Illustrated: Skin changes with age

Presentations of some common dermatological conditions seen in the elderly. By Dr Jean Watkins

Senile purpura

Senile purpura is common in the elderly and is due to extravasation of blood, secondary to fragility of the blood vessels associated with the dermal tissue atrophy that occurs with ageing and UV radiation. Minor trauma, often unnoticed by the patient, may be followed by purple patches and macules. They occur most frequently on the forearms and backs of the hands. The lesions will gradually resolve over the following week or so, although some residual brownish staining, due to the deposition of haemosiderin, may persist for a while. No treatment is required.


Normal changes

Ageing of the skin is a process that begins in the mid-twenties. Certain factors, for example, genetic make-up, nutrition, smoking and exposure to UV light, help to hasten the process. It has been shown that individuals who smoke 10 cigarettes a day for 10 years are more likely to develop deeply wrinkled, leathery skin. With age, the fatty subcutaneous layer thins and in females after the menopause, the sebaceous glands produce less oil. Particular features of ageing are wrinkling and exaggeration of lines. Skin is thinner, transparent and sags.


 

Xerosis and pruritus

Scratches, scarring and postinflammatory hypopigmentation give some idea of the intense itching this woman experienced. Among the problems that old age brings to our skin, dryness (xerosis) is one. It follows the reduction in oil production from the sebaceous glands. This may start after the menopause in women and usually after the age of 80 in men. Itching is a common feature of skin that is dry, fissured and flaking. Secondary infection may occur. Plentiful use of emollients is necessary to counteract this problem. Topical steroids and/or antipruritics may also be helpful in troublesome cases.


 

Sebaceous hyperplasia

Sebaceous hyperplasia is common in the elderly and may cause concern about possible basal cell carcinoma. However, sebaceous hyperplasia is entirely benign and there seems to be no risk of malignant transformation. Such a presentation would give the opportunity to advise the patient to reduce sun exposure as much as possible. Although these lesions may be found on other areas, they occur most commonly on the face and present with small skin-coloured or yellowish nodules with a central pore. They may be single or multiple and up to 5mm in diameter. In cases of doubt, biopsy the lesion.


 

 

Senile purpura

Senile purpura is common in the elderly and is due to extravasation of blood, secondary to fragility of the blood vessels associated with the dermal tissue atrophy that occurs with ageing and UV radiation. Minor trauma, often unnoticed by the patient, may be followed by purple patches and macules. They occur most frequently on the forearms and backs of the hands. The lesions will gradually resolve over the following week or so, although some residual brownish staining, due to the deposition of haemosiderin, may persist for a while. No treatment is required.


 

Hair

With age, the amount of melanin in the hair shaft reduces until the hair is grey or white. Nutrition, genetic predisposition and some medical conditions, such as B12 deficiency and pernicious anaemia, may be associated with this. Although some women may be affected, alopecia is much more common in men. They develop male pattern alopecia before more generalised loss. This type of alopecia is inherited. Occasionally women are affected, as in this patient, due to excessive levels of androgens.


 

Photoageing: solar elastosis

Any skin changes that occur with age are likely to be more marked and present in those who have been overexposed to the sun, especially if they have fair hair, blue eyes and are susceptible to sunburn. Solar elastosis develops when there is damage to the elastin protein in the dermis; the skin takes on a thickened, lined and leathery look, often referred to as 'red neck syndrome'. It is commonly seen in outdoor workers, as in this man who was a keen gardener. Once the damage is done, it cannot be undone, and the only advice is to avoid exposure, apply sunscreen and use emollients.


 

Solar lentigo

Solar lentigo are symptomless, flat or slightly raised pigmented macules, with a clearly defined edge. This man with multiple pigmented macules and freckles on his back had been an enthusiastic sunbather. Lentigo start small, gradually increase in size and may coalesce to form patches. They may appear suddenly or over years. Lentigo are benign but patients should always be checked to ensure malignant melanoma, which tend to occur in similar areas, are not missed. Advice should be given about sun avoidance and reporting any change in colour, size, irregularity of edges or other symptoms.


 

Cherry haemangioma

Cherry haemangioma (or Campbell de Morgan spots) tend to appear after the age of 40 and are increasingly common in the elderly. They are of no clinical significance, except in the occasional patient with sudden development of multiple lesions, which may be related to an underlying malignancy. Single or multiple lesions appear as small, bright red or purplish, dome-shaped papules that occur mainly on the trunk and proximal areas of limbs. No treatment is required but a biopsy may be performed if there is doubt about the diagnosis.


 

  • Dr Watkins is a retired GP in Hampshire

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