When freckles first appear in later life, they are usually associated with skin damage from sun exposure. This offers an opportunity to warn the patient of the risks of sun exposure and to advise adequate sun protection.
Regular applications of antioxidants, such as retinoids, may be helpful in inducing fading or repeated treatments with chemical peeling, some pigment lasers or cryotherapy.
However, further sun exposure is likely to lead to a recurrence of the pigmentation.
Continued sun exposure will damage the elastic fibres in the dermis and lead to several differing manifestations in the skin. Obvious signs may be wrinkles, atrophy, dry, thinned skin or yellow/orangey plaques or blackheads unrelated to acne vulgaris. The latter are more common around the mouth and eyes.
One particular feature of elastosis is cutis rhomboidalis nuchae, in which deep furrows are seen on the back of the neck. Often this is termed 'red neck', used to describe lorry drivers in the USA who have had their neck exposed to the sun while loading and unloading their vehicles.
Solar (actinic) keratoses
For 20 years this woman had lived in the Far East. She presented with dry skin and multiple flat, reddened or scaly lesions on her lower legs arms and face.
In themselves, these solar keratoses are harmless but should be considered precancerous and potentially may lead to basal (BCC) or squamous cell carcinoma (SCC). In a patient with more than 10 solar keratoses, the risk of malignant change is 10-15 per cent.
Treatment is aimed at removal of all the keratoses so that new, undamaged skin can fill the gap - by cryotherapy, curettage and cautery, excision or diclofenac gel.
Generalised essential telangiectasia
Permanently dilated capillaries in the skin appear, forming a network of vessels or red markings on the skin. They may be associated with alcohol intake or dermal damage with elastotic degeneration caused by sun exposure. They may occur anywhere on the body, including the mucous membranes and whites of the eyes. On examination, pressure on the affected site will cause the vessels to empty and blanch.
Cosmetic camouflage may be helpful and laser treatment has produced some beneficial results.
This elderly patient presented with a one-year history of a brown spot on her face. It appeared to be gradually increasing in size and getting darker.
Simple lentigo are common in the elderly and may occur anywhere on the body. Colour may vary from light brown to black. Sun damage may be important in their development. They develop when keratinocytes in the basal cell layer of the epidermis are replaced by melanocytes. In themselves they are benign but may develop into a malignant melanoma.
Sebaceous hyperplasia is a common problem that tends to occur in later years. It is thought to be caused by the decreasing levels of androgens and that a cofactor in the development of these benign lesions of the sebaceous glands is exposure to UV light. They have also been linked with long-term immunosuppression.
Soft, whitish yellow or skin-coloured papules with central umbilification may occur anywhere on the body, but commonly on the forehead, cheeks and nose. Sometimes, they may become inflamed and bleed after scratching or shaving.
Treatment is not normally required.
Skin cancer is always a risk for those who have had too much sun over the years, especially in the fair skinned, who tend to burn easily. Bald-headed patients are particularly prone to such lesions.
UV radiation leads to changes in the cell components of the skin and the immune system. Bowen's disease, BCC or SCC or melanoma are all possibilities and if found the rest of the body should be checked.
In this case biopsy proved the lesion to be a SCC, and because the lesion was quite extensive, the patient elected to have radiotherapy rather the excision of the lesion.
Actinic purpura is often seen in the elderly. Excess sun exposure causes damage to the connective tissue of the dermis.
Patients notice symptomless, purple blotches and ecchymoses as red blood cells leak into the dermal tissues. The patches occur most frequently on the extensor surfaces of the forearms and dorsum of the hands.
The blotches resolve spontaneously within three weeks but may leave some residual brown staining. It is often more of a problem for those taking anticoagulants and steroids. No treatment is necessary further; sun exposure should be avoided.