# Geriatric Skin

> Geriatric skin for NEET-PG Dermatology: asteatotic eczema, bullous pemphigoid, crusted scabies, pruritus workup and Leser-Trelat sign.

- Canonical URL: https://prepelephant.com/topics/neet-pg/dermatology/geriatric-skin
- Exam / course: NEET-PG · Subject: Dermatology
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Geriatric Skin", PrepElephant, https://prepelephant.com/topics/neet-pg/dermatology/geriatric-skin

## 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.