A CLINICAL STUDY OF GERIATRIC DERMATOSES

Introduction: The geriatric population is composed of persons over 65 years of age and very few studies are available on the dermatologic diseases in this group. This study was done to study the spectrum of cutaneous manifestations and prevalence of physiological and pathological changes in the skin of elderly people. Material and Methods: Two hundred consecutive patients aged more than 65 years of age attending the outpatient clinic or admitted as inpatients in the Department of Dermatology at Vydehi Institute of Medical Sciences and Research Centre were subjects for the study. A detailed history of cutaneous complaints, present and past medical ailments was taken. A complete general physical, systemic examination and dermatological examination was done and all findings were noted in a pre designed proforma. Skin changes observed due to ageing were classified as physiological and pathological. Findings were collated in a master chart and results analyzed. Results: Out of 200 patients studied, 71% were males and 29% were females. Pruritus was the single most common complaint elicited (44%). Among the physiological changes, xerosis was the commonest (93%). Among the pathological changes skin tumours, eczemas, infections were the common findings. Conclusions: The geriatric dermatoses are different in different populations as some of the skin changes seen in western skin and Indian skin are not identical.


INTRODUCTION
Ageing is a natural process. People aged 60 years and above are generally referred to as older population. 1 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 and further to 301 million in 2051, hence dermatologic care in geriatric population needs emphasis. 2 Common skin disorders seen in the elderly are xerosis, pruritus, photoaging (dermatoheliosis), benign tumors like acrochodrens, seborrheic keratosis, cherry angioma and infections like herpes zoster, dermatophytosis, etc. Eczematous conditions like asteatotic eczema, stasis eczema, discoid eczema are common in elderly 3 . The dermatology practice of the future will see an increase in the number of geriatric patients and geriatric health care has become a major international issue. 4 In India, very few studies have been done to look into the cutaneous manifestations in the elderly people though several studies have been carried out in the west. 5 In this scenario, with life expectancy in India going up to 63.9 years in males and 66.9 years in females in 2004 6 , this study was undertaken to study the spectrum of cutaneous manifestations and prevalence of physiological and pathological changes in the skin of elderly people.

Intrinsic ageing
Genetic factors which control intrinsic ageing include:

Photoageing
It is the aging caused by both direct and indirect effects of UV radiation.
This results in damage to telomeres, generation of free-radicals and these effects are largely influenced by skin type. 14 Generation of free radicals results in 50% of UV induced damage. Signs of photoageing like wrinkling, increased elastin and collagen damage are due to DNA damage induced by UV radiation. 14 Damage to cellular DNA, lipids and proteins is caused by generation of free radicals is mainly by ultraviolet A, and to a lesser extent by ultraviolet B. 14 Marker for UVA damage which is found in dermal fibroblasts of photoaged skin is 4977 base pair deletion, it is found in mitochondrial DNA.The mitochondrion has the highest turnover of free-radicals in the cell and is responsible for cellular energy production. Mutations in its genome may be associated with the changes seen with photoageing because many of the genes involved in this process are encoded in mitochondrial DNA. 15 Neutrophils increase oxidative damage through their production of free-radicals. This may be due to elevated levels of proinflammatory cytokines like IL-1, IL-6, vascular endothelial growth factor[VEGF] and tumour necrosis factor alfa. These are caused by transcription factor nuclear factor NF-κB which is activated by UV radiation. Amplification of the UV response is by attracting neutrophils that contain preformed neutrophil collagenase  and by stimulating the transcription of inflammatory cytokines. MMPs expression is also increased by NF-κB. The process of angiogenesis, is assisted by reductions in thrombospondin-1, an angiogenesis inhibitor, and increases in platelet-derived endothelial cell growth factor, an angiogenesis activator and increased vascular endothelial growth factor(VEGF) levels. In elderly people photocarcinogenesis as well as telengiectasias in sun exposed areas are caused by UV induced changes in gene expression.
Epidermal growth factor, TNF-alfa and IL-1 receptors are activated in keratinocytes and fibroblasts within 15 minutes after UV exposure. This leads to the expression and also activation of the nuclear transcription factor activator protein 1(AP-1). Matrix metalloproteinases(MMPs) is the enzyme responsible for degradation of the extracellular matrix.This enzyme is regulated by transcription of AP-1. The major metalloproteinase responsible for collagen degradation is MMP-1which is found in both epidermal keratinocytes and dermal fibroblasts. It requires iron for its activation. The transcription factor NF-κB is also activated by UV radiation via an iron-dependent mechanism. 16 There is a dose-response relationship between UV exposure and MMP induction. Up-regulation of MMP can occur even with a minimal dose of UV, well below that required to produce erythema. These elevated levels of MMP can be maintained by minimal repetitive exposures to UV radiation, it may be equivalent to 5 to 15 minutes of exposure to midday sun every other day. Both local and systemic immunosuppression produced is by UV radiation. This is partly mediated by altered cytokine expression and also by DNA damage. 14

Theories of ageing :
There are several theories about the aging process. These are : a] Waste product theory : Most cells of the ageing show increased concentrations of lipofuscin [ageing pigment] particularly in heart and brain .
Lipofuscin granule is heterogenous , irregular in shape and contains proteins, carbohydrates , lipids along with various lysosomal enzymes . It is caused by free radical induced damage .
b] Cross-linkage theory : there are several forms of collagen in mammalian skin such as Type I and Type III . Type I is found predominantly in adult , whereas Type III is found in higher concentrations in embryonic and young skin . There is also cross linking of DNA polymers with changes in the histone and non histone protein fractions . There is age related increase in the number and quantity of non -histone chromatin fractions in ageing tissues . c] Free radical theory : Superoxide radical is a by-product of various enzyme reactions caused by UV light , ultrasound , X and gamma rays , toxic chemical and metal ions . Free radicals also cause lipid peroxidation . There are age related reductions in glutathione , glutathione reductase and superoxide dismutase from the blood cells , liver and eyes which are found to be protective against free radical induced damage .  12 This results in variability in epidermal thickness and individual keratinocytes size. There is decrease in epidermal fillagrin which results in dry and flaky skin especially over the lower limb. 10 Increased susceptibility and fragility of the epidermis is due to atrophy of the stratum spinosum, thinning of the epidermis by 10%-50% and increased heterogeneity of size of basal cells. 17 An endocrine function of human epidermis that declines with age is vitamin D production. There is decrease in DNA damage repair capacity and in addition antioxidant defense system decline with age. The epidermal repair rate after wounding declines with age. Decrease in the number of enzymatically active melanocytes per unit surface area of skin, reducing the body's protective barrier against UV radiation. Increase in cellular mutability or tendency to become senescent is caused by combination of these changes. 10 There is widening of inter keratinocyte space in sun protected skin which is evidenced by electron microscopy. Also there may be reduplication of lamina densa and anchoring fibril in basement membrane zone. 12 Dermis: Wrinkling of ageing skin is almost entirely the result of changes in dermis . The collagen per unit area of unexposed skin, bulk of the dermis decreases with age. This UV mediated down regulation of collagen synthesis is mediated by AP-1 and transforming growth factor beta (TGF-β). The elastic fibers are progressively reduced and the collagen bundles become disoriented and fragmented. There is disintegration of elastic fibres with age and after the age of 70 most fibres appear abnormal. These changes are due to reduced synthesis and elastolysis. 14 Although substances enter aged skin more easily than young skin, they are removed more slowly into the circulation because of changes in the dermal matrix and reduction in the vasculature, resulting in alteration in permeability of skin. 18 Increased biosynthetic activity is reflected by highly activated endoplasmic reticulum, fibroblasts become stellate shaped. There is steady increase in number of mast cells, mononuclear cell and neutrophils. In papillary dermis there is loss of collagen I and III with an associated increase in matrix metalloproteins after the age of 70 years. The increased levels of mitogen activated protein kinases in aged skin produces oxidative damage. Reactive oxygen species and free radicals are the key drivers for degeneration. 12 Eccrine glands: As a result of a combination of reduction in the number of glands and its output, spontaneous sweating on the fingertips declines in old age. 19 This leads to increase in core and skin temperature in elderly individuals. There is an age associated structural alteration in eccrine gland. 17 The impaired response of sweat glands to central and peripheral stimuli is due to diminished thermoregulatory ability in elderly.
Apocrine gland: Less odour is produced due to decrease in size as well as function of the apocrine gland. 10 Sebaceous glands: Production of sebum is at greatest in early adulthood and gradually lessens in old age. Sebaceous glands increase in size inspite of their decreased output because turnover of sebaceous cells is slower in senility. 10 This along with diminished sweat gland output probably contributes to xerosis.

Nerves and sensation:
Pacinian and Meissner's corpuscles decrease to l/3 rd of their density. 20 Structural irregularities and variation in size is seen. Ageing often decreases sensory perception and increases threshold for pain. 21 Consequently, the elderly are predisposed to injuries such as thermal burns.
These alterations have negative impact on the ability of the elderly to perform delicate maneuvers, compromising their ability to compete in the workplace. 1 Hair: Hair has no vital function in humans, however its psychological functions are extremely important. 21 By the end of 5th decade, approximately half of the population has 50% gray hair and virtually everyone has some degree of graying due to deficient tyrosinase or loss of melanocytes from hair bulb. 12 With ageing the scalp hair becomes gray, finer and also the hair follicles decrease in number. On the scalp, the temples usually show graying first, followed by a wave of greyness spreading to the crown and later to the occipital area.
Loss of hair pigmentation is associated with a decrease and eventual cessation of tyrosinase activity in the lower bulb. Melanocytes are absent from the bulbs of white hairs although non-melanized melanocytes are still present in the outer root sheat. 22 Decrease in hair follicle density is due to atrophy and fibrosis. There in an increase in proportion of telogen hair follicles.

Angiogenesis
An age associated marked loss of dermal vessel density, and surface area have been described.
This explains why aged skin is characterized by, reduced UV induced erythema, decreased skin temperature, reduction of cutaneous vascular responsiveness and reduced nutrient supply which leads to ulceration. 17

Vitamin D synthesis
The concentration of 7-dehydrocholesterol, showed 50% reduction from age 20 to 80. Factors that contribute to deficiency state are behavioral factors, including limited sun exposure and malnutrition.

Immune Function
Immunological decay occurs as people age in both the T cell and B cell mediated immunity, cell mediated immunity in particular undergoes significant deterioration.

Menopausal flushing
It is described as a sudden feeling of intense heat in the face, neck and chest, often accompanied by discomfort and sweating. It typically lasts for 3to5 min. Some women develop palpitations, throbbing in the head and neck, headaches, waves of nausea and anxiety attacks. 33 Estrogen therapy is most effective. 34 If it is contraindicated other drugs like progestins, clonidine, paroxetine, gabapentin, venlafaxine can be considered. 35

Keratoderma climactericum
This term has been used to describe the appearance of tough skin on the palms and soles, especially around the heels. Formerly reported as a specific association with the menopause, the same changes are seen in men and women at other ages, many of whom are obese. It may therefore be a nonspecific event. It may respond to systemic retinoids. 36

Complications of HRT
HRT may be responsible for a number of cutaneous problems. Estrogen therapy may exacerbate, increased skin sensitivity, spider angioma, chloasma, darkening of naevi, the skin changes of porphyria cutanea tarda or lupus erythematous, photosensitivity, pompholyx, erythema multiforme, urticaria and acanthosis nigricans. 37

Role of Smoking in Aging skin
Smoking is associated with decreased water content in the stratum corneum and accelerated hydroxylation of estradiol leading to decreased estrogen in skin, which in turn contributes to dryness and atrophy. It is defined as an unpleasant sensation that leads to intensive scratching.
Pruritus in aged is most commonly observed event. 40 The term senile pruritus or Willan's itch is most commonly due to unknown etiology. 41

Wrinkling :
The aged skin is very fragile, translucent, wrinkled and easily bruises.
It is the commonest sign of ageing, defined as crease (or) furrows in the skin surface. They are also seen in congenital and acquired skin disorders.
Histologically, there is epidermal thinning, decrease in chondroitin sulphate and deposition of abnormal elastic tissue in the papillary dermis. 44 Wrinkling can be classified into three types morphologically. 45

Crinkles :
This is a very fine wrinkling which occurs even in areas protected from sunlight, which may disappear when the skin is slightly stretched. They are caused by deterioration of vertical subepidermal fine elastic fibers. 46 Elastic fibres begin to deteriorate from the age of 30 onwards regardless of sun exposure. 47 Marked form of crinkles seen in mid-dermal elastolysis.

Glyphic Wrinkles
These are accentuated skin markings and occur in skin damaged by sunlight producing elastic degeneration. It is caused by elastotic degeneration caused by sunlight. It is present on sides and back of neck.

Linear Furrows:
These are long, straight and slightly curved grooves seen on the faces of elderly people. They include horizontal frown lines along the forehead, "Crows Feet" radiating from the lateral canthus of the eye, creases from the nose to the corners of the mouth.
In youth the linear furrows caused by facial muscle contraction disappear due to elastic recoil, but in older people they are permanent. 45 Cigarette smoking is a potent independent cause, cigarette face is described as pale, grey, wrinkled skin seen in heavy smokers who are five times more likely to be wrinkled. 48 Pathogenesis is not very clear, but causative factors might include ischaemia due to vasoconstriction induced by nicotine, sympathetic nerve stimulation, increased platelet aggregation, decreased prostacyclin formation, decreased tissue oxygenation, increased tissue carboxy hemoglobin and reduced collagen deposition. The additive induction of MMP-1 expression which causes wrinkling may be induced by both UVA and tobacco smoke. 49

Senile xerosis and asteatotic eczema :
It is otherwise known as 'eczema craquele'. Skin of the aged feels dry to touch which may be due to the reduced water content of the stratum corneum without actual water loss. 50 It is worse in the winter known as winter eczema prurigo (or) pruritus hiemalis. The texture of the skin assumes a cracked appearance resembling crazy paving (i.e. short vertical fissures connect the horizontal fissures) which is most pronounced on the legs. Frequent washing, central heating in cold climates also aggravates the problem by reducing atmospheric humidity. It is necessary to rule out the use of diuretics. This condition is extremely pruritic, responds well to application of mid potency topical steroids, emollients , avoidance of excessive use of soaps and frequent washing. 51

Eczematous disease of Geriatric population
The aged skin can suffer from any clinical type of eczema.

a) Stasis eczema
It is seen on the lower extremities and is associated with long standing venous insufficiency. It is characterized by bilateral circumferential dermatitis of ankle and calf areas. The triad of alopecia, waxy appearance and yellow brown pigment from haemosiderin deposition is diagnostic with or without edema. Elderly patients can have stasis dermatitis in other sites, if they are not mobile, such as buttocks, heels, forearm or other sites that rest on solid surface which give rise to decreased blood flow and later develop into pressure ulcers. 52

b) Nummular eczema or Discoid eczema :
This is much more common in elderly, characterized by coin shaped or oval lesions that appear anywhere in the body . This can be mistaken for tinea corporis, psoriasis, contact dermatitis or neoplasia. 52

c) Seborrheic dermatitis
Flexural pattern is more often seen in these aged individuals who are confined to bed. This may be mistaken for intertrigo and flexural psoriasis. 53

d) Atopic Eczema :
It may continue into old age (or) appears for the 1 st time.

e) Contact dermatitis of irritant or allegic origin :
These are less common in elderly due to decreased occupational exposure and reduced immune reactivity that occurs with age. 48

Senile purpura (Actinic purpura, Bateman's purpura)
Purpura is defined as extravasation of blood into the skin and mucous membranes. It is a common finding in the elderly. It is due to loss of dermal connective tissue support resulting in increased fragility of dermal vessels. Lesions are most commonly seen over the dorsa of hands, forearms, following trivial trauma. The lesions dark red or purplish macules of varying sizes. It is diagnosed clinically by the sites of the lesions, associated atrophic changes, and by the absence of any general bleeding tendency. Primary amyloidosis is the rare cause of purpura in the elderly. It is due to deposition of amyloid material in and around dermal blood vessels. This is most marked in the body folds, especially around the eyes. Intake of aspirin, anticoagulants like warfarrin and heparin must be ruled out. It may resolve spontaneousely after a few weeks. No treatment is needed for this benign disorder. 57

Infectious diseases in elderly
A variety of infections including bacterial, viral, and fungal may occur commonly in the elderly population.

Bacterial infection :
Due to alteration in skin architecture and loss of barrier function both staphylococcus and streptoccal infections are seen frequently. 58  Treatment : Antivirals like aciclovir in the dose of 800mg 5 times per day for 5 days or valacyclovir 1gm tds for 5days or famiciclovir -0.5g tds for 7 days can be given . Ideally the treatment is to be started within 3 days of the appearance of rash. But in old age it can be started even after 3 days. 58

Post-herpetic Neuralgia
It is a commonest complication of HZ, defined as persistence or recurrence of pain in an affected area for more than 1month after the lesions have healed. 60 It is more common in patients more than 60yrs (50%). 61  Molluscum contagiosum : may occur in elderly but immunocompromised state must be ruled out. 8 It is characterized by dome shaped umblicated papules transmitted by skin to skin contact. It can be treated by needling, cryotherapy, electrodessication and curettage.
Onychomycosis : Toe nail onychomycosis is more common . It is caused by Trichophyton rubrum, mentagrophytes and Epidermophyton floccosum. 63 It most commonly presents with discolouration beginning at the free edge of the nail, lateral nail fold, subungual hyperkeratosis leading to separation of nail plate from the nail bed . It is usually asymptomatic in the elderly. The only problem it produces is,it is difficult to cut the nails with the ordinary scissors .
Diagnoses can be confirmed by nail clippings for KOH mount , fungal culture .
Finger nail onychomycoses is similar to that of toe nail onychomycoses . The nail plates become opaque and friable and has a yellowish colour . It can be treated with antifungal agents like terbinafine, itraconazole, fluconazole. 64 Tinea corporis : It is most commonly caused by T. rubrum . Lesions on the trunk and limbs are typically annular , this appearance is due to elimination of the fungus from the cen1tre of the lesion as the infection spread at the margins .
Diagnosis can be confirmed by scrapings from the edges of the lesion . It can be effectively treated with fluconazole, griseofulvin for 4-6 weeks .
Tinea cruris : It is uncommon in the elderly. It has a characteristic appearance which is often confused with intrtrigo, flexural psoriasis and sebhorreic dermatitis.Treatment includes both topical and systemic antifungal drugs. 8

Tinea Pedis
Usually presents as scaling pruritic areas in the toe-webs and on the soles of the feet. It occurs much more frequently in men. Tinea pedis is probably usually acquired as a result of contact with infected squamous debris on the floors of showers and swimming baths. It produces chronic, fine, scaling on the soles of the feet, toe webs.
The diagnosis can be confirmed by taking scrapings of scaling, mounting in 10% KOH, and examining the material under the micro scope.
Characteristic fungal mycelium can be seen. Tinea pedis usually responds to treatment with topical antifungal preparations like whitfield's ointment broad spectrum imidazoles -miconazole, clotrimazole, enconazole, sulconazole.
If topical therapy is not completely effective, oral antifungal drugs like fluconazole and griseofulvin for 6 weeks can be given. 65

Scabies
Scabies is often misdiagnosed in the elderly. It is due to the fact that elderly may not present with extensive inflamed or excoriated lesions, they might present only with features of xerosis. The infestation is acquired as a result of close physical contact with another individual suffering from scabies , for example, holding hands, or sharing a bed with an infested person. Transient contact does not lead to transmission of the parasite.
The major symptom of scabies is itching, characteristically worse at night. The itching is thought to be due to hypersensitivity to mite faeces, though there may be some contribution from burrowing activity of the mites. Scratching produces secondary eczematization and may introduce bacteria into the skin, resulting in folliculitis and/ or impetigo. In some patients, eczema is the major feature of their skin lesions, which are wrongly treated by steroids. It can be diagnosed by scrape of the roof of the burrow with a scalpel blade, then transferred to a microscope mineral oil are 10% KOH as a mounting medium. 1

Norwegian (crusted) Scabies
Norwegian scabies is so called because it was first described in Patients are frequently mentally recarded or suffering from dementia, this is more common in elderly.

Treatment
Gamma benzene hexachloride is an effective scabicide, and is nonirritant. This should be applied from neck to toes, and left on the skin for 8-12 hours then washed off. 5% permethrine is also commonly used . Single dose of oral ivermectin 200µg/kg body weight or two doses at an interval of two weeks can be given. 7

Pediculosis
Generally uncommon in elderly, scalp itching is the usual symptom due to acquired hypersensitivity to the saliva of the louse. If the hair is never washed then plica polonica (matted hair ) results. It can be treated with topical gamma benzene hexachloride or 1% permethrine . 7

Neoplasms
Both benign and malignant neoplasms have been noticed in the elderly population with increased frequency.

Seborrheic Keratosis (Senile wart, basal cell papilloma)
Seborrhoeic warts are the most common benign skin tumour seen in the elderly. The cause is unknown but a familial tendency has been suggested.The lesions are multiple, most commonly on the upper trunk and face. They start as sharply defined brown macules and develop into slightly raised, brown to black, oval papules, or into polypoidal lesions with a stuck-on appearance. The colour is even but may vary from skin coloured, waxy-yellow, lightly pigmented or dark brown to balck depending on the amount of melanin present.
Their size may vary from a few millimeters to several centimeters, their shape often ovoid, with the long axis along dermatomal lines. Their greasy appearance is not realted to seborrhea, the term seborrhoeic referring to their pattern of distribution.
It may mimic solar lentigo, lentigo maligna, pigmented solar keratosis, melanocytic naevi. The slight surface irregularity is the main clinical clue but biopsy confirmation is often necessary.
The eruptive pattern of numerous seborrhoeic warts (the Leser-Trelat sign) is indicative of associated internal malignancies like, gastrointestinal tract, breast and also leukemia, lymphoma and melanoma. 66 Two clinical variants will be described: Dermatoses papulosa nigra and stucco keratosis.

Skin tags (Fibroepithelial polyp, Acrochordon)
Skin tags are small firboepithelial polyps that are seen on the neck, axillae and groin of middle-aged and elderly people, increasing in frequency with age and obesity. They may be caused by simple outgrowths of the skin, pedunculated seborrhoeic warts or melanocytic naevi. They are often multiple, usually 1-4 mm in size rarely more than 3 cm. They are pigmented and multiple, primarily of cosmetic importance only. Skin tags are more numerous in some diseases such as acromegaly, acanthosis nigricans and polyposis coli. 73 Treatment includes electrodessication for small lesions, larger lesions should be excised.

Cherry angioma or Senile haemangiomata
Also known as campbell de Morgan spots or senile ectasia. They are dome shaped, bright red to purple in color, upto few cm in diameter. They commonly present over chest, trunk and upper limbs. Their number increases as the age advances. Sudden appearance of multiple lesions may accompany the development of an internal malignancy. 74 Histologically they are capillary hemangiomas.

Bowen's disease
It is a SCC in situ which occurs most commonly in fair skinned individuals. The highest incidence is in the sixth to eighth decade. Etiology includes exposure to chronic UVB radiation and arsenic, human papilloma virus (HPV) infection with oncogenic types like 16, 18, 39, 51,etc., metastases are rare. 75 Both sun exposed and covered sites are involved. 76 It is usually a single lesion, well circumscribed, round to oval, pink to salmon red or dark red, scaly patch or plaque, few millimeters to several centimeters in diameter. Surface may become hyperkeratotic, crusted, fissured or ulcerated.
Histopathology : it is thought to arise from outer root sheath of the hair follicle or the epidermal cells of the acrotrichium. There is hyperkeratosis, parakeratosis and acanthosis, full thickness epidermal dysplasia with an intact basement membrane. Atypical keratinocytes with loss of polarity having a "windblown" appearance. 77 Pagetoid cells are seen haphazardly throughout the epidermis. Moderate lymphocytic infiltrate is seen in the upper dermis.
Due to the cultural habit of chewing betel nut and areca nut is common in India, many elderly suffer from oral sub mucosal fibrosis. 78 Bidi smokers, common in many aged individuals is another cause for lip cancer.
Actinic keratosis: It is a premalignant condition that is more common in 65 years of age or older. 79 Main risk factor is UVB exposure. It develops on the skin exposed to UVB.

Keratoacanthoma (Molluscum sebaceum)
It is a common benign self-resolving tumour believed to arise from hair follicles. It is an abortive malignancy, rarely pregresses to SCC. 81 Ultraviolet radiation seems to be a major factor.It is three times more common in males. It has a peak incidence between 60 and 65 years. Contact with tar, mineral oil can also be a trigger. It is associated with carcinoma of the larynx, multiple internal malignancies, leukemia, HIV infection and it can occur in transplant recepients. 82 Over 50% occur on the face, followed by the back of the hands, ears, forearms, neck and legs. It predominantly affects sun exposed surfaces.

Squamous Cell carcinoma
Squamous cell carcinoma (SCC) is a second most common form of malignant tumour that arises from the epidermis or its appendages. It frequently arises on the sun exposed skin of middle aged and elderly individuals. Lifetime risk of developing SCC is 7-11%. 83 It has high risk of metastases. Most SCCs arise from actinic keratoses(0.025%-16%). 80 It is more common in men.
The different clinical types of SCC are as follows: 7 1) Keratotic or invasive SCC: it is a raised, firm, pink to flesh colored papule or plaque with smooth, verrucous, or papillated surface, and indistinct margins.
2) Nodular SCC: the lesion is more elevated with features similar to keratotic SCC.  Treatment : Electrodessication and curettage is indicated for small(less than 10 mm) lesions. Excision is done for tumours larger than 3 cm. 87 Other options are laser, photodynamic therapy. Radiotherapy is more suited to medium-sized lesions around the eye and generally is used more in the elderly because of less concern with the cosmetic result, and general lack of fitness of the patient for surgical intervention. 7

Basal cell carcinoma
Basal cell carcinoma (BCC) is a most common malignant tumour of the skin. 63 It is more common in adult males especially in the elderly. Male to female ratio is 3:2. It occurs on areas of chronic sun exposure. It is locally invasive, rarely metastasizes. It is composed of cells similar to those in the basal layer of the epidermis and its appendages. 88 It is recognized by the pearly waxy papules, with central depression, a rolled out or thready translucent border with erosion or ulceration, bleeding, crusting and telengiectasia. 89 Etiology includes ultraviolet radiation (mainly UVA to some extent UVB), ionizing radiation(X-ray and grenz ray), arsenic exposure, immunosuppression( HIV, organ transplants), 90 7 Acral lentiginous melanoma is more common in India. It is frequently seen on the soles than on the palms. 96 Superficial spreading melanoma is the most common type in light skinned people. 97 Sites of predilection are the back in men and the legs in women. It presents as a pigmented macule or patch with an irregular border that gradually develop into a thin plaque . Nodular melanomas begin as nodules without going through a phase of macular pigmentation. 98 They occur most frequently on trunk , followed by head and neck and legs . Some nodules may be amelanotic showing little or no pigmentation these may be difficult to diagnose clinically .

Pigmentation abnormalities
The most obvious senile changes in skin are pigmentation abnormalities.

Freckles (Ephelides)
These are small (less than 5 mm in diameter), circumscribed, poorly marginated, pale brown macules that appear exclusively on the sun exposed skin. Freckling is due to increased amount of melanin.There is no increase in number of melanocytes. 102

Idiopathic Guttate hypotmelanosis
Also known as disseminate lenticulate leukoderma. It is due to reduced number of melanocytes. They appear well circumscribed, like porcelain white chip inverted into the skin. They vary in size from few millimeters to 0.5 cm. It is most frequently found in anterior surface of legs and forearms. Other sites are chest, trunk and abdominal wall. Two clinical types. 1.Actinic type (seen in sunexposed sites), 2. non actinic type (seen in non sunexposed sites e.g. trunk). 103 Differential diagnosis includes vitiligo, Tinea versicolor, post inflammatory hypopigmentation. Histopatholgy shows deficient epidermal melanin, decreased number of melanocytes, incompletely melanised melanosomes. 104 Dopa reaction is reduced are absent.

Bullous Disorders
Blistering disorders like bullous pemphigoid and cicatricial pemphiogid are common in the elderly.

Bullous pemphigoid
It is generally a disease of elderly, the median age of onset ranges from 60 to 75 years. 105 It is more common in men. Although bullae are the most characteristic feature of bullous pemphigoid, they are not always present initially and the process may begin with a rather non-specific phase. This initial period or 'prepemphigoid is generally associated with intense irritation, which may precede the development of visible skin lesions by several months. Later, large, tense blisters develop both on an erythematous and on normal skin.
There may or may not be mucosal involvement. Histopathology shows subepidermal bullae with numerous eosinophils. 106 On direct immunofluoroscence there is linear deposition of IgG, C3 to the epidermal basement membrane zone.
Treatment includes topical steroids with topical antibiotics for mild disease .systemic drugs like prednisolone, azathioprine, intravenous immunoglobulin are used in more severe form of the disease .

Cicatricial pemphigoid :
It is also seen in elderly (the peak incidence is between the age of 60 and 80 years). 107 It is more common in women. It is a chronic subepidermal

Dermatitis Herpetiformis
Even though it is common in young adults it is also seen in elderly.It is intensely pruritic, chronic, recurrent papulo vesicular disease. The eruption is symmetrical, polymorphic, consisting of erythematous, urticarial, papular, vesicular or bullous lesions. It is associated with gluten -sensitive enteropathy.
Histopathology shows deposition of granular pattern of IgA in the papillary dermis, papillary tip microabscess. 109 Treatment : Dapsone is the mainstay of treatment. Gluten free diet mandates avoidance of wheat, barely, rye, oats

Linear IgA disease
It is a chronic acquired subepidermal disease of children and adults with cutaneous and mucosal involvement. Histopathology shows linear deposition of IgA antibody on the basement membrane zone. Adult form is most common after the age of 60yrs. 110 There is characteristic annular lesion with blistering around the edge.
Treatment includes topical and systemic steroids, dapsone, azathioprine, tetracycline can be used.

Drug eruptions
Elderly patients are generally on several medications due to the multiple medical disorders. Sudden onset of skin lesion in a patient without any prior skin disease should always raise the suspicion of drug eruption. 111

Psychodermatological disorders
Psychodermatological disorders seen in the older population include delusion of parasitosis, lichen simplex chronicus, neurotic excoriations and prurigo nodularis. Other disorders seen in elderly individuals are:

Leg ulcers
An ulcer is defect of epidermis and dermis produced by sloughing of necrotic tissue. It is a common problem in the elderly. It is due to chronic venous insufficiency, neuropathy due to diabetes , leprosy or tabes dorsalis and trauma.It is also seen in those with impaired mobility due to cerebrovascular accidents, chronic infections such as leprosy, tuberculosis, syphilis.

Lichen planus
It is an inflammatory, papulosquamous disorder affecting skin, nails, hair, mucous membranes. It is more common in females especially in 6 th decades. The classical lesions are pruritic, erythematous to violaceous, flattopped, polygonal papules and plaques distributed mainly on the flexor aspect of the extremities. It is associated with intense pruritus. Genital lichen planus is more common in elderly females. 120 It is essential to exclude lichenoid drug eruptions due to drugs in elderly individuals.

Psoriasis
It can occur at any age. There is a bimodal age of onset, the first peak at 15-20 years, second one at 55-60 years. 121 It presents as chronic, symmetrical, well defined erythematous, dry red scaly papules and plaques situated most commonly over extensor aspects of extremities, scalp, palms and soles.
Involvement of joints, nails is also common. Treatment includes topical keratolylitcs, emollients. Systemic drugs like methotrexate may be considered , if hepatic and renal fuctions are normal.

Lichen sclerosus et atrophicus (LSEA): (white spot disease, lichen albus)
It is a chronic inflammatory dermatoses with relapsing and remitting course, that causes significant discomfort and morbidity. It is most commonly seen in adult women, but also in men and children. Any skin site may be affected but it is more common in the anogenital area (85-98%) with intractable itching and soreness, progression destructive scarring is common. Extra genital LSA is less common (15-20%).
It has a bimodal peak in incidence from prepubertal children to post menopausal age group in women, male to female ratio of 10:1 to 6:1.

Erythroderma
It is a generalized inflammatory skin disorder manifesting with erythema and scaling affecting more than 90% of the body surface area. It can be classified as primary erythroderma arising on normal looking skin due to an underlying systemic disorder or drugs. Secondary erythroderma arises from preexisting dermatoses. It is more common in males.
Clinical features include erythma and scaling involving more than 90% of body surface area. 125 Large scales are seen in acute cases and smaller one in chronic cases. There may be enlargement of lymph nodes, it is called dermopathic lymphadenopathy,which should not be mistaken for lymphomas.
Systemic manifestations include fever or hypothermia, malaise, chills and bodyache. There may be high output cardiac failure.
Underlying causes must be ruled out. Drug induced erythroderma and erythroderma arising from preexisting dermatoses has good prognosis.

Recently described entities :
Senescent actinic depigmentation of scalp was recently described.
Predominantly in men, but rarely seen in women, with androgenic alopecia in persons aged older than 65 years. 126 Patients present with hypopigmented and depigmented macules on the scalp. Yoga sign is another recently described condition that is seen in people sitting cross legged on hard floors without carpets 127 .

STUDY DESIGN
This is a descriptive study of new patients attending outpatient clinic in the Department of Dermatology, Venereology, Leprosy at Coimbatore Medical college hospital, Coimbatore.

INCLUSION CRITERIA
All patients aged more than 60 years and above attending the outpatient clinic were included .

EXCLUSION CRITERIA
Severely ill and immunocompromised individuals.

METHOD OF COLLECTION OF DATA
 Informed consent was taken from all the patients prior to the examination.
 Detailed history including the duration of the disease, site of involvement, occupation, leisure activities and demographic details were taken.
 Thorough systemic & dermatological examination will be done.
 Investigations like complete blood count, liver function test, renal function test, random blood sugar was done.
 Other investigations like KOH mount, Tzanck smear, skin biopsy, immunofluorescence was done for all relevant cases or if the diagnoses could not be arrived clinically.
 All these data were recorded in a proforma, tabulated and analyzed statistically

OBSERVATION AND RESULTS
A total of 150 cases with age above 60 years attending OPD of Coimbatore Medical College Hospital were included in the study

CHART 4: ASSOCIATED DISASES
In our study diabetes mellitus was the commonest associated disease seen in 45 cases (30%), followed by hypertension in 40 cases (26.6%), both diabetes mellitus and hypertension was seen in 10 cases, anaemia in 9 cases (6%), bronchial asthma in 8 cases (5.3%), ischaemic heart disease in 7 cases

Total 17
In our study among the 17 cases of papulosquamous disorders psoriasis was seen in 12 cases and lichenplanus in 5 cases.    Squamous cell carcinoma 1

Grand Total 5
Among the premalignant conditions 1 case of Bowen's disease was seen. The most common malignant condition seen in our study was basal cell carcinoma seen in 3 cases,and squamous cell carcinoma of lips was seen in 1case. Pemphigus vulgaris 3

Grand Total 10
Bullous pemphigoid was seen most frequently among the bullous disorders in 7 cases, pemphigus vulgaris in 3 cases.

DISCUSSION
Ageing is defined as an irreversible process, beginning or accelerating at maturity, which results in an increased range or number of deviations from an ideal state. Old skin is dry and rough, atrophic, wrinkled, unevenly pigmented, shows loss of elasticity, and is prone to develop a number of tumors. 3 Ageing skin has susceptibility to dermatological disorders due to the structural and physiological changes that occur as a consequence of intrinsic and extrinsic ageing.

NUMBER OF CASES IN RELATION TO AGE AND SEX
In this study, a total of 150 patients varying in age from 60-91 years were examined. Of these, 93 patients (62%) were males and 57 (38%) were females.

SKIN CHANGES WITH AGEING
Ageing skin is particularly vulnerable to environmental insults due to the structural and physiological changes that occur as a consequence of both intrinsic and extrinsic ageing.

a) Xerosis
It literally means dry skin. It is called as asteatotic eczema, when it is associated with eczematous changes. It was a common finding in our study and observed in 96 patients out of 150 (64%).
Chopra et al 135 noticed in 108 (50.8%) cases. Beauregard and Gilchrist 131 found in 85% of cases. Tindall and Smith 134 observed an incidence of 77%.
Our study was similar to Chopra et al observation.

b) Wrinkling
This was a next most common finding in our study and observed in 84 patients out of 150 (56%). This incidence was lower than found in other studies. Beauregard  Grover and Narasimhalu 136 seen in 13 cases (6.5%).

e) Senile lentigenes
In our study senile lentigenes was found in 12 cases out of 150 (8%).It was comparable to the study conducted by Patange and Fernandez 128 who observed an incidence of 12%. Beauregard and Gilchrist 131 noticed it in 70.6%.
Tindall and Smith 134 reported an incidence of 51%. Racial influence could be the cause for lower incidence seen in our study.

4) PATHOLOGICAL SKIN CHANGES
In this study following pathological skin conditions were observed : observed contact dermatitis in 2% and seborrehic dermatitis in 3.6%.
Incidence of eczema in our study was higher than found in other studies.
Our study was similar to Johnson study in contact dermatitis and to Beauregard and Gilchrist observation in stasis eczema.

a) Papulosquamous disorders:
It includes psoriasis and lichen planus in this study.
In this study psoriasis was seen in 12 cases out of 150 (8%),which was similar to that seen by Patange
Incidence of lichen simplex chronicus in a study conducted by Chopra et al 135  which was comparable to our study. The incidence of other psychocutaneous disorders in our study was lower than that found in other studies.

f) Miscellaneous skin conditions
In our study, cutaneous amyloidosis (macular, lichen) was seen in 10 cases (6.6%), leg ulcers seen in 8 cases (5.3%), chronic urticaria was seen in 4 cases of acrokeratoelastoidosis marginalis in their study. We couldn't find incidence of other conditions in previous studies.

HAIR CHANGES
Graying of hair was seen in nearly all cases. In our study 64.91% of females showed diffuse thinning of hair.Androgenetic alopecia was seen in 70 out of 93 males (75.26%). Interestingly one case of plica polonica (matted hair) was seen in our observation.
In a study conducted by Patange 128