Geriatric Skin
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Direct answer
Skin past the age of sixty dries, thins, bruises and itches — and each of those complaints is either normal ageing or the surface of internal disease, which is the geriatric dermatology skill. Xerosis with crazy-paving shin fissuring is asteatotic eczema, managed with lukewarm bathing, bland emollients and urea creams. Generalised pruritus without primary lesions obliges a workup — cholestasis, uraemia, thyroid disease, iron deficiency, lymphoma and drug causes — before the label "senile pruritus" is permitted. The tense bullae and urticarial plaques of an elderly patient signal bullous pemphigoid, the commonest autoimmune blistering disease of old age; hyperkeratotic crusted scabies spreads silently through nursing homes; and a sudden crop of seborrhoeic keratoses with internal malignancy is the Leser-Trelat sign. Any non-healing ulcer or chronic scar earns a biopsy, because Marjolin's ulcer waits inside.
What you must remember
- Asteatotic eczema (eczema craquele): dried, fissured, crazy-paving shins of winter and over-bathing; treat with emollients containing urea 10 per cent, short lukewarm baths, soap substitutes — and check thyroxine status in refractory cases.
- Pruritus workup list (the exam loves the order): full blood count with smear, fasting glucose, renal and liver profiles, thyroid function, ferritin, HIV and chest radiograph — lymphoma and cholestasis being the hunts that matter most.
- Bullous pemphigoid anchors: over-seventies, tense bullae and urticarial plaques, intensely itchy; linear IgG and C3 at the basement membrane with antibodies to BP180 (NC16A domain) and BP230; associated with dementia and Parkinson disease; limited disease takes potent topical steroids, extensive disease prednisolone 0.5 mg/kg plus steroid-sparing agents, with doxycycline-nicotinamide a studied alternative.
- Crusted (Norwegian) scabies: hyperkeratotic, psoriasiform, minimally itchy because of immunosenescence, teeming with mites, explosively contagious in institutions — isolate, treat with ivermectin 200 micrograms/kg plus permethrin, and treat contacts.
- Two marker signs: senile (actinic) purpura — non-palpable purple patches on forearms and dorsal hands without thrombocytopenia, from vessel and dermal atrophy, benign; and the Leser-Trelat sign — abrupt crops of seborrhoeic keratoses with internal malignancy, classically gastrointestinal adenocarcinoma.
- Herpes zoster in the elderly: treat with antivirals within 72 hours of rash onset to blunt post-herpetic neuralgia, whose risk climbs steeply with age.
- Ulcer discipline: a venous ulcer or chronic scar failing to improve over six weeks to three months of adequate care deserves biopsy for squamous carcinoma — the Marjolin rule.
- Indian realities: pressure-ulcer prevention over the sacrum and heels of bedridden elders, polypharmacy review for drug eruptions (thiazide photosensitivity a classic), and households applying topical steroids for every itch.
One elderly itch, worked through systematically
An 82-year-old widow, frail, attends with three months of generalised itching without rash, sleeping in two chairs, on amlodipine, a thiazide and paracetamol. Examination finds no primary lesions — only shin xerosis and linear excoriations across the back. The systematic layer comes first: the count shows microcytic anaemia with low ferritin — iron deficiency, so colonoscopy follows, the consult's most important decision; alkaline phosphatase is mildly raised but antimitochondrial antibodies return negative; renal and thyroid function, chest radiograph and smear are unremarkable. The symptomatic layer runs in parallel: soap substitution, urea 10 per cent cream, short nails, and a cautious night-time sedating antihistamine given falls risk. Six weeks on, iron therapy has lifted the haemoglobin and the itch together — and the lesson stands: in the elderly, an itch workup is an internal-medicine workup wearing a dermatology coat.
Where candidates slip
The reflex sin is dismissing the elderly itch as dry skin: "senile pruritus" is a diagnosis of exclusion — after cholestasis, uraemia, thyroid disease, iron deficiency and lymphoma are excluded, the list itself is the answer being tested. The second slip is pemphigoid recognition: candidates anchor on blisters and miss the pre-bullous urticarial, intensely pruritic stage that dominates real practice, or confuse linear IgG-C3 basement-membrane fluorescence with pemphigus vulgaris's intercellular fishnet. Third, the crusted scabies trap: minimally itchy, scaly, "psoriasis-like" plaques in an institutionalised elder are not treated as psoriasis — the mite burden and the contact-treating obligation are the examined facts. Finally, ulcer neglect: the six-week non-healing rule and Marjolin's ulcer turn a dressing question into a biopsy decision, which is precisely how the viva frames it.
Frequently asked questions
Which diseases must be excluded before labelling senile pruritus?
Cholestasis, chronic kidney disease, thyroid dysfunction, iron deficiency, lymphoma and other malignancy, HIV, and drug causes — in that practical order.
What distinguishes bullous pemphigoid immunopathologically?
Linear deposition of IgG and C3 along the basement membrane zone, with antibodies to BP180 and BP230, versus pemphigus's intercellular IgG pattern.
Why is crusted scabies a public-health emergency in nursing homes?
Minimal itch masks enormous mite loads, so undiagnosed cases seed outbreaks among residents and staff, demanding isolation and simultaneous contact treatment.
What is the Leser-Trelat sign?
A sudden eruption of numerous seborrhoeic keratoses accompanying internal malignancy, classically gastrointestinal adenocarcinoma.
When does a chronic ulcer in the elderly mandate biopsy?
When it fails to heal despite six weeks to three months of appropriate care, to exclude Marjolin-type squamous cell carcinoma in the ulcer base or scar.