronic (>6 weeks). Most of the patients (66%) had chronic disease. Among the acute disease category, more than half (46, 54.11%) was constituted by infections alone (P = 0.0001, Chi-square test).

Average age of presentation in the dermatitis group was 67.87 ± 7.29 years, which was lower than the patients suffering from seborrheic dermatitis (71.57 ± 7.41 years). Mean age of presentation was lower in irritant contact dermatitis (ICD) (63.5 ± 4.43 years), though this difference in age was not significant (P = 0.15, Kruskal–Wallis test). Both the genders were equally affected in pompholyx and nummular dermatitis, but in stasis dermatitis, only males were affected. To know whether this difference was significant, we clubbed various types of dermatitis into two groups, exogenous and endogenous. Exogenous dermatitis included ACD and ICD and endogenous group included rest of the conditions. After clubbing, it was found that this difference was not statistically significant (P = 0.950, Chi-square test).

Dermatitis was more common in rural population (58.10%). Patients who were involved in indoor activity had more chance of getting dermatitis (58.10%), as compared to persons who did outdoor activities, but this difference was not statistically significant (P = 0.103, Chi-square test). 49 patients had diabetes mellitus (19.6%). Association of diabetes mellitus was found to be significant (P = 0.0014, Chi-square test).

Association of systemic diseases with infection was statistically significant (P = 0.0007) whereas significant association of diabetes with other dermatoses like dermatitis, papulo-squamous disease, and immunobullous disease was not found in our study population (P = 0.48, 0.14, 0.37, respectively).

13 had one or other type of malignancies (5.2%). Commonest was basal cell carcinoma (BCC) (7 patients) followed by squamous cell carcinoma (SCC) and melanoma. Mean age for BCC was 68.42 ± 11.37 years and for SCC, it was 66.33 ± 7.09 years, though the difference in age was not significant (P = 0.39, Kruskal–Wallis test) [Table 2].
Table 2: Skin malignancy in study population

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All the patients had shown signs of aging. Among them, commonest was idiopathic guttate hypomelanosis (51.2%) followed by xerosis (45.2%) and seborrheic keratoses (42.4%). Cherry angiomas were present in 33.2% patients. Senile acne was present in 17 patients (6.6%). In our study population, common skin conditions related to sun exposure were wrinkling (97.6%), followed by freckles (35.6%), purpura (10.8%), and telangiectasia (5.6%). Photoaging was graded into four subgroups depending on severity, by using Glogau scale. People who were involved in outdoor activity were found to have higher Glogau scale (3.01 ± 0.69), while people involved in indoor activity had lower Glogau scale (2.44 ± 0.74) and this difference was statistically significant.(P < 0.001, ANOVA test) [Table 3].
Table 3: Association of photoaging with indoor-outdoor activity and occupation

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247 patients had wrinkling with or without other signs of photoaging. Most of them had wrinkling of grade II and III, and it was present in 101 (40.89%) and 103 (41.7%), respectively. Grade IV wrinkling was present in only 15 (6.07%) patients and among them, 10 patients were involved in outdoor activity. This difference was statistically significant (P < 0.0001, Chi-square for trend) Table 3.

Grading of wrinkling could not be done in three patients due to severe edema of the face as they were suffering from erythroderma (n = 2) and anasarca (n = 1). Freckles were present in 35.6% (n = 89) of the study population. Among them, 32 patients were involved in outdoor activity, and the association was not significant (P = 0.86, Chi-square test) [Table 3]. Out of 27 (10.8%) patients of purpura; 9 were present in those who were involved in outdoor activity and 18 people have indoor activity. The difference was not statistically significant (P = 0.81, Chi-square test) [Table 3]. Telangiectasias were present in 5.6% (n = 14) patient, (nine had history of outdoor activity). The difference was statistically not significant (P = 0.06, Chi-square test).

Conditions of some of the patients have been shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6].
Figure 1: An elderly lady with signs of photoaging

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Figure 2: Note the senile comedones and elastotic changes, suggestive of Favre Racouchet syndrome

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Figure 3: Classical photograph of basal cell carcinoma

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Figure 4: Cherry angiomas and idiopathic guttate hypomelanosis

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Figure 5: Senile ecchymosis on the forearm of a diabetic man

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Figure 6: Acquired ichthyosis in an elderly man

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   Discussion Top


In our study mean age was 67.87 ± 7.29 years, male to female ratio being 1.90:1, similar to study done by Pavithra et al.[8] Similar findings were also present in the study of Patange et al.[9] However Lane and Rockwood[10] observed more number of females than males. The preponderance of males in our study could be attributed to the fact that elderly females are more dependant, both financially and socially; and it is unlikely for them to come to the OPD unless the disease is severe.

Most common dermatoses were infections (n = 75) followed by dermatitis (n = 74), papulo-squamous disease (n = 46), and immunobullous disease (n = 16). Durai et al. had noted that commonest dermatoses were generalized pruritus, followed by infections, eczemas, vesiculobullous diseases, and adverse drug reactions.[11]

74 patients were affected by dermatitis accounting for 29.6% of total disease burden. Commonest was allergic contact dermatitis 10% (n = 25) followed by stasis dermatitis 4.4% (n = 11), pompholyx 3.2% (n = 8), nummular eczema 2.4% (n = 6), and irritant contact dermatitis 1.6% (n = 4). Contact dermatitis was very common in our study, affecting 29 (11.6%) patients, comparable with the findings of Durai et al. where the share of contact dermatitis was 10.6% among various dermatitis.[11] A study by Pavithra et al. documented relatively lower incidence of eczema compared to our study. Among the eczemas, they found higher incidence of asteatotic eczemas, closely followed by stasis eczema, contact dermatitis, and nummular eczemas.[8] Incidence of stasis dermatitis (4.4%) and nummular dermatitis (2.4%) in our patients were similar to the findings of the above mentioned study. In Singapore,[6] commonest was endogenous eczema (8.4%), which was less as compared to our study (11.4%). Nummular dermatitis in our study population had the share of 2.4%, whereas it was commonest dermatitis in a study done by Cvitanovic et al.[6] Patients with asteatotic eczema were less frequently encountered in our study, and this could be attributed to the humid weather conditions prevalent in the eastern part of the country.

Contact dermatitis was seen more frequently (11.4%) among the various eczemas (74, 29.4%). Elderly population is expected to have less incidence of contact dermatitis because of decreased occupational exposure and declining immune reactivity that occurs with age. Incidence of eczema in our patients exceeded the documented range (20.4–24.7%) various studies. Among dermatitis, we have seen more of contact dermatitis (11.6% vs. 7.5%, 10.6%), but less of stasis dermatitis (4.4% vs. 5.9%. 6.2%), and seborrhoeic dermatitis (2.8% vs. 3.9%. 10.5%).[9],[11],[12]

In the present study we have found that 18.4% of the study population had one form of papulo-squamous disease, commonest being psoriasis 9.2%, followed by lichen planus 2.4%. In a study by Cvitanovic,[6] psoriasis was seen in 6.20% of the total study population. Sahoo et al.[13] found psoriasis in 9% and very similar results were reported from Turkey[5] where psoriasis was present in 8.1%. In a study done by Chopra,[14] psoriasis was present in 5.6%.

Incidence of lichen planus in our study was 2.4% which is more than what was reported from Turkey[5] (1.5%). Bullous pemphigoid is common after 60 years due to the age-associated increase in circulating antibodies and change in basement membrane, consistent with our study. Overall incidence of blistering disease in our study was 6.4% which was higher than the study done by Pavithra S et al.[8] However Yalcin et al.[5] and Chopra[14] reported a further lower incidence of 1.5 % and 2.9% respectively in their groups. In our study, we observed pemphigus vulgaris in nine (3.1%) individuals and bullous pemphigoid in eight (1.6%) individuals, respectively. In our study, we observed bullous pemphigoid in 7 patients (2.8%), pemphigus foliaceous in 6 (2.4%), and pemphigus vulgaris in 2 patients (0.85). In the study done by Durai[11] have found higher incidence of pemphigus vulgaris (3.1% vs. 0.8%) and lower incidence of bullous pemphigoid (1.6% vs. 2.8%).

In our study, hypertension was the commonest systemic disease association (23.2%) followed by diabetes mellitus 19.6%, and 5.6% of people were affected by both disease. In the study done by Pavithra et al.,[8] associated systemic diseases, diabetes mellitus was the commonest (16.8%) followed by hypertension (9.2%) while a smaller (3.6%) number of cases had a combination of the two. This was also noted by Patange et al.[9] We had found other systemic disease in 5.2% of the patient which is higher than the study done by Pavithra et al.[8] where they found 3% patients with disorders like IHD, CVA, CRF, etc., These findings were however not mentioned by others[10],[12],[15],[16] Study by Durai[11] found higher incidence of diabetes (28.9% vs. 19.6%) and hypertension (25.5% vs 23.2%) than our study, however Sahoo et al.[13] observed lower incidence of diabetes (10.5% vs 19.6%) and hypertension (2.5% vs 23.2%).

Malignant tumors were present in 13 patients. Commonest skin tumor was basal cell carcinoma followed by squamous cell carcinoma. Prevalence of malignant skin tumors in various studies[5],[6],[17] range from 4.4% to 29.8%. Our study had low frequency of malignant tumors (5.2%), comparable to the study done by Durai[11] but lower than the frequency found in other studies outside India,[18] which may be explained on the basis of genetic variability or photoprotective role of melanin in skin type IV/V.

All the patients showed signs of aging, commonest being idiopathic guttate hypomelanosis (51.2%), followed by xerosis and seborrheic keratosis in 45.2% and 42.4%, respectively. Incidence of seborrheic keratosis in various studies ranges from 24.2% to 74.5%.[9],[19],[20] A higher prevalence was seen by Smith et al.[21] (88%), and Beauregard and Gilchrest[12] (61.2%). Incidence of cherry angioma in our study was low (33.2%) as compared to the study of Patange,[9] but significantly lower than that reported by Tindall et al. (86%).[22]

Idiopathic guttate hypomelanosis in our study was present in 51.2% people which is comparable to Patange and Fernandez[9] (49, 24.5%) but higher than Sahoo et al.[13] (13, 6.5%). Higher frequency was reported by Grover and Narasimhalu[20] (153, 76.5%). Senile comedones were present in the 6.6%, higher than Durai et al.[11] (4.6%) but similar to Grover and Narasimhalu[20] (13, 6.5%). We have found xerosis in 45.2% of the patient, comparable to Chopra et al.[19] 50.8% but lower than Grover and Narasimhalu[20] 85.5%. Durai et al.[11] have found much higher prevalence of xerosis when compared to other studies (99.6%).

75 (30%) patients were suffering from infection; fungal (38, 50.66%), followed by bacterial (24, 32%), and viral (13, 17.33%). There was significant difference between the infective dermatoses and occupation of the patient (0.046). Seventy four patients were affected by dermatitis which spells 29.6% of total disease burden. Average age of patient was 67.87 ± 7.29 years, which is lower than seborrheic dermatitis (71.57 ± 7.41) but higher than irritant contact dermatitis (63.5 ± 4.43). In our study population, commonest systemic disease was hypertension (58, 23.2%) followed by diabetes mellitus (49, 19.6%). Association of diabetes mellitus was found significant (P = 0.0014) and this association was more obvious in infective conditions (P = 0.0007). The correlation was statistically significant in cases of candidiasis. Photoaging in the form of wrinkling (247, 98.8%), freckles (89, 35.6%), purpura (27, 10.8%), telangiectasia (14, 5.6%) were graded according to Glogau scale. People who were involved in outdoor activity had higher Glogau scale (3.01 ± 0.69) compared to people involved in indoor activity (2.44 ± 0.74) and this difference in the Glogau scale was significant (P = 0.001).


   Conclusion and Limitations Top


We evaluated and explored the disease pattern and extent of geriatric dermatoses among the group of patients attending the dermatology OPD of our institute. However, this study may not reflect the true demographic pattern and burden of the disease. We could not screen all the geriatric patients and cumulative data involving geriatric patients from all the outpatient departments would have given the true disease burden of geriatric dermatoses. However, the study gives us a fair idea about the pattern of dermatological diseases in the elderly population. This will further help in ensuring the availability of medicines in government set-ups, to address the dermatoses in the elderly population, with the help of various schemes (e.g., http://janaushadhi.gov.in/pmjy.aspx, https://wbhealthscheme.gov.in/and https://cghs.gov.in/).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the jou?rnal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Yalcin B, Tamer E, Toy GG, Oztas P, Hayran M, Alli N. The prevalence of skin diseases in the elderly: Analysis of 4099 geriatric patients. Int J Dermatol 2006;45:672-6.  Back to cited text no. 5
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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