Background: The importance of the geriatric population has been increasing expeditiously in the health-care system. The epidemiology of skin disorders is an interesting subject to challenge physicians to comprehensively manage the elderly. Objectives: The objective of the study was to determine the prevalence of the most frequent dermatologic disorders among elderly outpatients and identify major associated determinants. Methods: This retrospective observational study recruited subjects aged 60 years and older attending the dermatologic clinic at the Faculty of Medicine, Vajira Hospital, in Thailand. The medical records were collected between January 2017 and December 2020. The data were analyzed according to age, sex, season, underlying medical diseases, and areas of involvement to identify the associated factors for the frequently presented dermatologic diagnoses. Results: In this study, 521 outpatients (including 218 males and 303 females) with a mean age of 71.34 years (range, 60–04 years) were enrolled. The most common dermatoses were eczematous dermatitis (35.7%), cutaneous infection (18.2%), xerosis (15.5%), and psoriasis (7.3%). The distribution of the prevalent dermatologic disorders still did not change during the COVID-19 pandemic. A significant association was found between xerosis and age of 80 years and older (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.09–3.78; P = 0.026). The risk of developing xerosis cutis significantly decreased with dyslipidemia (OR, 0.45; 95% CI, 0.26–0.78; P = 0.004). Conclusion: The three foremost cutaneous disease groups are eczematous dermatitis, skin infection, and xerosis cutis. Dry skin is strongly connected with the age of 80 years and above; however, xerosis is coincidentally correlated with dyslipidemia.
Keywords: Dermatitis, dyslipidemias, geriatrics, skin diseases, xerosis
|How to cite this URL:|
Laopakorn J, Hanthavichai S. Prevalence and associated factors of skin diseases among geriatric outpatients from a metropolitan dermatologic clinic in Thailand. Dermatol Sin [Epub ahead of print] [cited 2022 Sep 29]. Available from: https://www.dermsinica.org/preprintarticle.asp?id=354329
| Introduction|| |
The geriatric population has been growing continuously in many countries. Thailand is contemplated as one of the world's rapidly aging societies. In 2015, the proportion of the population aged 60 years and above in Thailand was 15.6%. Moreover, Thailand will become a super-aged society that the share of the population aged 60 years and above will be 30.2% in 2035. Recent government policies have been providing considerable attention to the elderly situation.
The diseases of elderly individuals are due to the senile process and the gradual deterioration of anatomical structures, histological features, and physiological changes in many organ systems, including the skin. The pathophysiology of aging skin comprises epidermal and dermal thinning, a decrease in collagen and elastin, atrophy of subcutaneous fat, hair loss, and delayed nail growth. Therefore, the classification and prevalence of common skin diseases between the elderly and younger age groups are remarkably different. Dermatologic diseases not only affect elderly patients physically but also distress them mentally and significantly increase the risk of depression. Even though dermatoses are not serious, dermatologists can substantially improve the quality of life and psychological well-being of geriatric patients.
Nowadays, information on the epidemiology of skin diseases and contributing conditions in the elderly population in Thailand, particularly in the capital city, is limited. Therefore, collecting longitudinal retrospective data is necessary to demonstrate the distribution of dermatologic diseases, associated demographic factors, and seasonal influences. This observational study was designed to determine the prevalence of dermatologic disorders and identify the relationship of these dermatologic disorders to factors, including age, sex, underlying medical illnesses, and seasonal variation, in elderly outpatients attending a metropolitan dermatologic clinic of a university hospital.
| Materials and Methods|| |
We retroactively reviewed and randomly assembled the medical records of outpatients aged 60 years and older who visited the dermatology clinic of Vajira Hospital, Navamindradhiraj University, Bangkok Metropolis, Thailand. The recruitment period was started from January 2017 to December 2019. For comparison of the prevalence of skin disorders between the pre-COVID-19 pandemic and the COVID-19 period, we also extended the recruitment period and recorded all geriatric outpatient visits from January 2020 to December 2020. This observational study complied with the Helsinki declaration and was approved by the Vajira Institutional Review Board (IRB number: COA 031/63). The diagnosis of skin diseases was mainly based on clinical diagnosis by dermatologists and recorded according to the International Coding of Diseases-10 classification. Pathological examination, skin biopsy, microbiological examination, and laboratory investigation were occasionally performed to identify a definite diagnosis if necessary. Clinical and demographic data were obtained from the medical records and used for data analysis (i.e., age, sex, season at presentation, coexisting medical problems, principal diagnosis of skin diseases, and locations of involvement). Seasonality was divided into summer (February, March, April, and May), rainy (June, July, August, and September), and winter (October, November, December, and January). The dermatoses were sorted into 13 disease categories, as follows: (1) eczematous dermatitis, (2) cutaneous infection, (3) xerosis cutis, (4) psoriasis, (5) skin hyperplasia and neoplasm, (6) vesiculobullous disorders, (7) drug eruptions, (8) hair and nail disorders, (9) pruritus, (10) autoimmune disorders, (11) urticaria, (12) pigmentary disorders, and (13) others.
Stata (version 13.0; StataCorp, College Station, TX, USA) was used for all statistical data analyses. The patient characteristics were classified according to gender, age groups (60–69 years; 70–79 years; and ≥80 years), and seasons. The statistical associations of these variables with cutaneous disorders were determined using the Chi-square test or Fisher's exact test. Furthermore, multiple logistic regression analysis was performed to identify independent factors associated with the three most common disease groups. In the multiple logistic regression analysis, the included variables were completely classified into four categories, as follows: (1) age group: 60–69 years (reference), 70–79 years, and ≥80 years; (2) gender: male and female (reference); (3) coexisting chronic medical diseases: hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease; and (4) location of involvement: whole body (reference), arms and legs, hands, feet, and others. Differences with P < 0.05 were considered statistically significant.
| Results|| |
This study enrolled 521 patients, including 218 males (41.8%) and 303 females (58.2%). The mean age of all participants was 71.34 ± 8.39 years (range, 60–104 years). These elderly subjects were categorized into three groups depending on age range, as follows: 60–69 years (256 cases, 49.1%); 70–79 years (163 cases, 31.3%); and more than 80 years (102 cases, 19.6%). Most elderly outpatients had been concomitantly diagnosed with hypertension (57.0%), dyslipidemia (41.5%), diabetes mellitus (31.3%), chronic kidney disease (10.9%), cancer (10.9%), coronary artery disease (9.2%), and cerebrovascular disease (8.6%). In addition, almost half of the enrolled outpatient visits (10,260 of 22,421 visits; 45.7%) in the dermatologic clinic comprised elderly individuals.
The most common dermatologic disorder in the study group was eczematous dermatitis, with a rate of 35.7% (186 cases). The second and third most frequent disease groups were skin infection (95 cases, 18.2%) and xerosis cutis (81 cases, 15.5%) [Table 1]. The distribution of the prevalent dermatologic disorders was quite similar to that of the coronavirus pandemic period (January 2020–December 2020).
|Table 1: Comparison of the distribution of dermatological diseases between pre-COVID-19 pandemic and COVID-19 period|
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Regarding the eczematous dermatitis group, eczema (i.e., unspecified dermatitis) was the most prevalent type (24.6%), followed by contact dermatitis (5.6%), seborrheic dermatitis (3.6%), lichen simplex chronicus (1.3%), and atopic dermatitis (0.6%). For the cutaneous infection group, the most commonly recorded infectious agent was viruses (8.6%), followed by fungi (5.6%), bacteria (3.3%), and parasites (0.8%). The viral infection subgroup was distributed as follows: herpes zoster (5.6%), herpes simplex (1.9%), wart (1.0%), and viral exanthem (0.2%). The fungal infection subgroup was classified as candidiasis (3.8%), dermatophytosis (1.6%), and pityriasis versicolor (0.2%). The bacterial infection subgroup was orderly consisted of infective dermatitis (1.7%), abscess (0.6%), cellulitis (0.4%), folliculitis (0.4%), and staphylococcal scalded skin syndrome (0.2%). The parasitic infestation group consisted of scabies (0.4%) and pediculosis (0.4%).
According to the age group, gender, and seasonal distribution, the relationships of these categorical factors with cutaneous disorders were analyzed [Table 2]. No interrelation was found between age groups and the type of skin disorder, except for xerosis cutis, which was statistically significant to occur more frequently in older elderly individuals, particularly those aged over 80 years (25.5% vs. 15.23% (70–79 years) and 11.7% (60–69 years), P = 0.005). Evaluating distinctions between genders, female patients had a particularly higher rate of skin infection compared with male patients (21.1% vs. 14.2%; P = 0.044). Regarding seasonal variations, drug eruption and pruritus were more likely to be associated with rainy (P = 0.012) and summer (P = 0.048) seasons, respectively; however, multiple logistic regression analysis cannot be performed afterward due to the small number of patients with inadequate statistical power to show reliable results.
|Table 2: Association of age group, gender, and season with dermatological diseases|
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Multivariable logistic regression analysis was proceeded to identify independent factors in the three most frequent skin disorders [Table 3]. Regarding age interval categorization, the over 80-year age group had a statistically significant connection to xerosis cutis (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.09–3.78; P = 0.026). Dyslipidemia showed an inverse correlation with xerosis cutis (OR, 0.45; 95% CI, 0.26–0.78; P = 0.004). However, no relationship was found between gender and cutaneous infection (OR, 0.65; 95% CI, 0.39–1.08; P = 0.095).
|Table 3: Multivariable analysis of factors associated with eczematous dermatitis, skin infection, and xerosis cutis|
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The preference sites of involvement in the three most common disease groups were significantly demonstrated compared with the nondisease group, except for xerosis cutis. The involvement areas of eczematous dermatitis were more often found in the hands (OR, 24.52; 95% CI, 10.27–58.58; P < 0.001), arms and legs (OR, 7.86; 95% CI, 3.76–16.46; P < 0.001), and feet (OR, 5.92; 95% CI, 2.39–14.56; P < 0.001). Patients with skin infection outstandingly showed an increased involvement of the feet (OR, 47.18; 95% CI, 10.22–217.76; P < 0.001) and arms and legs (OR, 4.73; 95% CI, 1.02–21.84; P = 0.047), excluding the hands (OR, 1.81; 95% CI, 0.25–13.23; P = 0.558).
| Discussion|| |
This study indicated that the prevalence of eczematous dermatitis is the highest among cutaneous disorders in senile outpatients (35.7%), and this finding is similar to those of previous studies (24.2%–43.7%).,,, Furthermore, skin infections and xerosis cutis are the second and third most commonly diagnosed dermatoses in our dermatology clinic.
Interestingly, the findings of this study are consistent with those of the study conducted in 2014 by Jiamton et al., which reported that the two most common dermatologic disorders of elderly outpatients were eczematous dermatitis and skin infections with prevalence rates of 31.2% and 21.9%, respectively. Patients with eczematous dermatitis had rashes on the legs more frequently than noneczematous disorders; meanwhile, the preferred locations of dermatitis from this study were the upper and lower extremities. No associations were observed between eczematous dermatitis and underlying medical diseases, which is a finding similar to that reported in this study.
A systematic review of the epidemiology of skin conditions in elderly patients as well as this our study has shown that the most prevalent dermatologic diseases from the hospital and long-term care settings are dermatitis, fungal infections, xerosis, and benign skin tumors. In contrast, a cross-sectional study from a referral center in Iran has reported that the most common skin disorders among elderly patients were benign neoplasms (65%), precancerous lesions (26.1%), cutaneous infections (17%), and dermatitis (16.6%). The higher proportions of benign skin tumors and precancerous lesions were probably related to the different conditions of the participants, which mostly comprised inpatients in distinct climates and greater exposure to solar radiation.
The relationship between cutaneous infection and aging was anticipated and reported in several studies. In this study, the second predominant group of skin disorders is a cutaneous infection, and viruses are the principal pathogens, followed by fungi, bacteria, and parasites. Other studies have revealed that the prevalence of skin infections ranges from 21.0% to 28.7%, which is slightly higher than the 18.2% reported in this study.,, However, fungi have been reported in preceding studies as the main etiology of cutaneous infections, which is a finding different from the results of this study.,,, The high occurrence of fungal infection with aging can be explained by the decreased immunological function, low keratinocyte turnover rate, declination of nail growth, reduced desquamation of infected epidermis, and loss of skin barrier integrity. A significant interconnection between diabetes mellitus and the development of fungal infection, particularly onychomycosis, was noticed in the study by Reszke et al.; nevertheless, this study does not show that relationship. In addition, a preceding study from Taiwan has demonstrated that aging men with diabetes mellitus have a marginally greater risk of bacterial infection and scabies.
Resembling this study, precursory studies have reported that herpes zoster is usually the principal cause of viral infection in the elderly.,, These senescent conditions can certainly cause changes in the declined virus-specific immune regulation, especially cell-mediated immunity, and increase the risk of reactivation of latent varicella-zoster virus. Furthermore, cutaneous infections and other common cutaneous disorders and old ages also have notable interrelations. According to recent evidence by Akhtar et al., the diagnosis of skin infections among patients aged over 65 years was most probably found in those with eczema (27.6%), dermatitis (13.8%), xerosis (13.8%), and bullous pemphigoid (8.8%).
The present study revealed that the xerosis cutis group has specifically a noteworthy correlation with ages 80 years or older, and this association is compatible with the results reported in a descriptive single-center study and previous survey studies.,, The prevalence of xerosis cutis in this study is lower than that reported in some previous studies with complete evaluations, including clinical interviews and detailed skin examinations, and the reported frequencies have ranged from 58.6% to 99.1%.,, The other specific reasons for this discrepancy are probably due to reporting only the main diagnosis for each subject in this study and the inability to contain the totally presented dermatologic diseases and general skin problems in the elders, including xerosis.
The negative relationship between dyslipidemia in aged patients and dry skin has been detected, but there was no any clinical literature to confirm this relationship. The reason why dyslipidemia is a protective determinant of xerosis cutis seems to be an incidental finding. Because lipid-lowering drugs and hypercholesterolemia in nephrotic syndrome correlate with the disruption of lipid constituents in the epidermis and dry skin; hence, these pieces of evidence are contradictory to our findings., However, the prolonged conditions of hypercholesterolemia and hypertriglyceridemia feasibly induce high lipid contents in the epidermis and probably increase the production of ceramides for lessening the risk of xerosis, even though the scientific evidence to support these postulations remains unproven.
A multicenter observational study in long-term care facilities has demonstrated that the prevalence rates of commonly recorded skin diseases, which were diagnosed by dermatologists using head-to-toe skin examinations, are up to 99.1% of elderly residents. Moreover, another survey study in aged care facilities noticed that 88% of elderly residents have at least one important skin disease, and those with less severe physical disabilities are at a higher risk of inflammatory dermatoses. The evidence emphasizes the importance and pervasiveness of undetected dermatologic problems, particularly among senior nursing home residents. In addition, health-care practitioners should pay attention to possible concomitant skin problems, although skin conditions might not be the primary reason for requesting medical attention, because these dermatologic conditions may contribute to certain complications and need appropriate interventions.
The limitations of the study are the single center and the university hospital setting, which cannot allow extrapolating in the general population; nevertheless, this study offers an informative overview of the burden of skin diseases among elderly patients at a referral center. The results of this study demonstrated the prevalence of the principal diagnoses which were the main complaint of the dermatology outpatient visits, but not the entirely presented dermatoses and general skin problems in the elders, such as pigmentary diseases. The selection bias in this study seems to be negligible due to long-term enrollment and systematic random sampling of all senior subjects. Furthermore, the understudied population can possibly represent the distribution of geriatric dermatoses in the metropolitan outpatient departments because most primary health centers and secondary medical care hospitals in the urban area usually transfer elderly patients to the dermatologic clinic of our university hospital.
| Conclusion|| |
Geriatric dermatology is also an imperative issue that should be specifically considered and a challenge in comprehensively managing the well-being of the aging society. In this study, we found that the proportion of elderly individuals in the dermatology clinic is unexpectedly high, comprising approximately half of the entire outpatient visits. The most common skin disorder among this population is eczematous dermatitis, followed by cutaneous infection and xerosis. Further multicenter prevalence studies for the hospital setting and epidemiological data in the community are required to ascertain the distribution of common skin diseases in different elderly populations and to improve the preventive management of dermatological care.
The authors gratefully acknowledge support for the production and publication of the manuscript from the Faculty of Medicine Vajira Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, 681 Samsen Road, Dusit, Bangkok 10300
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]