Dermatoses in elderly patients attending a private skin clinic in North Kerala: A retrospective chart review

Dear Editor,

The World health organization has defined a person aged 65 years or above as elderly.^[1] It is predicted that world population aged 60 years or more will double, by 2050.^[2]

Kerala has the highest old age dependency ratio (ratio of persons aged 60 years and above to the working age population) among Indian states (142 for India and 196 for Kerala according to 2011 senses).^[3]

This shows that a significant proportion of patient population in need of medical attention would be contributed by those aged 65 years and above. Often the elderly find it difficult (due to the comorbidities and mobility issues associated with old age) to receive medical aid in time. Having an information on the disease burden in this age group would help to formulate policy decisions to improve the quality of life of the elderly.

We did a retrospective chart review of consecutive 200 patients aged 65 years or above and who attended the outpatient department of our dermatology clinic (private sector) situated in North Kerala. The Institutional Ethics Committee of Aster MIMS Hospital, Kannur, approved the study.

Majority of the patients belonged to the 65–74 year age group (144, 72%), followed by the age group of 75–84 years (48, 24%). Eight (4%) patients were 85 years or above. The youngest and oldest were 65 and 104 years, respectively.

One hundred and twenty-eight (64%) patients were males and 72 (36%) were females (male to female ratio 1.8:1). Ninety-four patients (47%) had comorbidities including diabetes mellitus (62, 31%), hypertension (58, 29%), chronic obstructive pulmonary disease (2, 1%), ischemic heart disease (2, 1%), thyroid dysfunction (2, 1%), renal failure (1, 0.5%), and seizure disorders (1, 0.5%).

The most common complaint that prompted a dermatology consultation was pruritus (158, 79%). This was associated with xerosis in 51 cases (51/158, 32.3%). Interestingly, the total number of patients who manifested xerosis was 51 and all of them suffered from pruritus.

The most common diagnoses documented were eczema/dermatitis (87, 43.5%), infections and infestations (40, 20%), and papulosquamous diseases (24, 12%) [Table 1].

Among the eczema/dermatitis requiring dermatology consultation, asteatotic eczema (24, 27.6%) predominated [Table 2] followed by contact dermatitis (22, 25.3%) and stasis dermatitis (10, 11.5%).

The infections diagnosed were fungal (22/200, 11%), viral (8/200, 4%), and bacterial infections (7/200, 3.5%). Parasitic infestations were diagnosed in 3 cases (3/200, 1.5%).

Among the 26 papulosquamous disorders diagnosed, there were 15 cases of psoriasis (15/26, 57.7%), six patients had lichen planus (6/26, 23.1%), four had erythroderma (4/26, 15.4%), and one had pityriasis rosea (1/26, 3.8%).

Seborrehic keratosis and acrochordons necessitated a dermatology consultation in 10 patients each (10/200, 5%). In 1 (1/200, 0.5%) patient, the reason for consultation was senile purpura. No diagnosis of malignant or premalignant skin conditions was made during the 2-year period.

Pruritus being the most common dermatology symptom in elderly as observed by us was consistent with the observations of others.^[4,5] It has been reported that a high proportion of elderly suffered from xerosis, which in turn could lead to asteatotic dermatitis. The xerosis diagnosed in 25.5% of those aged 65 years and above as observed by us was lower than the previous reports.^[5,6] This could be due to the fact that our findings were derived from a retrospective chart review. Hence, xerosis, when not associated with any symptoms and when not reported as a complaint by the patient, may not be mentioned in diagnosis. All 51 patients with xerosis seen by us complaining of pruritus underscores the same. Use of emollients and protection against sun exposure can reduce the skin xerosis associated with aging.

The low frequency of fungal infections (11% vs. 30–40% in literature) noted by us may also be a reflection of the economic strata and living conditions of patients attending a private clinic.^[5,6] Fungal infections predominating among skin infections affecting elderly as observed by us was consistent with current information.^[5,6]

Eczematous conditions contributing to a significant proportion of dermatological case load in elderly was consistent with literature. Though previous authors noted contact dermatitis to be the common cause of dermatitis, the most common cause for dermatitis in our study was asteatotic dermatitis.^[6]

A low frequency of seborrheic keratosis and acrochordons recorded by us could again be due to the fact that these conditions find a mention in case chart only when the patient states it as a complaint and seeks medical care for the same.^[4-6] We also do not have information on specific manifestations of photoaging or pigmentary abnormalities like idiopathic guttate hypomelanosis. Retrospective chart review carried out in a single center was the major limitation of the study.

This retrospective chart review showed that the elderly suffered from several and varied dermatological diseases. Simple measures like application of emollients can help to alleviate the symptoms in many. Cross-sectional and prospective studies at the community level may help to estimate the disease burden and document the clinical pattern of dermatoses in elderly, which are essential to plan future strategies.