Introduction to skin diseases in older adults
The purpose of this chapter is to review some of the major skin problems of older people, from the perspective of practical use by physicians who are not specialist dermatologists, (Box 150.1). Emphasis is put on diagnosis and principles of management (Jafferany et al., 2012).
Clinical examination in dermatology
Clinical examination is essential to the assessment of skin problems. The key is to examine the entire skin, which means that patients are seen naked while respecting their modesty, and with good lighting. These conditions may be difficult to obtain if patients have difficulty undressing themselves or rooms are poorly lit. The complete clinical examination includes areas that are difficult for self examination such as the back, buttocks, folds, anal, and genital areas. This is essential to seek skin cancer, or to spot evidence of physical abuse or neglect. It also signals the concern of the doctor; older people, like all patients, are reassured by such interest. For well-known patients seen frequently, the principle of an annual entire skin examination with a goal of cancer screening can be proposed.
Skin ageing has two components: chronological ageing, which involves all the integument and photoageing which is superadded in the areas usually exposed to sunlight. Everyone can check this duality by comparing a photo-protected area and a sun-exposed area: face and buttocks, or both sides of the forearms (Fig. 150.1). Photoageing poses major problems, because it involves the aesthetically visible areas, but more importantly because it increases the risk of skin cancer. An attitude of caution in this regard must be acquired early in life. Photoprotection (avoiding sun exposure, wearing clothes, using sunscreens) and the regular use of topical retinoids are the only effective measures to prevent or alleviate the effects of photoageing.
The intrinsic or chronological ageing of the skin
Intrinsic ageing consists essentially of epidermal thinning, flattening of the normally scalloped dermal-epidermal junction, dermal thinning, and a decrease of the fibres of the extracellular matrix, of the number of fibroblasts and of the microvessel density. This results in the visible fine surface wrinkles, changes in the surface contour, reduced skin elasticity and dry skin, called senile xerosis.
Intrinsic ageing is more obvious on the areas not usually exposed to sunlight. On the trunk, it is reflected in the changes of contour, gravitational sagging of some body areas, and the growth of small benign lesions: acrochorda, seborrhoeic keratoses, and cherry angiomas, which do not have pathological significance. On the inner side of the arms, shallow wrinkles, ptosis, and xerosis are easily visible.
In terms of hair, ageing results in greying and whitening (canities) and a diffuse scarcity of hair with decreased density and diameter of the hairs. This senile alopecia is often difficult to distinguish from androgenetic alopecia in its two patterns: male (vertex and temporal gulfs) and female (diffuse). An increase in the growth of the eyebrows, and sometimes of ear or nasal hairs is observed in older men. In women, some degree of hirsutism (moustache, sideburns) may occur due to postmenopausal oestrogen deficiency.
With age, the nail growth rate decreases and physiological longitudinal streaks become visible.
Extrinsic skin ageing or photo-induced ageing
Photo-induced ageing is mainly due to chronic sun exposure. This photoageing involves the face, neck, back of hands, forearms, and also the neckline and the legs in women.
On the face, there are two varieties of photoageing:
◆ In the hypertrophic variety elastosis predominates, an actinic change of dermal elastic tissue. Clinically, there is a thickening of the skin, thick and ridged wrinkles producing streaks on the cheeks, a criss-cross diamond pattern in the neck and in the nape of the neck, comedones around the eyes, and numerous sebaceous adenomas on the whole face.
◆ In the atrophic variety the thinning of the epidermis and dermis dominates, mainly due to a decrease in dermal collagen, an inevitable consequence of UV exposure. Here the skin is thin, slightly wrinkled, atrophic, and at high risk of actinic keratoses and carcinomas.
In both cases, there are pigmentation disorders, seen as actinic lentigines, and variable dyschromia. Ageing is also responsible for atrophy of the subcutaneous tissue and the ‘gravitational’ tissue sagging. Loss of elasticity results in falling cheeks (which can cause perioral intertrigo or angular cheilitis) and neck ptosis (‘double chin’).
On the back of the hands, ageing is characterized by epidermal thinning resulting in increased fragility, dermal and hypodermal atrophy revealing vessels and tendons, and actinic lentigines. It also shows actinic keratoses, which are potential precursors of carcinomas.
On the extension sides of the forearms and of the legs, ageing is essentially atrophic, with dermatoporosis as a main consequence. In addition to atrophy, there are several types of dyschromia, including actinic lentigines and idiopathic guttate hypomelanosis, made of small lenticular white macules.
Clinical consequences of skin ageing
Senile xerosis or dry skin related to age is common (White-Chu & Reddy, 2011). In a recent French survey, it was estimated at 55% of people over 65 (Paul et al., 2011). It predominates on the limbs but involves the entire integument. Senile xerosis may cause pruritus, leading to notable discomfort, insomnia, and scratching induced thickening of the skin (lichenifications) and abrasions that can be gateways to infections. More than just a reduction in the water content of the skin, xerosis reflects a defect in epidermal differentiation and a failure of the barrier function.
Senile pruritus is a common consequence of senile xerosis (Reich et al., 2011). However, it must be considered as an exclusion diagnosis. Other causes of pruritus must be eliminated:
◆ pruritic dermatoses: eczema, drug eruptions, urticaria, bullous pemphigoid, lymphoma;
◆ systemic conditions: thyroid disease, liver disease, kidney disease, Hodgkin’s disease;
◆ psychogenic pruritus.
The term dermatoporosis was recently proposed (Kaya & Saurat, 2007) to designate the functional consequences of skin ageing. Dermatoporosis is a mechanical fragility of atrophic photoaged skin in old people; it is manifest on the front side of the legs, the back of the hands and the dorsal forearm. The cause of dermatoporosis is the loss of the mechanical strength properties of the skin, or its viscoelasticity. The key mechanism is a decrease in hyaluronic acid, and possibly other essential components of the dermal tissue quality. The main cause of dermatoporosis is ageing, but prolonged corticosteroid therapy, especially systemic but also topical, has very similar effects on the skin as ageing.
Several stages of dermatoporosis have been described:
◆ the first stage is senile skin atrophy;
◆ the next stage has been long recognized; it is senile purpura, also known as Bateman purpura or actinic purpura (Fig. 150.2). In the absence of any coagulation disorder, the most minor trauma triggers bruising, bleeding being related to the fragility of dermal vessels in areas of photoageing and to the absence of a cutaneous ‘cushion’ to absorb shocks. These bruises are successively purplish, red, purple, and leave a permanent brown pigmentation;
◆ linear or stellate atrophic white pseudo-scars resulting from minimal trauma;
◆ when dermatoporosis progresses, there may be traumatic lacerations, epidermal detachment caused by trauma or friction, which usually heal fairly quickly, but require daily care (Fig. 150.3);
◆ the most serious consequence of dermatoporosis consists of dissecting hematoma (Kaya et al., 2008). The local pressure effect of these deep haemorrhages causes tissue necrosis requiring urgent surgery, and potentially long hospitalization.
Prevention of dermatoporosis relies on photoprotection but it’s a little late to start this in old age! Preventing its consequences is helped by wearing gloves, protective clothing, and possibly shinguards for risky activities (e.g. housework, gardening). The application of topicals containing retinoids and hyaluronic acid is recommended in the initial stages.
These are small ‘growths of flesh’, also called fibroids or molluscum pendulum. They appear around the armpits and groin, and are devoid of any pathological significance.
Cherry angiomas are small intensely red papules related to the expansion of dermal capillaries. They are very common on the trunk and rarely exceed a few millimetres. They have no pathological significance or particular consequence.
Seborrhoeic keratoses (SK) are benign epidermal proliferations, very common after the age of sixty. They have always a well-demarcated limit with normal skin. At first they are small slightly rough grey bumps. Then they increase in size, become exophytic and brown (Fig. 150.4), progressively darker, even black. They can reach a large size, and form brown or black papillomatous growths. Even when very thick, SK remains over the surrounding skin, which is neither infiltrated nor inflamed. The flat SK that may eventually resemble a naevus or melanoma are easily distinguished by dermoscopy (no melanocyte network). A biopsy is sometimes necessary to obtain a histological confirmation in cases of strong clinical uncertainty. SK may become numerous, dark, thick, unsightly, but they do not cause any discomfort, have no physical consequence, and never become malignant. They can be removed for aesthetic reasons by curettage or cryotherapy. The aetiology of seborrhoeic keratoses is unknown, but they have nothing to do with viral warts (caused by HPV), nor with a hygiene problem.
Potentially malignant tumours
Actinic keratoses (AK) are common: they were formerly known as senile keratoses or pre-epitheliomatous keratoses. They develop on chronically sun-exposed areas, and can be considered as the transition between photodamage and photo-induced carcinomas. AK may indeed be regarded as precancerous lesions, that some clinicians prefer to treat like a carcinoma in situ. The sites of predilection are the scalps of bald men (Fig. 150.5), forehead, nose, face, back of hands, and forearms. They are pink or light brown spots, rough to the touch. This roughness is a helpful clinical sign in practice. Evolving, AK become increasingly hyperkeratotic, warty, and can become horny excrescences. It is advisable to treat AK to prevent progression to squamous cell carcinoma. The simplest, cheapest and most effective therapies are cryotherapy with liquid nitrogen and the application of an ointment containing 5% 5-fluorouracil, but there are other options. It is important to review patients at least twice a year to ensure the effectiveness of these treatments, track resistant lesions, or incipient carcinomas.
Bowen’s disease is a carcinoma in situ with specific histolopathogy, close to actinic keratoses. It can develop anywhere but most commonly on trunk, arms and legs, and is more common in older women than men. Occasionally Bowen’s disease invades the deeper layers of skin so close monitoring so as to initiate local treatments is necessary. Actinic cheilitis must be actively treated to prevent a transformation into an invasive carcinoma.
Lentigo maligna (LM) is a slowly evolving melanocytic proliferation, situated on the face (cheeks) of older people. It has the appearance of an irregular pigmented macule, which expands gradually (Fig. 150.6). Dermatoscopy is useful for differentiating early lentigo maligna from actinic lentigines or flat seborrhoeic keratoses; a biopsy confirms the diagnosis. LM should be considered not as a precancerous lesion, but as a genuine melanoma in situ, and the management is the same as for all melanomas, including surgical excision with an adequate margin, which may cause problems for individuals when on the face. This is one of the best indications for micrographic surgery. An early diagnosis is of paramount importance. With the support of specialized oncologic follow-up, non-surgical alternatives can be proposed at the preinvasive stage.
Keratoacanthomas are epithelial tumours with histopathology very similar to that of squamous cell carcinomas, but which regress spontaneously. Clinically, they appear as papulonodules which grow in few weeks with a central hyperkeratotic crater. After a few weeks or months, they spontaneously involute. If the diagnosis is certain, then ongoing surveillance without treatment is acceptable.
Basal cell carcinomas
Basal cell carcinomas (BCC) are the most common of all cancers. They progress slowly, may be locally aggressive, but, with very few exceptions, do not metastasize. With early diagnosis and treatment, the prognosis is excellent.
In older people there are two pitfalls: ignoring the significance of an asymptomatic lesion, and using the pretext of old age to avoid surgery. But surgery under local anaesthesia is not traumatic and it is better to remove a small BCC at 80 years rather than a big one at 90 years.
BCC occur mostly on the faces of people with fair skin, but can be seen on all body sites. The clinical presentation is variable: small pearl-like papules, smooth or telangiectatic papules or nodules, superficial erosions that do not heal or spontaneous ulcerate, hyperkeratotic or erythematous plaques, infiltrated plaque with a pearly border (Fig. 150.7), as an area of scerotic infiltration, and an eczema-like fixed plaque. In any case, identification of a persistent recent lesion is an indication for a biopsy, which will establish the diagnosis. The treatment of choice is surgery, almost always possible under local anaesthesia, which results in more than 95% cure rate. Radiation therapy is used less often. Other modalities should be considered experimental. For large or recurrent BBC, or a surgically difficult location, it is wise to take advice from a multidisciplinary consultation meeting of dermatological oncology. Hedgehog inhibitors have been recently developed, which improve locally extensive or metastazing BCC.
Squamous cell carcinomas
Squamous cell carcinomas (SCC) are more severe than BCC, because they can metastasize, and are occasionally fatal. They often occur on pre-existing lesions such as actinic keratoses, mucosal leukoplakias, radiation dermatitis, scars from burns, or chronic leg ulcers. Risk factors include age, chronic sun exposure, immunosuppression, and exposure to certain carcinogens (formerly tars, currently PUVA). Clinically, SCCs appear as nodules, infiltrating and/or budding, and/or ulcerations (Fig. 150.8). A skin biopsy confirms the diagnosis. One must check for local metastatic lymphadenopathy. Surgical treatment (wide excision) and subsequent monitoring are guided by the recommendations of a multidisciplinary meeting.
Melanomas are the most severe of all skin cancers. In the context of this book, only some essential notions, specific to elderly patients will be developed.
Major recent advances in primary prevention (photoprotection) and early diagnosis (routine screening) benefit mainly young patients with superficial spreading melanoma (SSM), which have a relatively slow development and a good prognosis if removed early. By contrast, nodular melanomas occurring in elderly patients, mainly men, progress rapidly and still have a poor prognosis (Ciocan et al., 2013) (Fig. 150.9). Older people should receive more attention with skin cancer screening and early diagnosis of melanoma, the only guarantee of a good prognosis.
Therefore all practicioners need to know the signs suspicious of malignancy when presented with a pigmented skin tumour. Be aware hovever that some melanomas are amelanotic.
The ABCDE acronym:
A. Asymmetry of the lesion
B. Borders are irregular
C. Colour is non-uniform
D. Diameter greater than 6 mm
We emphasize E: any lesion with changing clinical characteristics must be shown quickly to a dermatologist. These ABCDE criteria are lacking in a number of cases, including nodular melanoma of older people. We again emphasize that any skin lesion should be definitively diagnosed, either clinically, by dermatoscopy or histology from a biopsy which is a simple but extremely helpful procedure.
Melanomas removed early, when their thickness is less than 1 mm, have a good prognosis. Larger lesions have a significant metastatic risk.
Merkel cell carcinoma
Merkel cell carcinomas or neuroendocrine carcinomas of the skin are relatively rare and serious tumours in older people. They occur most often on the face and neck, and are associated with chronic sun exposure and immunosuppression. An opportunistic virus (Merkel Cell Polyoma Virus, MCPyV) is probably the cause (Samimi & Touzé, 2014). A red or purplish nodule gradually increases in size and this finding alone indicates the need for a biopsy. Currently diagnostic delays are common, which explains the frequency of metastatic disease. Treatment is based on wide surgery and radiotherapy. Sentinel lymph node biopsy finds frequent micrometastases.
Consequences of functional disability
Bedridden people regardless of cause are at risk of pressure ulcers and prevention must be implemented systematically. The role of dermatologists here is secondary to geriatricians and specialized nursing teams. Once established, pressure ulcers are chronic wounds whose prognosis depends on being able to relieve the pressure, the quality of local care and the general condition of the patient. This is discussed in more detail in Chapter 53.
Consequences of venous insufficiency
Venous insufficiency due to varicose and/or sequelae of venous thrombosis, is responsible for trophic disorders: the features are oedema of the feet and legs, stasis dermatitis due to hemosiderin deposits (sequel of vascular purpura), livedoid vasculopathy (atrophie blanche), stasis dermatitis which may be complicated by contact dermatitis, lipodermatosclerosis (hypodermitis sclerodermiformis) and ultimately leg ulcers. Elastic compression is very important to prevent the consequences of venous insufficiency. This treatment is not easy to implement, and success requires the patient to be encouraged and supported (see also Chapter 98).
Before starting treatment, care should be taken to eliminate other causes of cutaneous ulcerations: arterial disease or arteritis, neuropathies, infections, ulcerated tumours, or the rare pyoderma gangrenosum.
Local care is essential for the closure of a leg ulcer. This is a complex subject that requires specialist advice and expertise of a staff trained in treating chronic wounds. Many dressings are currently available. They are only an adjunct to manual debridement which remains indispensable.
Consequences of sphincter incontinence
Patients with sphincter incontinence require special care. It is of paramount importance to avoid ongoing contact of urine or faeces with the skin. In addition to the psychological suffering of incontinence, there is a risk of an irritant dermatitis similar to the nappy (diaper) rash of infants. The first sign is just erythema, which may be sensitive or painful. Without adequate care, more irritation, erosions, and secondary infections can follow. Experience in paediatrics showed that cellulose absorbent nappies are an effective prevention when used properly and changed as often as necessary.
It is estimated that between 2% and 10% of seniors are victims of abuse at large. This problem is likely underestimated, and great attention is needed from all professionals. There are many forms of abuse (Chapter 139): psychological, physical, sexual, financial. Here we will indicate the cutaneous signs that may be suspect of elder abuse (Palmer et al., 2013): linear bruises evoking links, burns, lacerations, abrasions, traumatic alopecia, dirt, neglected, or poorly treated skin lesions.
Dermatitis in older people
Eczema, an erythematous, vesicular, and itchy dermatitis may have several causes. Atopic eczema does occur but is rare in old age; past history of several eruptions makes the diagnosis more likely. Contact eczema is often easy to diagnose: it starts on the area of contact with the sensitizing substance. Careful clinical inquiry is often more effective than skin tests (patch tests). Systemic drugs are a rare cause of eczema but drug intake has been identified as a cause or risk factor for extensive eczema. Culprit drugs include calcium channel blockers and thiazides (Summers et al., 2013). It is important to stop unnecessary drugs and treat with topical steroids.
In case of eczema rash of unknown cause and of prolonged evolution despite treatment, a biopsy is indicated to eliminate a cutaneous lymphoma (mycosis fungoides).
Older people are particularly subject to cutaneous adverse reactions to systemic drugs. In addition to the usual diagnostic challenge of drug eruptions, which is not simple, there are specific considerations for older people: they often take many drugs, may have several doctors and track multiple prescriptions, and take medications without a prescription. In addition, they may have trouble remembering the precise chronology of their drug intake.
All types of drug eruptions can occur in old age. We have already mentioned eczema rashes.
Severe cutaneous drug reactions deserve special attention. These are toxic epidermal necrolysis, Stevens-Johnson syndrome, drug-induced hypersensitivity syndrome (DRESS syndrome: drug reaction/rash with eosinophilia and systemic symptoms) and acute generalized pustulosis. Severity signs are the following: generalized rash, blistering or skin exfoliation, mucosal (eye, mouth) involvement, and systemic symptoms. In such cases, the suspected drug (usually recently introduced) should be discontinued, and the patient hospitalized with specialist dermatology involvement.
Less serious drug eruptions have very variable presentations: isolated pruritus, urticaria, maculopapular rash, fixed drug eruption, small vessel vasculitis (palpable purpura of the lower extremities), photosensitivity. Management depends on the severity of the clinical presentation, its evolution, and on the importance or otherwise of the suspect drug. For example, one of the most frequent providers of drug eruptions, allopurinol, is often prescribed for asymptomatic hyperuricemia, and may be stopped without clinical consequences.
Bullous pemphigoid, the most common autoimmune bullous dermatosis, is a disease of old age, which occurs almost exclusively after 60 years, the average age of patients being 80–85 years. Pemphigoid is increasingly common.
A pre-bullous phase manifests as pruritus and erythematous non-bullous rashes. Eosinophilia and immunological tests may lead to the diagnosis. Typical pemphigoid is a symmetrical itchy rash made of large solid blisters with clear content, generally developed on erythematous plaques (Figs 150.10 and 150.11). Blisters predominate on the abdomen and the anterior surface of the arms and thighs, but may involve the whole integument. Mucosal lesions may be seen, mainly in the mouth, but also conjunctivae and genital mucosae. Skin biopsy shows a subepidermal bulla and a dermal eosinophilic infiltrate. Direct immunofluorescence shows linear deposits of IgG and C3 on the dermo-epidermal junction. Indirect immunofluorescence and ELISA tests reveal autoantibodies directed against hemidesmosomal antigens (BPAG1, 230 kD, and BPAG2, 180 kD). The titre is not predictive of the course of the disease.
The classic treatment of pemphigoid was systemic corticosteroids, but this treatment may cause serious, even fatal side effects (Parker et al., 2008). The main determinant of prognosis is the general condition of patients, who often have multiple morbidities. It has been shown that the application of potent topical corticosteroids may be effective and better tolerated than systemic steroid therapy (Joly et al., 2009). This treatment consists of ‘professional’ applications (by trained nurses) of clobetasol propionate, at the initial daily dose of 10–40 g per day, depending on the importance of the rash. These applications are preceded by specific care: piercing the bullae leaving the roof in place, cleaning with chlorhexidine to prevent secondary infections, oily dressings to prevent cracks and wounds and ensure comfort. Topical corticosteroids are then tapered according to evolution. Under careful supervision by a dermatologist and associated with geriatric support, topical therapy is better tolerated than systemic corticosteroids, but is still a risk, and requires monitoring and the usual supportive measures. For long-term control of the disease, it is often necessary to add an immunosuppressant sometimes with low-dose oral corticosteroids to prevent need for prolonged local corticosteroid use. Thus pemphigoid requires well organized combined geriatric and dermatological medical and nursing expertise.
Onychomycosis and other fungal infections
Among the fungal infections, onychomycosis, tinea pedis, tinea cruris, and candidiasis occur commonly in older people. Onychomycosis, most often caused by dermatophytes, is common, and its treatment is relatively unsatisfactory, requiring local care and prolonged oral antifungal treatment. Both measures are difficult or impossible in older patients. On the one hand, they can often not reach their toes due to functional limitations. On the other hand, both their doctors and themselves may be reluctant to add another long-term oral medication. Podiatric care is therefore important for grinding/planing the nail hyperkeratosis that can reach a considerable size but is often overlooked. Keratolytic ointments may be helpful. If there is also intertrigo, it is treated with antiseptic and topical antifungals because it may be a portal of entry for bacterial infections (erysipelas).
Candidiasis manifests in the form of cutaneous, mucosal, paronychial, onychial, or chronic mucocutaneous or granulomatous lesions. It is commonly seen in intertriginous areas where the skin is warm and moist, such as submammary folds, inguinal, anogenital, and perioral areas. The main predisposing factors are maceration, heat, humidity, obesity, diabetes, antibiotic therapy, and chemotherapy. Topical antifungal creams are helpful in clearing the lesions.
Scabies is caused by Sarcoptes scabiei, an epidermal mite. It is very itchy and contagious, and these two characters facilitate diagnosis: it is the only contagious cause of itching. Contamination, only from human to human, takes place between people sharing the same bed or the same linen. Communities of older people are particularly susceptible to epidemics affecting residents and the nursing staff. These outbreaks are mild and relatively easy to treat, but often resented.
The key sign is acute, intense, and generalized pruritus, often worse at night. Sometimes there is a visible epidermal burrow dug by the mite in the interdigital commissures, but more often the signs are the consequences of scratching: irritations, abrasions, horripilations, lichenifications. If the clinical diagnosis is difficult, the mite can be visualized by dermoscopy, or by direct microscopic examination of scales.
In older or disabled individuals, there may be a special form of scabies, the diffuse hyperkeratotic form, sometimes generalized, called ‘Norwegian scabies’ (Fig. 150.12). It is important to be aware of this because it causes little or no itching, but is highly contagious to other patients in the institution and to nursing staff, who will present with classic scabies, potentially transmissible to their relatives.
The treatment of scabies involves either application of benzyl benzoate or of pyrethrin, or oral ivermectin. It is important to treat simultaneously all patients and contacts, and to clean and disinfect clothes and beddings, where the mites can survive a few days. It is usually also necessary to reduce anxiety by reassurance of the patients, their relatives, and the nursing staff.
Herpes zoster is a posterior radiculitis related to the reactivation of VZV, latent since childhood varicella. It is an erythemato-vesicular rash whose unilateral character limited to a dermatomic area allows easy diagnosis. Treatment is with acyclovir or valacyclovir, usually for five days, although herpes zoster heals spontaneously except in situations of immunosuppression. The essential rationale of treatment, indicated especially in older people, is the prevention of post-herpetic neuralgia, which can be very painful and debilitating.
Older people are rarely free from skin problems and a certain degree of dermatological expertise is required to distinguish between benign consequences of ageing, dermatitis requiring intervention, and life-threatening dermatoses. Older people do not usually have easy access to dermatologists. Preliminary experiments of telemedicine showed that for specific situations, such as leg ulcers or for an expert’s advice, remote consultations can be useful (Rubegni et al., 2011). Meanwhile, close attention and early referral may be needed to avoid unnecessary suffering.
Ciocan, D., Barbe, C., Aubin, F., et al. (2013). Distinctive features of melanoma and its management in elderly patients: a population-based study in France. JAMA Dermatology, 149, 1150–7.Find this resource:
Jafferany, M., Huynh, T. V., Silverman, M. A., & Zaidi, Z. (2012). Geriatric dermatoses: a clinical review of skin diseases in an ageing population. Int J Dermatol, 51, 509–22.Find this resource:
Joly, P., Roujeau, J. C., Benichou, J., et al. (2009). A comparison of two regimens of topical corticosteroids in the treatment of patients with bullous pemphigoid: a multicenter randomized study. J Invest Dermatol, 129, 1681–7.Find this resource:
Kaya, G. & Saurat, J. H. (2007). Dermatoporosis: a chronic cutaneous insufficiency/fragility syndrome: clinico-pathological features, mechanisms, prevention and potential treatments. Dermatology, 215, 284–94.Find this resource:
Kaya, G., Jacobs, F., Prins, C., et al. (2008). Deep dissecting hematoma: an emerging severe complication of dermatoporosis. Arch Dermatol, 144, 1303–8.Find this resource:
Palmer, M., Brodell, R. T., Mostow, E. N. (2013). Elder abuse: dermatologic clues and critical solutions. J Am Acad Dermatol, 68, e37–42.Find this resource:
Parker, S. R., Dyson, S., Brisman, S., et al. (2008). Mortality of bullous pemphigoid: an evaluation of 223 patients and comparison with the mortality in the general population in the United States. J Am Acad Dermatol, 59, 582–8.Find this resource:
Paul, C., Maumus-Robert, S., Mazereeuw-Hautier, J., Guyen, C. N., Saudez, X., & Schmitt, A. M. (2011). Prevalence and risk factors for xerosis in the elderly: a cross-sectional epidemiological study in primary care. Dermatology, 223, 260–5.Find this resource:
Reich, A., Ständer, S., & Szepietowski, J. C. (2011). Pruritus in the elderly. Clin Dermatol, 29, 15–23.Find this resource:
Rubegni, P., Nami, N., Cevenini, G., et al. (2011). Geriatric teledermatology: store-and-forward vs. face-to-face examination. J Eur Acad Dermatol Venereol, 25, 1334–9.Find this resource:
Samimi, M. & Touzé, A. (2014). Merkel cell carcinoma: The first human cancer shown to be associated with a polyomavirus. Presse Med, 43, e405–11.Find this resource:
Summers, E. M., Bingham, C. S., Dahle, K. W., et al. (2013). Chronic eczematous eruptions in the ageing: Further support for an association with exposure to calcium channel blockers. JAMA Dermatol, 149, 814–18.Find this resource:
Tseng, H. F., Smith, N., Harpaz, R., et al. (2011). Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. J Am Med Assoc, 305, 160–6.Find this resource:
White-Chu, E. F. & Reddy, M. (2011). Dry skin in the elderly: complexities of a common problem. Clin Dermatol, 29, 37–42.Find this resource: