Dermatologic Problems of Older Women

Skin changes in elderly women

The normal cell cycle of the epidermis is 26 to 42 days and results in desquamation of skin cells. In aging, the length of the cell cycle increases. The epidermal turnover rate slows 30% to 50% between the third and eighth decades of life. The cells in the superficial stratum corneum are older and may have impaired function and desquamation [3]. Intrinsic aging of the skin is associated with the following abnormalities: abnormal barrier homeostasis, reduction in stratum corneum lipid

Thin skin

The skin of postmenopausal women histologically shows a thinned epidermis with flattening of the rete ridges. Women 65 and older demonstrate a loss of approximately 20% of dermal thickness [7]. It is currently believed that decreases in skin thickness seen with aging are caused by hormonal effects on collagen, elastic fibers, and dermal hyaluronic acid content [8]. These changes predominate in women compared with men and it has been postulated that estrogen has an important role in determining

Xerosis

Dryness is a frequent finding in both women and men over 65 years of age. It is a normal finding in aging skin. Xerosis, or dryness of the skin, affects at least 75% of this age group, thus making it the most common skin disorder in the elderly [16]. Dry skin results from abnormalities in the stratum corneum that occur intrinsically with aging. Decreased moisture in the stratum corneum is secondary to an increase in stratum corneum transepidermal water loss (TEWL). The increased TEWL is

Pruritus

Pruritus, or itch, may be the most common symptom of skin disease, particularly for the seventh and eighth decades [24]. Itch is defined as a sensation that makes the person scratch the affected area. In classic pruritus, itching occurs in the absence of skin findings. In elderly women, pruritus often results initially from xerosis, in which the skin is dry and rough. It may frequently occur in the evening or at other quiet times. This itch–scratch cycle eventuates in lichenification,

Seborrheic keratosis

Often fondly referred to by seniors as barnacles, the seborrheic keratosis (SK) is the most common skin growth in women 65 and older. The SK is a benign epidermal neoplasm with many variants and clinical presentations. SKs frequently necessitate an office visit because they can be dark brown, irregular in shape, and raised, thus resembling a malignant melanoma. The patient or family members may insist that the lesion be checked. This actually provides a wonderful opportunity for the physician

Rash of unknown origin

The rash can be a vexing problem in elderly skin as it may not have a classic presentation. A strong knowledge of differential diagnosis is key to helping diagnose a rash. Eczematous dermatitis is the most common cause of a rash in the older female. The most common diagnoses include contact dermatitis, nummular dermatitis, asteatotic eczema, gravitational dermatitis (stasis dermatitis), and lichen simplex chronicus.

Drug eruptions

There is always a reason and a dermatologist is trained to find it. Using the tools of history, morphology, and location, the culprit usually is identified. Historically a drug rash may start any time from minutes (fixed drug eruption) to months (gingival hyperplasia from phenytoin) after exposure to the offender. Morphologically the reactions are mostly exanthems and urticaria [26]. Infrequently a patient may present with pruritus and no skin findings. A clinical clue may be a positive wheal

Intertrigo

Intertrigo is seen frequently in older women. Clinically it presents as erythematous macerated areas in skin folds. It may burn or itch, and as it progresses fissures, erosions, and even infection may result. The submammary area is the most frequent site, but other areas affected may be subaxillary, genitocrural, gluteal, and interdigital skin. The primary cause of intertrigo is friction that results from two surfaces in apposition [27], [28]. In addition to redundant skin, risk factors for

Seborrheic dermatitis

Seborrheic dermatitis frequently is seen and misdiagnosed or overlooked entirely in the elderly. Older women who complain of a facial rash or redness are often given the diagnosis of dry skin or rosacea, when in fact they have seborrheic dermatitis. Although seborrheic dermatitis affects infants and younger people, it becomes more common with advanced age. Seborrheic dermatitis in the elderly may be associated more frequently with genitocrural involvement that mimics tinea cruris or intertrigo.

Herpes zoster

The incidence of herpes zoster is increased in older women and men. A major complication of herpes zoster in the elderly is development of postherpetic neuralgia, the incidence of which is as high as 20% in persons 60 years and older. The unilateral dermatomal eruption usually presents as erythematous papules or vesicles associated with pain, burning, or itching. Rarely the patient may complain only of burning pain or itching in a dermatomal distribution (zoster sine herpete). Because some

Actinic keratosis

The actinic keratosis (AK) is the most common precancerous skin lesion. It occurs primarily in light skin types [29]. It affects over 50% of the elderly fair-skinned persons in hot, sunny climates [29], [30]. The diagnosis of AK has increased throughout the United States. This may be attributed to the increased aging of the population and a heightened awareness of AK as a precursor to squamous cell carcinoma. AKs present on sun-exposed body surfaces and photodamage accompanies them. Clinically,

Solar purpura

A frequent finding in elderly women, solar purpura is caused by trauma and torsional stresses in photo-damaged skin. The use of blood-thinning agents such as aspirin, NSAIDs, and Coumadin may contribute to the purpura (see section on Thin Skin elsewhere in this article).

Alopecia in elderly women

Alopecia is not an infrequent finding in elderly women. Although medications, chronic disease, and telogen effluvium may cause alopecia, most alopecia in this age group is caused by female pattern hair loss (FPHL). The frequency and severity of FPHL increases with age [40]. FPHL begins anytime past menarche and tends to be in one of two patterns: diffuse central thinning or frontal thinning. Most women with FPHL have no biochemical evidence of androgen excess [41]. There is a subset of women

Rosacea

Rosacea is a common skin disorder that peaks in the third and fourth decades. Women are affected more often than men in the earlier stages at a 3:1 ratio and have a milder course. They are less likely than men to develop late stage rhinophyma. Rosacea is associated with solar elastosis. A new classification system developed by the National Rosacea Society can assist a clinician in formulation of a treatment plan [43]:

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  Subtype 1: Facial redness; may respond to topical metronidazole, azelaic acid,

Legal issues in elderly women

With an increasing elderly population, the dermatologist will be faced with making health care decisions that will impact the patient and the patient's family and caretakers. The legal authority for advance health decisions law that became effective July 1, 2000 defines a health care decision as any decision made by a patient or patient's agent, conservator, or surrogate regarding the patient's health care [44]. These decisions include:

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  Selection and discharge of health care providers

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  Approval or

Summary

Women are living longer today, composing the majority of persons aged 65 and older. Their dermatologic needs are unique and cross ethnic and cultural lines. With this increased life expectancy comes an increased occurrence of skin disorders. The identification and treatment of these conditions is important for the practicing clinician.