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Eczema in the elderly

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					     Eczema in the elderly


     Dr Alyson M Bryden, Specialist Registrar in Dermatology at Ninewells Hospital
     and Medical School in Dundee, examines common skin issues in later life.

     Atopic eczema is on the increase and        consists of dry, scaly skin, usually on      become leaky leading to large, dilated
     has trebled in frequency over the past      the shins, but which may also involve        and tortuous veins (varicose veins).
     30 years. As it is most common in           the arms and hands. The skin                 This process may be exacerbated if the
     children and young people, the focus        appears dry with fine superficial            patient has a history of deep venous
     of attention has centred on this group.     cracking sometimes referred to as a          thrombosis, a family history of varicose
     It is important to remember however         'crazy-paving' pattern.                      veins, is overweight, has damaged
     that eczema also affects the older          Sometimes bleeding may occur due to          joints or muscles in the leg that may
     generation and, as our population           this cracking of the skin. It often starts   stop blood being pumped back up the
     gets healthier and more of us are           in winter and may clear in summer,           veins effectively, or sits for long periods
     living longer, it is likely to become       but eventually can cause problems all        of time with their legs hanging down.
     more of an issue. Eczema does not           year round.
     respect age or general health. It can                                                    Varicose veins can cause varicose
     affect anybody, at any age, and does        As in most forms of eczema, the              eczema to appear, and both are
     not require any background genetic          treatment is to minimise water loss as       common in the elderly. It is thought
     pre-disposition. It can present in          much as possible and the use of              that as many as 20% of people over
     unusual ways in the elderly, have           moisturisers (emollients) is essential.      70 may suffer with this condition. The
     different causes or aggravating factors     These should be used at least twice a        skin changes are thought to be the
     compared to eczema in the young             day, along with appropriate                  result of damage to the small blood
     and can present challenges when             moisturising bath or shower                  vessels in the skin, which is secondary
     recommending treatment. In this             preparations. Avoiding abrupt                to increased pressure in the veins.
     article I will discuss the most common      temperature changes can also be              Red, scaly areas that are often itchy
     types of eczema that may affect older       helpful (e.g. taking lukewarm baths or       can develop. They usually appear
     people and suggest which treatments         showers).                                    initially on the inner lower leg, but can
     are suitable.                               Reducing the frequency of bathing can        spread if untreated to involve other
                                                 also be helpful and short baths or           areas on the same leg, the other leg,
     Asteatotic eczema                           showers are recommended in order to          or occasionally on other parts of the
                                                 minimise water loss in the skin.             body.
     It is known that skin becomes drier as      Moisturising soap substitutes should
     we grow older and this usually                                                           Varicose eczema can also occur
                                                 be used, as soap tends to dry out the        directly over a varicose vein. The main
     manifests in our 50s, often initially       skin and worsen the condition.
     affecting the lower legs. This change is                                                 aim of treatment is to correct the
     thought to be due in part to a                                                           venous hypertension that is causing
     disturbance in the fatty layer present in   Stasis dermatitis or                         the problem. This may be done with
                                                                                              support stockings or compression
     the very outer part of skin that helps      varicose/gravitational                       bandages, which help to pump blood
     retain moisture.1 It can be exacerbated     eczema
     by increasing age, underlying illness,                                                   back up the leg.
     malnutrition, skin cleansers/solvents,      As humans walk upright, the leg veins        Venous surgery in the form of vein
     minor trauma, low humidity and dry,         are under enormous pressure                  'stripping' or injection may be
     cold, windy weather.                        throughout our lives. Decades of             recommended in suitable patients.
                                                 pumping blood back up the legs to            Lifestyle changes are important, i.e.
     This disturbance in skin barrier            the heart can eventually lead to wear
     function may lead to asteatotic                                                          losing weight, calf muscle exercises,
                                                 and tear of these delicate structures.       etc. Skin treatments include the liberal
     eczema (also known as eczema                Valves that stop blood from going
     craquelée or winter eczema). It                                                          and regular use of bland moisturisers
                                                 back down into the legs again can
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and also moderately potent steroid           However, older people seem to be             and the development of positive
ointments (if required).                     more susceptible to becoming allergic        reactions may be delayed compared
All skin treatments of varicose eczema       to some chemicals frequently used in         to the younger age group.3
should be kept as simple as possible         skin creams, ointments and dressings.
as it is known that these patients and       This is thought to be due to the fact        Discoid eczema
those with venous ulcers are                 that older people tend to use a lot of
                                             these products in the treatment of dry       Discoid eczema (also known as
particularly prone to developing                                                          nummular eczema) is a type of
contact allergies to constituents of         skin, leg ulcers, etc.
                                                                                          eczema characterised by the typical
creams, ointments, dressings and             Care should be taken when                    round or coin-shaped areas of
sometimes even bandages.2                    interpreting positive/allergic patch test    eczema that develop, usually on the
If a contact allergy is suspected then       results in elderly people as the intensity   limbs and buttocks. It can be an
patch testing to suspected chemicals         of positive reactions tends to be less
should be performed by a
dermatologist. It is important to
recognise and treat varicose eczema
and any underlying venous
hypertension, as their existence means
that the skin of that leg is very
vulnerable and at high risk of
developing a venous ulcer. As in most
things, prevention is better than cure –
once a venous ulcer has developed it
may take many months of intensive
treatment to heal again.


Allergic contact
dermatitis
This condition occurs when an
individual becomes allergic to a
specific substance in their
environment. The skin retains
specialised white cells (lymphocytes)
that 'remember' this allergy and will
cause a strong reaction when the skin
is re-exposed to it. This eczematous
reaction is often worst at the site of re-
exposure.
For example, if a person who has
become allergic to nickel commonly
handles money (which contains this
metal), the hands will often be the
worst-affected area. It has been
suggested that contact allergy in
general becomes less common with
advancing age.

                                                                                                                                13
     intensely itchy condition and may          strength possible that controls              oral anti-yeast tablets have been used
     cause significant distress.                symptoms), soap substitutes, lukewarm        in severe outbreaks.
     The lesions can be very inflamed, red      baths or showers, wearing cool, non-
                                                wool clothing, and taking sedative
     and weeping, or more commonly are
                                                anti-histamines at night if required.
                                                                                             Eczematous drug
     thickened and scaly in texture. It is                                                   eruptions
     classically seen in elderly males,         A number of older people will also be
     particularly in winter, although women     taking a variety of other medication,        Many medications may cause a rash
     may also develop this unpleasant           which may interact with anti-                as a side effect. In some cases this
     condition. The initial patch usually       histamines. These tablets may also           may be mistaken for eczema. The risk
     arises on the lower leg and may then       cause confusion or an excessive              of developing an adverse reaction to
     spread to other areas. Infection with      sedative effect in the elderly and           a medication increases as one gets
     bacteria, often caused by scratching,      caution should be advised.                   older, is higher in those taking multiple
     can occur.                                                                              medications (often the elderly), and is
                                                Other treatments may include                 thought to be more common in
     This type of eczema unfortunately          phototherapy or the                          women.
     tends to be chronic and is often worse     immunosupressants topical tacrolimus
     in winter. Treatments include emollients   or pimecrolimus. Oral                        If a rash begins suddenly it is always
     (creams and/or bath oils to correct        immunosupressant therapy may be              worth looking at any recent new
     dryness) and strong topical steroid        recommended in severe cases.                 medication to see if it may be to
     ointments. Antiseptic creams or                                                         blame. The GP can usually change
                                                                                             any suspected drug for an alternative
     lotions to control infection can be        Seborrhoeic eczema                           preparation. Don't forget that over-the-
     useful and antibiotics may be required
     if secondary infection of the plaques of   This condition commonly affects              counter medicines such as painkillers,
     eczema with bacteria occurs.               babies and is known as cradle cap. In        cough treatments, vitamins can also
                                                adults, it tends to start in puberty as it   cause reactions.
     If potent topical steroids are of no       is linked to activation of the sweat
     help, the newer topical                                                                 The same is true for herbal remedies,
                                                glands in the skin and an abnormal           homeopathic treatments and Chinese
     immunosupressant ointments such as         reaction to the common yeast known
     tacrolimus have been reported to be                                                     medicines. Always tell your doctor if
                                                as Malassezia. It is not infectious.         you are taking anything 'extra' that they
     of use. Coal tar preparations either on
     their own or in combination with weak      Although generally less severe, the          may not be aware of.
     topical steroids can be helpful.           condition is often found in the elderly.     The rash caused by a drug reaction
     Phototherapy (light treatment) either in   It tends to affect the areas of skin         may take many weeks or months to
     the form of UVB or PUVA (UVA light +       where sweat glands are most                  resolve and until it does treatment
     psoralen tablets) will often help to       prevalent, i.e. scalp, face and upper        should take the form of that for
     clear acute attacks.                       trunk. Scalp dandruff is often               eczema – i.e. emollients, topical
                                                associated. Red, flaky skin may              steroids if required, soap substitutes
                                                develop on the forehead, eyebrows,           and good general skin care.
     Atopic eczema                              eyelashes, around the nose and on
     Readers of this magazine will be well      the chest and back.                          The treatment of eczema in older
     versed in the background and                                                            people can be challenging due to a
                                                There is no permanent cure for               number of factors:
     treatments of atopic eczema. Although      seborrhoeic dermatitis but the
     less common in older people, atopic        condition can be suppressed with             • Most forms of eczema are extremely
     eczema may arise 'out of the blue' in      treatment. Medicated shampoos to               itchy and can cause marked distress.
     some, or may persist throughout            control dandruff, mild topical steroids        This can be severe in the elderly as
     adulthood in others.                       (often combined with an anti-yeast             they may live alone and have no
     Treatment is as for atopic eczema in       cream), ketoconazole cream and                 support. Symptoms are often worse
     the young, i.e. regular moisturiser use,   frequent washing with soap and water           if there is no one to turn to.
     topical steroids (preferably the weakest   can all be useful. Phototherapy and            Understanding and empathy are
                                                                                               very important.
14
• Creams can be tricky to apply. Is the       may be required on a regular basis,      Tavadia S, Bianchi J, Dawe RS et al. (2003)
                                              e.g. for application of treatments,      Allergic contact dermatitis in venous leg ulcer
  person even able to open the tube?                                                   patients. Contact Dermatitis, 48 (5), 261-65
  If they have visual impairment, how         for assessment, or for phototherapy.
                                              A number of elderly people either                             ,
                                                                                       Piaserico S, Larese F Recchia GP et al.
  will they know what is a moisturiser
                                                                                       (2004) Allergic contact sensitivity in elderly
  and what is a steroid? Arthritis in the     don't drive or have given up their
                                                                                       patients. Aging Clin Exp Res. 16 (3), 221-25
  fingers can make it extremely               licenses. Although patient transport



                                                                                         Clothes
  difficult to squeeze out and put on         is available, in my experience this
  treatments. If the eczema is on the         may be unreliable and time-
  back or lower legs, are they able to        consuming. They may therefore


                                                                                          Line
  reach these areas? If an individual         need to enlist the assistance of
  has any of these difficulties, who is       family or friends for transport.
  going to help them – a family             Due to the above confounding factors,
  member, friend, carer or district         it is often necessary to admit elderly
                                                                                        The clothes line is an opportunity
  nurse? As most treatments are at          people to dermatology wards for the
                                                                                        for members to pass on and find
  least twice daily this can be a huge      treatment of eczema. This will become
                                                                                        outgrown or unwanted (but good
  commitment. It is important to            more difficult in the years to come with
                                                                                        condition) cotton clothing.
  recognise that an elderly patient         an expanding elderly population and
  may need help and lots of support if      a shrinking number of dermatology           If you have cotton clothing looking
  their eczema is going to be               beds.                                       for a new home, write to the Editor
  treated well.                                                                         of Exchange, National Eczema
                                            Although the treatment of eczema is         Society, Hill House, Highgate Hill,
• Does the person understand the            similar in all age groups, some             London N19 5NA or email:
  diagnosis and the treatment plan?         specific points should be kept in mind      exchange@eczema.org
  If they have visual or hearing            for the elderly group. Treatments
  difficulties this can be a problem. I     should be kept simple as confusion          We need to hear from you by 5
  have found that older people are          can occur if too many creams or             July in order to be able to include
  extremely polite and want to please       tablets and instructions are given.         details in the September edition
  the doctor by agreeing that they          Written information can be helpful as       of Exchange.
  have understood everything,               can the presence of a family member         I  Two cotton tops with
  whereas the truth is that they haven't    or friend. As with all forms of eczema,     integral closed mittens. Both
  been able to hear or fully follow the     it is vital that the patient understands    are size 160 cm (fits 11–12-
  conversation. The result is that both     that this is not infectious and cannot      year-old), one natural, one
  patient and doctor become                 be passed on to anyone else. This is a      blue, both in good condition.
  frustrated the skin condition does        common misconception, especially in         Free but you will need to pay
  not improve. It can be extremely          the elderly. Most elderly patients are      £2.00 to cover postage and
  helpful if a friend or relative is        extremely stoical and view eczema as        packing. If you are interested
  present during the consultation.          something they just have to put up          in the above, please email
• Many older people are on a large          with. It is massively rewarding to be       mary.purton@ntlworld.com
  number of medicines for other             able to help relieve the symptoms of        I Mitten pyjamas, age 3
  conditions. This needs to be taken        eczema and to help people adjust to         (used but serviceable): one
  into account when recommending            living with eczema and not being            pair blue (Cotton Comfort),
  tablet therapy for eczema (e.g.           controlled by it.                           one pair white/fish design
  antihistamines, immunosupressant                                                      (homemade). Also one pair
  treatments such as ciclosporin or         References                                  tights, 92 cm (nearly new),
  azathioprine) as interactions may                                                     purple. All free – please email:
                                            Hara M, Kikuchi K, Watanabe M et al.
  occur with their existing medicines.      (1993) Senile xerosis: functional,
                                                                                        jeremytrew@hotmail.com if you
                                                                                        would like any of these items.
• Attendance at either the local GP         morphological, and biochemical studies.
  practice or dermatology department        J Geriatr Dermatol, 1, 111-120

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