Pattern of geriatric dermatoses at a Tertiary Care Teaching Hospital of South Rajasthan , India

Aging is an inevitable and continuous process with a variable spectrum of manifestations of all organ systems including the skin [1]. Due to the degenerative and metabolic changes occurring throughout the skin layers during the aging process, some inevitable changes such as dryness, wrinkling, and laxity of the skin, and atypical presentations of dermatologic diseases are observed in elderly patients [2,3]. These dermatoses can lead to significant morbidity and affect the quality of life but are rarely fatal [4]. The global share of older people (aged 60 years or above) increased from 9.2% in 1990 to 11.7% in 2013, and will continue to grow as a proportion of the world population, reaching an estimated 21.1% by 2050 [5]. In India, there were 72 million elderly persons above 60 years of age as of 2001 and this number is likely to increase to 179 million in 2031 [6]. Advances in medical care has prolonged lifespan and expanded the elderly demographics, therefore now there is a greater need to evaluate various cutaneous disorders in the growing geriatric population. This study was aimed to know the magnitude, pattern, contributory factors ABSTRACT


INTRODUCTION
Aging is an inevitable and continuous process with a variable spectrum of manifestations of all organ systems including the skin [1].Due to the degenerative and metabolic changes occurring throughout the skin layers during the aging process, some inevitable changes such as dryness, wrinkling, and laxity of the skin, and atypical presentations of dermatologic diseases are observed in elderly patients [2,3].These dermatoses can lead to significant morbidity and affect the quality of life but are rarely fatal [4].
The global share of older people (aged 60 years or above) increased from 9.2% in 1990 to 11.7% in 2013, and will continue to grow as a proportion of the world population, reaching an estimated 21.1% by 2050 [5].In India, there were 72 million elderly persons above 60 years of age as of 2001 and this number is likely to increase to 179 million in 2031 [6].Advances in medical care has prolonged lifespan and expanded the elderly demographics, therefore now there is a greater need to evaluate various cutaneous disorders in the growing geriatric population.This study was aimed to know the magnitude, pattern, contributory factors and systemic association of various dermatoses among geriatric patients in South Rajasthan.

MATERIALS AND METHODS
All the patients aged 60 years and above attending the dermatology outpatient department at a tertiary care centre during a period of one year were enrolled.A detailed history taking followed by general physical, systemic and cutaneous examination, and necessary investigations were carried out.The findings were recorded in a proforma for analysis and interpretation of data.For statistical analysis of the data, Chi-square (χ2) test was applied.The results were considered significant at P < 0.05.

Ethics
This study was performed on human subjects; thus, all patients were aware of the presence of the study and they were fully informed about the drug and its side-effects.

DISCUSSION
Skin changes in the elderly occur either due to natural aging process, or due to pathological dermatological conditions.Compared to general population, the pattern of cutaneous changes seen in elderly population may be different or unique.In addition, elderly patients often have multiple medical problems and because of this they often need multiple medications, and all this adds to dermatological morbidity.Therefore the ambit of dermatological care needed for the elderly population is different from that for other age groups.
A total of 610 patients aged 60 years and above were examined over a period of one year.The hospital incidence of geriatric patients was 1.54% in this study.
In a few studies female have outnumbered male patients [14,15].
Most common (55.6%) age group recorded in our study was 60-69 years, which is similar to other studies [13,16].Because different studies have chosen different age parameters for elderly population, it is difficult to draw a comparison.Majority of our patients had the disease for more than one year before they sought medical consultation.This delay can be attributed to two reasons-1) Most dermatoses in elderly people either do not cause significant morbidity and mortality or 2) Because of dependency on others elderly people do not find it easy to visit hospital.There is a very thin line in deciding what is physiological and what is pathological in older person's skin.Many changes and lesions are normal, except occasionally in degree and number.In this study we considered wrinkling, senile    Wrinkling was the commonest physiological change seen in the present study 273 (44.8%).Similar findings have been reported in other studies also [9,10,17].Presence of wrinkling in more number of males 223 (53.6%) compared to females 50 (25.8%)could be due to more outdoor activity in males exposing them to increased ultra violet rays.Senile purpura was seen in 108 (17.7%) patients in our study.We found xerosis in 83 (13.6%) patients.Various studies have reported prevalence of xerosis from 7% to 99.8% [7,[12][13][14]18].Senile comedones were seen in 76 (12.5%) patients in our study.Almost similar incidence (11.5%) was observed in another study [7] while study by Raveendra L [12] reported slightly higher (28%) incidence.Senile lentigines were observed in 2.8% of patients.Grover et al [9], Raveendra L [12] and Sheethal et al [13] reported it in 10%, 15% and 30% patients respectively.
The relative incidence of infections and infestations was 244 (15.7%).The incidence of this compares well with other studies [11,13,15,16].Some studies though have reported a higher incidence [7,9,12].Fungal infections were the commonest infections seen in elderly.This is in unison with other studies [4,7,9,[10][11][12]14,16,19,21].The higher incidence of fungal infections in elderly people is probably the result of lack of personal care, decrease in epidermal turnover and immunologic functions [3].Viral (10.6%) and bacterial (10.2%) infections were the next common infections; which is much lower than fungal infections.This is consistent with the findings of other studies [7,9,10,12,15,19].Factors like poor hygiene, neglect, underlying disease like diabetes, bedridden status may also contribute to infections.Dermatitis (10.1%) and pruritus (5.0%) were other common conditions.The figure of dermatitis is consistent with the finding of Patange et al [7].
In different studies, the incidence of premalignant and malignant neoplasm has varied from 0.5% to 15.5%.In our study, frequency of these skin tumors (0.5%) was lower than the other studies [11,14,16,19].Indian study by Sayal et al [17] has also reported lower incidence (0.3%) of skin tumors.Raveendra L [12] found no malignant skin conditions in their study.This lower incidence of skin tumors in Indian studies compared to studies from west can be attributed to the fact that pigmented skin offers more protection against ultraviolet radiation compared to individual with Fitzpatrick skin types I and II.
Systemic diseases were recorded in 180 (29.5%) patients.A similar incidence of systemic disease has been reported in another study also [7].We found hypertension (96; 15.7%) as the commonest problem.This is shared by other studies [9,12,16] also, however incidence was much higher.Diabetes mellitus (59; 9.7%) was the second most common systemic disease in our study.This is similar to other studies [9,12,16]while some other studies found it to be the commonest systemic disease [7,14,18].

CONCLUSION
With the expected increase in the geriatric population in the coming years, the dermatological problems in geriatric population are of great relevance.Our study shows that physiological changes seen with ageing such as wrinkling, senile purpura, xerosis, senile comedone, atrophy and senile lentigens are major cutaneous findings.Eczemas of various types and fungal and bacterial infections are the common dermatological morbidities.Benign tumors such as cherry angiomas are also commonly seen but incidence of skin malignancy is low in our geriatric population.The dermatological morbidities in geriatric population can be minimized by reassurance, regular use of emollients and proper education regarding routine care of skin.

Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Statement of Informed Consent
Informed consent was obtained from all patients for being included in the study.

Figure 2 :
Figure 2: Wrinkling over forehead and senile comedones on right cheek.

Figure 3 :
Figure 3: Associated systemic conditions in geriatric patients.

Table 1 :
Age and gender wise distribution of geriatric patients

Table 2 :
Distribution of cutaneous diseases in geriatric patients *Some patients had more than one entity

Table 3 :
Pattern of benign tumors in geriatric patients

Table 4 :
Pattern of infections and infestations in geriatric patients