Aging Skin

Common problems of aging skin

Fenske, Neil A.; Grayson, Leonard D.; Newcomer, Victor D.

Citation: Patient Care, April 15, 1989 v23 n7 p225(8)

(includes related article) (special issue: Caring for the Aging Patient)

Subjects: Geriatrics Practice
Skin Aging
Geriatric dermatology Analysis
 

Reference #: A7593733

Full Text COPYRIGHT Medical Economics Company Inc. 1989

As the skin loses its ability to defend itself, the cumulative damage from ultraviolet radiation increases, While intrinsic aging changes may be unavoidable, measures taken throughout life can limit the damage.

Intrinsic aging: Numerous structural and functional changes combine to age the skin, resulting in thinning, fragility, and loss of elasticity. Circulation and innervation decrease, and the structural attachment between the dermis and epidermis deteriorates. A variety of neoplasia appear on the skin as a part of the aging process. Benign growths include seborrheic keratoses, cherry angiomas, and skin tags. A common premalignant lesion is the actinic keratosis, which appears on areas of chronic sun exposure.

Aging of the skin is a process involving intrinsic structural and functional changes in combination with extrinsic factors such as exposure to ultraviolet (UV) light, wind, or thermal extremes (see “Aging and the skin,” page 226). As it ages, the skin becomes thinner-at times almost like parchment-and inelastic. Because the structural attachments between epidermis and dermis break down, the epidermis can actually tear away with slight trauma, as when a person is pulled across a bed or adhesive tape is removed abruptly. With age, dermal and epidermal circulation becomes less efficient and vascular walls become thinner. As a result, elderly people tend to bruise easily.

The most common benign lesions of aging skin are acrochordons, also known as skin tags. These are found in areas of skin laxity and friction such as the armpits and groin, and beneath the breasts in women. Skin tags generally develop before age 40 in women, but after age 50 in men. Seborrheic keratoses are wartlike growths that first appear as flat, brown lesions, but may become large, verrucous, and cosmetically compromising. They are harmless, however, and can simply be scraped off with a curette or removed with liquid nitrogen.

Cherry angiomas (De Morgan’s spots) are benign proliferations of the capillaries, usually seen on the trunk. Areas of mottled pigmentation most often found on the lateral aspects of the neck, known as poikiloderma of Civatte, typically result from excessive sun exposure. This discoloration is most common among women who play golf or other outdoor games.

A common premalignant skin lesion is the actinic keratosis, which develops on areas of the body that have been chronically sun-exposed.* Solar lentigines, though usually considered benign, may occasionally develop into malignant melanoma. Some patients today are concerned by the small red papules of senile ectasia, mistaking these harmless lesions for Kaposi’s sarcoma. Senile ectasia is not premalignant.

Skin cancer: The aging process predisposes the skin to development of carcinoma. There is a 20% loss of remaining melanocytes per decade after age 30, lessening the skin’s ability to protect itself from ultraviolet (UV) light. T-cell function is diminished, Langerhans’ cells are lost, and the overall inflammatory response is muffled. Sun exposure is responsible for 90% of all skin cancer, but risk also depends on skin color, sex, and where the person lives. Basal cell carcinoma usually remains localized, but squamous cell carcinoma may metastasize.

After age 30, a person loses approximately 20% of his or her epidermal melanocytes per decade. These cells produce pigment-leading to a suntan-in response to UV light to protect the skin from further assault. The inevitable concomitant of decreased melanocyte population is increased susceptibility to UVinduced damage. Moreover, older people are often unable to acquire an even suntan because the remaining melanocytes tend to form irregular aggregates (clumps that are visible in some persons as solar lentigines).

As we age, T-cell function decreases and Langerhans’ cells die off. Loss of these immunocompetent cells increases a person’s likelihood of infection and cancer, systemically and with respect to the skin. Even without sun exposure, older skin apparently is simply more prone to become cancerous than younger skin. Contact with a known carcinogen such as 3,4-benzpyrene results in cancer more often in older than in younger skin. This appears to be a result of an intrinsic cellular heterogeneity inherent in aging.

This muffled inflammatory response of the skin allows an older person to sit out in the sun without becoming sunburned for a longer period of time than when he was younger, but not without incurring significant UV-indueed damage. Because a person may think he does not burn as easily as before, he is likely to assume he can tolerate the sun better, when this is not the case. The cellular insult is as bad or worse, the defense capability is less, and the body’s warning signs are less effective.

The development of skin cancer is a doserelated phenomenon that relies on this intrinsic predisposition in combination with the extrinsic effects of photoaging. A lifetime of actinic assault places a person at considerable risk, particularly if he is fairskinned or lives in an area of great sun intensity. Photoaging is responsible for many of the ordinary wrinkles and brown spots common to older people, but it is also responsible for 90% of skin cancers.

Specific factors that contribute to a person’s likelihood of developing skin cancer include ethnic origin, sex, and where he lives. Fair-skinned persons of Celtic or Scandinavian origin are at the greatest risk, particularly those with red or blonde hair and blue eyes. Similarly, whites in general develop skin cancer 27 times more frequently than blacks. Males are more commonly affected, probably because they more commonly work outdoors. Makeup and lipstick may provide some protection for women, who are less prone to develop malignancies involving the lips and other parts of the face.

The most common cancer of aging skin is basal cell carcinoma, which accounts for 80% of all skin cancers (see Figure 1, page 228). Although basal cell carcinoma rarely spreads, the lesion is usually removed before it can destroy any surrounding tissue.

These are the warning signs of basal cell carcinoma:

• An open sore that persists for three weeks or more

• An irritated red area that may be painful or itchy

• A smooth growth with an elevated border

• A pearly or translucent nodule that resembles a mole; this can be red, pink, white, black, or brown

• A white or yellow lesion that is similar to scar tissue

Squamous cell carcinoma is more dangerous, since it can metastasize. The lesion itself may be irregular, scaly, or bleeding. Although squamous cell carcinoma often develops from a preexisting actinic keratosis, it can also arise in an area of chronic trauma or irritation. The lower lip is a common site. Melanoma, which is the most lethal of the common skin cancers, can also occur in younger people. The incidence of skin cancer doubles with every four degrees’ proximity to the equator, and is thus 5.7 times more common in Texas than in Minnesota. A given patient would be expected to develop skin cancer about 10 years earlier and would be prone to multiple lesions were he to live in an area of high, rather than low, UV intensity. High altitude also can increase the hazard of intense UV exposure.

Dermatologists recommend a thorough skin examination once a year for all older people (see “Some resources for help with skin care”). This examination should include both exposed and nonexposed areas of the body. A person with a history of skin cancer should be examined every six months. People of all ages need to watch their skin for development of any new spots and especially for any change in an old lesion. Also, if one small area of skin cancer is found, a careful examination for other lesions is in order.

Elderly patients should understand that a change in a skin lesion or mole need not be dramatic or quick. Most cancerous lesions on the skin of older people tend to develop slowly, in contrast to cancerous lesions of younger people, which tend to develop and spread more quickly.

Preventing photoaging: Avoidance of sun exposure is the single most significant measure a person can take to protect skin. Long-sleeved clothing, sunglasses, and hats should be worn, and sunscreen with a sun protection factor of at least 15 should be used routinely. Conventional sunscreens containing para-aminobenzoic acid are useful for UV-B radiation, but it now appears that UV-A may be harmful as well; newer sunscreens block both. Protection should begin early in life, and sunscreens must be used generously and consistently to be effective.

Avoidance of sun exposure can greatly reduce the effects of photoaging. Dermatologists recommend that individuals of all ages, particularly those who are fair-skinned and live in areas of intense sun, restrict outdoor activities as much as possible to times of least sun-before 10 AM or after 4 PM. Clothing should be loose, light-colored, and made of tightly woven fabric. A man’s longsleeved shirt can filter out approximately 50% of the UV rays, and an undershirt can increase this to 70% for the body and shoulders. A hat with a large brim or nap covering the neck is also important. These measures will not eliminate exposure to UV radiation-or the risk of skin cancer. Even with proper clothing, and even in the shade or on an overcast day, a person who spends significant time outdoors needs to use a sunscreen with a sun protection factor of at least 15.

It was previously thought that only UV-B radiation was significant in causing sun damage, but now it appears that UV-A may also play a part, and possibly infrared radiation as well. UV-A is present in sunlight year round, and is more penetrating and abundant than UV-B. Newer sunscreens have been developed that contain oxybenzone and Parsol 1789, which block both UV-A and UV-B. Some authorities believe that these formulations will be much more effective in preventing photoaging and skin cancer, and should now be used routinely. Others, however, feel that sunscreens containing paraaminobenzoic acid, which filter only UV-B, still can be be helpful if used consistently.

To be effective, any suncreen must be used correctly. A sunscreen that has a sun protection factor of 15 when tested in the laboratory will provide a factor of 7 if only half the required amount is used. And in fact, studies show that the average person uses only about half the proper amount of sunscreen. In some patients, tretinoin (Retin-A) appears to alleviate the effects of photoaging (see “What to expect from tretinoin,” page 234).* It is worth reminding some patients that the photoaging that takes place during the summer can be repaired, to some extent, by a winter of little sun exposure. Continuing the UV exposure at a tanning parlor during the winter is a foolhardy practice that can contribute to hastening of photodamage and aging of the skin.

Dry skin:The majority of older people are afflicted by some degree of xerosis and itching, particularly during the winter. Cortisone cream and a thick emollient may be applied if inflammation is severe; the emollient alone may be used when inflammation is absent. Therapeutic moisturizers are usually more effective for the severe dryness of aged skin than are cosmetic moisturizers. Supertafted soaps can also be beneficial. Moisturizing products need not be exotic to be effective-plain petrolatum is very useful if applied to damp skin.

Xerosis is the most common problem that develops as skin ages. The exact cause of skin dryness or roughness with aging is unknown, but the decrease in moisture content of the stratum corneum and altered function of the eccrine and sebaceous glands probably contributes. The problem is generally worse in winter, with dry air and heat helping to remove what little moisture the skin may have. In some circumstances, however, there may be an underlying cause such as thyroid dysfunction. Itching may result if the dryness is sufficiently severe, and if the person scratches inflammation may ensue. The itching can be worsened by ingestion of coffee, alcohol, or spicy foods, and by some medications commonly used by older people, such as diuretics.

Although some dermatologists suggest that elderly people bathe less to avoid drying out the skin, others feel that many patients find this practice unacceptable. With minimal use of soap and sufficient use of emollients, the elderly can bathe every day if they wish (see the patient education aid, “Keeping your skin healthy,” page 258). After the bath or shower, the person should blot the skin nonabrasively with a towel, not wipe it completely dry. If the dryness is so severe as to have caused cracking and inflammation, a cortisone cream can be applied to the damp skin, followed by an emollient that will seal in moisture. If there is no inflammation, an emollient such as mineral oil, lanolin, or jojoba oil can be used alone over the damp skin to seal in moisture.

Many moisturizing products are available. Moisturizers and emollients do not need exotic ingredients or an impressive price tag to be effective, however. One of the best emollients to use on damp skin after bathing (though many patients find it cosmetically unacceptable) is plain white petrolatum (Vaseline). In general, unscented products are preferable, because the added fragrances can have an irritant effect.* Some dermatologists recommend the substitution of cleansing cream for soap, but others prefer superfatted, nonsudsing soaps, which can clean the skin without removing the natural oils.

Therapeutic moisturizers containing lactic acid or urea are more effective for the severe dryness of aged skin than are cosmetic moisturizers. These products are intended to alleviate the causes of dryness, rather than simply make the skin temporarily feel lubricated. Some authorities believe that ordinary cosmetic moisturizers actually worsen the dryness, although they may provide a temporary moisturizing sensation. Caution patients not to overuse therapeutic moisturizers, however, because they can cause perioral or rosacea-like dermatitis on the face. Increasing the humidity of the house during the winter may be beneficial. Some authorities also recommend bath oils for dry skin, but others consider this too hazardous for the elderly person, because of the danger of falling in the slippery tub.

PREPARED BY NANCY WALSH

REFERENCES FOR Fenske NA, Grayson LD, Newcomer VD: Common problems of aging skin (N Walsh, ed). Patient Care 23:225-238, April 15, 1989.

1 Bickers DR: Sun induced disorders Emerg Med Clin North Am 1985;3 659-676

2 Elias PM Epidermal effects of retinoids Supramolecular observations and clinical implications J Am Acad Dermatol 1986:15(4 pt 2) 797 809

3 Fenske NA, Lober CW Structural and functional changes of normal aging skin J Am Acad Dermatol 1986;15571-585,

4 Katz SI: The skin as an immunolog ic organ. J Am AcadDermatol 1985:13 530-536,

5 Kligman LH Photoaging Manifestations, prevention and treatment Dermatol Clin 1986;4:517-528

6 Kligman AM Grove GL, Hirose R, et al Topical tretinoin for photoaged skin. J Am Aca d Dermatol 1986;15(4 pt 2) 836-859,

7. Kripke ML Immunology and photocarcinogenesis. New light on an old problem J Am Acad Dermatol 1986; 14 149-155

8 Potts RO, Buras EM Jr, Chrisman DA Jr Changes with age in the moisture content of human skin. J Invest Dermatol 1984 82:97-100

9 Richey HK Fenske NA Normelanomatous skin cancer; New concepts in pathogenesis South Med J 1987:80 362-365.

10 Stern RS, Weinstein MC, Baker SG Risk reduction for nonmelanoma skin cancer with childhood sunscreen use Arch Dermatol 1986;122 537-545

11 Strabeig B. Wulf HC, Klemp P, el al: The carcinogenic effect of UVA irradiation J Invest Dermatol 1983;81:517-519

12 Weiss JS Ellis CN, Headington JT. et al Topical tretinoin improves photoaged skin A double blind vehicle controlled study JAMA 1988;259 527 532

ARTICLE CONSULTANTS

NEIL A. FENSKE, MD professor of internal medicine and pathology and director, division of dermatology, University of south Florida College of Medicine, Tampa; and chief of dermatology, H. Lee Moffitt Cancer Center and Research Institute and James A. Haley Veterans Hospital, Tampa

LEONARD D GRAYSON, MD clinical assistant, department of medicine, Southern Illinois University School of Medicine. and chief, department of allergy, QP&S Clinic, Quincy

VICTOR D. NEWCOMER, MD professor of dermatology, University of California, Los Angeles, UCLA School of Medicine, Los Angeles

Aging and the skin

Human skin normally acts as a barrier between the exterior environment and the homeostatic environment of the body, providing mechanical and sensory protection. By the time a person is in his or her 80s, however, there has been a 15-20% reduction in overall skin function. Thinning of the skin, structural breakdown, and loss of vascularity contribute to this functional deterioration.

Cutaneous innervation also diminishes, increasing the likelihood of mechanical injury, and thinning of subcutaneous tissue lessens the person’s insulating capacity and increases the risk of hypothermia. Malnutrition, to which older persons are prone because of poor eating habits (especially after the death of a spouse), can further exacerbate the deterioration of the skin.

Some resources for help with skin care

American Academy of Dermatology P.O. Box 3116 Evanston, IL 60201 (312) 869-3954

The Skin Cancer Foundation 245 Fifth Avenue Suite 2402 New York, NY 10016 (212) 725-5176

National Cancer Institute 9000 Rockville Pike Building 31 Room 11 A48 Bethesda, MD 20892 (800) 4-CANCER

FIGURE 1: Skin cancer lesions often appear initially on areas of the body that have been chronically exposed to actinic radiation. Basal cell carcinoma (a), which is most common among persons with fair complexions and light hair, does not usually spread beyond the local skin. Squamous cell carcinoma (b) is more dangerous in that it can metastasize, particularly to regional lymph nodes.

What to expect from tretinoin

Long-term use of tretinoin (Retin-A) in some patients appears to improve the texture of the skin and smooth the fine wrinkles characteristic of photoaging. Skin color also improves. and some small premalignant lesions disappear. Deep wrinkles and expression lines are usually not affected by tretinoin.

A double-blind study evaluating the response of 30 patients to tretinoin therapy found that after 12 weeks of treatment, 93% of patients showed at least some cosmetic improvement, particularly in fine wrinkling and facial color. The main adverse consequence these patients encountered was a dermatitis characterized by erythema, swelling, and scaling, which generally improved with emollients. The investigators acknowledge that their study participants were relatively young (mean age 50, age range 35-70), and that further studies are needed to determine the long-term success of the treatment for reversal of photoaging.’

Not all clinicians are finding equivalent success with tretinoin, however, and furthermore caution that patients must be very careful to avoid sun exposure during treatment. They also must avoid sun-sensitizing substances such as products containing sulfur, resorcinol, salicylic acid, or benzoyl peroxide.