Careful Attention to Aging Skin

By Jaimie Lazare
Aging Well
Vol. 5 No. 5 P. 18

Aging makes skin more susceptible to dryness. Dry skin in older adults can be simply a sign of age-related skin changes or signify underlying medical problems. Because dry skin can lead to other skin complications, it’s important to monitor carefully.

If older adults’ skin appears rough, scaly, flaky, or cracked, this can indicate xerosis, or dry skin. Although dry skin can affect anyone, it’s particularly common among older adults. Age-related dermal changes such as a thinner epidermal layer, a reduction in skin cell turnover, and the skin’s limited capacity to retain moisture contribute to xerosis.1 Over time, skin loses its suppleness, yet such physiological changes alone don’t determine whether a patient will develop dry skin. Other factors such as the environment, genetics, and ethnicity are also contributing factors.

Skin loses its elasticity as the production of collagen and elastin decreases. Additionally, hyaluronic acid isn’t produced at the same rate as in earlier stages of life, creating an imbalance between the production of hyaluronic acid and its breakdown by enzymes. Because of these changes, skin becomes progressively thinner, more fragile, less elastic, and drier. Even the natural oil-producing sebaceous glands gradually lose their ability to moisturize the skin. All of these physiologic changes contribute to the development of drier skin as people age, says Charles E. Crutchfield, III, MD, a clinical professor of dermatology at the University of Minnesota Medical School and medical director of Crutchfield Dermatology.

Even as early as the age of 40, the skin becomes more susceptible to drying. Lipids primarily act by preventing evaporation of the natural moisture in the skin, providing a barrier to water loss. Without adequate lipids, people simply lose too much water from the skin and it dries out, according to Jamie B. MacKelfresh, MD, an assistant professor in the dermatology department and director of the Dermatology Residency Program at Emory University School of Medicine in Atlanta.

Underlying Causes 
In addition, older adults often have comorbidities for which they take many medications. Multiple conditions and numerous medications can contribute to dry skin in older adults, MacKelfresh says. Diuretics as well as renal, cardiovascular, and thyroid problems can contribute to xerosis, she says.

Crutchfield notes that older adults’ skin has an increased tendency toward dryness because of the decreased production of moisturizing sebaceous oils. As a result, the practice of taking long hot baths or showers without the application of a moisturizer or emollient immediately afterward is a common contributor to drying out older adults’ skin. Also, some older adults were raised to do a lot of scrubbing, washing, and extra cleansing of the skin, but exfoliants, harsh cleansers, and alcohol-based products such as astringents further dry aging skin that’s already predisposed to dryness, MacKelfresh says. These products remove more of the essential skin oils necessary to help keep the skin moist and retain water.

It’s also important to warn patients against using a lot of waterless antibacterial cleansers since these also contain alcohol that can dry out the skin. Even over-the-counter antiaging creams can be quite drying and actually harsh on the skin.

Assessing Xerosis 
Physicians should use a three-pronged approach when assessing older adults’ skin for signs of xerosis. Find out how long a patient has been experiencing problems with dry skin, determine whether the dry skin is widespread or concentrated, and ask whether a patient uses moisturizing lotions or creams and if so, whether they help or worsen the dry skin.2 A focused history is key for identifying and treating xerosis appropriately and reducing the risk of infection or sequela brought on by pruritic symptoms associated with dry skin.3

“A common symptom of dry skin is itching, and severe itching can lead to an itch-scratch-rash-itch cycle. The skin may become thickened in these areas from rubbing, and repeated skin rubbing in the same area may lead to chronic skin conditions called lichen simplex chronicus and prurigo nodularis,” says Rita Pichardo-Geisinger, MD, an assistant professor of dermatology at Wake Forest University in Winston-Salem, North Carolina.

Crutchfield stresses the importance of asking patients how long they have been dealing with dry skin. Assessing the duration of the skin dryness is important because it may be a condition called ichthyosis, which is a congenital defect that can develop with time and aging. If the dry skin appears to be severe or has occurred suddenly, it would require further investigation, he says.

MacKelfresh agrees on the importance of identifying the time of onset. “If somebody comes on with brand new dry skin that sort of came out of nowhere, then that is a clue that we might want to look into other things. For instance, heat stroke could be an underlying disease that is causing dry skin. Also, fungal infections of the skin can be a common cause, particularly in nursing homes and other care settings. So if it’s new and different, we definitely need to pay attention to make sure we’re not missing something else,” she says.

Many older adults may not be bothered by their dry skin. While performing a general exam, physicians will likely see dry skin on the legs. After looking at the legs, be sure to examine a patient’s arms. Ask whether he or she is experiencing flaking, itchy, irritated, or even sore skin, MacKelfresh says.

Crutchfield notes that while assessing dry skin is fairly easy, there are some rare issues physicians need to be aware of, especially in patients of color. On the lower leg, a condition called ichthyosiform sarcoidosis can occur, also with generalized exfoliating dermatitis, which can be confused with dry skin. Under these circumstances it’s appropriate to look for internal malignancy, according to Crutchfield.

While studies addressing the differences in ethnic skin are limited, one study has reported greater transepidermal water loss and desquamation in African American skin.4 Pichardo-Geisinger says that while transepidermal water loss appears to occur more in African Americans due to the characteristics of the stratum corneum and reports have pointed out that people of Anglo-Saxon origin have more fair, dry thin skin, the clinical focus doesn’t rely heavily on such factors. “I believe dry skin is due more to internal or external factors than race or ethnicity,” she says.

Conservative Treatment to Start
“We almost always start patients on a nonprescription approach because treating xerosis is pretty simple, and it doesn’t have to be expensive,” MacKelfresh says. Thicker moisturizers work better because the thinner water-based lotions won’t help skin retain its moisture. Suggest that patients keep a moisturizer in the bathroom and apply a thick moisturizer within three minutes of taking a bath or shower and apply it more than once per day, she says.

“If that’s still not working, then there are some other products that contain alpha-hydroxy acids, which will help break down some of those thickened, dry skin cells. And you can find some of those over the counter. Beyond that … there are sometimes areas where you actually need to calm the skin inflammation with a cortisone-based cream,” MacKelfresh says.

Crutchfield recommends that his patients gently pat dry their skin with a cotton towel after a bath or shower, then apply a liberal amount of emollient moisturizing lotion. “The most important thing in preventing dry skin is using a gentle cleanser that does not contain harsh detergents, such as Vanicream cleansing bar and a good moisturizing emollient such as CeraVe cream or AmLactin XL lotion,” he says.
“For my patients who have extremely dry skin, I suggest they use AmLactin XL lotion once a day in addition to another moisturizer. AmLactin XL contains ammonium lactate that functions as a humectant, and it also causes the production of moisturizing oils in the skin,” Crutchfield adds.

“I recommend a fragrance-free regimen,” Pichardo-Geisinger says, “which consists of mild soaps and moisturizing lotions on a regular basis, particularly over-the-counter products with ceramides, such as Cetaphil Restoraderm or CeraVe, and products with oatmeal, like Aveeno Eczema Therapy; Vaseline Clinical Therapy is also excellent. A lactic acid lotion will improve the skin condition. Excellent over-the-counter products such as AmLactin 12% or Aqua Glycolic, which restore the skin’s adequate moisture balance, are recommended. In some cases a topical steroid cream needs to be used.”

As a precaution, only mild corticosteroid creams such as hydrocortisone should be applied to sensitive skin areas, which include the face, underarm, and groin. Using strong corticosteroid creams such as clobetasol for a long period of time may lead to skin problems such as thinning, stretch marks, and skin breakdown.5

Pichardo-Geisinger recommends that older adults avoid strong soaps and detergents, wear cotton and natural fiber clothing, avoid wool clothing, drink plenty of water, use a humidifier in the home when necessary, and limit sun exposure.

Special Cases
MacKelfresh recalls the case of an 85-year-old woman who was wheelchair bound. The woman’s daughter brought her to the office with a complaint of a severe itch and flaking skin on her shins that had recently developed during the winter. An examination revealed dry skin on various parts of the patient’s body but significant erythema, xerosis, and fissuring over her shins. The skin also displayed evidence of scratching in those areas.

MacKelfresh concluded that her patient’s condition was caused by the seasonal change, and her xerosis had transformed into dermatitis. She prescribed a topical steroid cream and provided the patient with careful instructions to use only gentle soap, take short warm (never hot) baths or showers, and apply a thick moisturizer within three minutes of bathing. By her four-week follow-up appointment, the patient’s skin had improved dramatically, and she no longer needed the steroid cream.

It’s important to carefully evaluate patients’ dry skin, particularly those with preexisting conditions such as diabetes or dementia. For those patients, be sure to do a thorough exam by looking for dry skin areas before they become problematic. “In a diabetic patient, if it’s left too long and they’re already having foot ulcers, more dry skin could just make them more prone to dermatitis and ulcers,” MacKelfresh says. “Make sure the caregiver in the situation of a patient with dementia or the physician who’s caring for a diabetic is also on board with your plan. So utilizing multiple members of the team is going to be key in those scenarios as well.”

Whether or not older adults are able-bodied and mobile, Crutchfield suggests using triamcinolone cream twice per day for one week to control itching in dry skin with an inflammatory component.

As the number of baby boomers in the United States grows, it is becoming increasingly important for clinicians to recognize and treat elder patients for skin problems. While prevention is key, treating dry skin is fairly easy and affordable.

— Jaimie Lazare is a freelance writer based in Brooklyn, New York.

Advice for Patients
Rita Pichardo-Geisinger, MD, an assistant professor of dermatology at Wake Forest University, offers some practical advice to help patients and their caregivers prevent and reduce the risk of developing dry skin:

• Wash gently. Avoid hot baths, frequent showering or bathing, and excessive skin scrubbing. Keep the water warm because hot water tends to strip away the natural oils produced by the skin. Use mild cleansers for the face and body such as Dove unscented, Cetaphil Restoraderm, CeraVe, or Aveeno. Avoid overwashing with harsh soaps and overusing alcohol-based products such as sanitizers and cleansing agents that are drying to the skin.

• Hydrate skin. Keeping dry skin hydrated is the best way to avoid potential problems such as itchiness and cracking. The best recommendation is to use a fragrance-free moisturizer. Among the effective products available over the counter are Cetaphil Restoraderm, CeraVe, Aveeno Eczema Therapy, Vaseline Clinical Therapy, AmLactin 12%, and Aqua Glycolic.

• Prevent itch. Elderly skin care is all about preventing dry skin. Aging skin requires special attention because it’s prone to dryness, which leads to itch and scratching. Moisturizing the skin will keep it hydrated and help to prevent the itch-scratch-rash-itch cycle.

• Pay attention. Examining elderly patients should always include evaluating their skin for signs of cancer or other conditions. Be sure to look for new growths or moles that appear to be changing. Identify skin changes such as peeling, chapped, red, or pruritic skin.

• Check patients’ feet. In older individuals the skin of the feet often gets dry and becomes susceptible to corns, calluses, warts, and fungal infections. Inspect patients’ feet and remind them (or their caregivers) to examine their feet. It is important to check the feet regularly, especially in patients with diabetes.

— JL

References
1. Pons-Guiraud A. Dry skin in dermatology: a complex physiopathology. J Eur Acad Dermatol Venereol. 2007;21 Suppl 2:1-4.

2. White-Chu EF, Reddy M. Dry skin in the elderly: complexities of a common problem. Clin Dermatol. 2011;29(1):37-42.

3. Lazare J. Ambiguous itching. Aging Well. 2011;4(3):22-24.

4. Wesley NO, Maibach HI. Racial (ethnic) differences in skin properties: the objective data. Am J Clin Dermatol. 2003;4(12):843-860.

5. Cole GW. What is the treatment for dry skin? http://www.medicinenet.com/dry_skin/page5.htm. Last reviewed January 18, 2012. Accessed July 1, 2012.