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Skin diseases of the lower extremities in the elderly
Dermatol Clin 22 (2004) 13 – 21
Skin diseases of the lower extremities in the elderly Athena Theodosat, MPH, MSII 350 Blackwood-Clementon Road, Apartment 106, Pine Hill, NJ 08021, USA
About 50% of older individuals rely on family and health care personnel to provide routine foot care [1]. Recent research has shown that older individuals are also at a high risk for developing foot disease and that they benefit from the same foot screenings and follow-up as patients with diabetes [1]. Even though the incidence of foot disease is high in the elderly population, many health care professionals give little attention to patient’s feet during office visits [2]. Some of the common problems affecting the geriatric patient’s feet include hyperkeratotic lesions, such as calluses and corns, and digital deformities, such as hallux valgus, hallux limitus, and hammer toe contractures [1,2]. Elderly patients also experience diseases of the toenails that stem from infections and previous trauma [3]. Infections and ulcerations can develop from untreated feet and diseases [2]. Onychologic infections involving the feet usually start on the nail plate and then spread to the web spaces and other areas of the foot [1]. Leg dermatoses in the elderly include but are not limited to xerosis, pruritus, stasis dermatitis, and venous ulcers [1,2]. This article focuses on skin diseases of the lower extremities, which is the second most common site of problems in elderly patients [1,2].
Foot dermatoses As people age, they begin to experience changes in the structure and physiology of their feet [2]. Most of the time, these changes in the feet result in unnecessary pain and discomfort [2]. Treatment is
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available and effective, but most patients are unaware of their options [4]. Many age-related conditions are discovered as a result of careful inspection of the patient’s feet. Managing foot problems early can prevent a decrease in mobility and quality of life for the elderly patient. Conservative treatment can resolve a variety of foot problems but surgery may be necessary to treat severe foot conditions [4]. Hyperkeratosis, which presents as a thickening of the outermost layer of the epidermis, is one of the most common disorders affecting the foot [5]. Mechanical forces and hereditary factors contribute to the development of hyperkeratosis. The rate of basal cell division generates new epidermal cells and determines how thick the skin becomes. Hyperkeratotic lesions occur over bony prominences of the body and places in the body that experience increased friction. When normal skin is exposed to pressure it can become hyperkeratotic; it is considered to be a disorder when symptoms develop [5]. Tylomata (calluses) and helomata (corns) are common hyperkeratotic disorders affecting the feet [6]. A corn is defined as a painful, well-demarcated callosity found over a bony prominence of the foot. Soft corns between the toes can lead to maceration and cellulitis. A callus is a broad plaque normally affecting the sole of the foot. The ball of the foot and margins of the heel are more susceptible to hyperkeratotic lesions. Both types of lesions are characterized by their degree of cornification, and can be found almost anywhere on the feet. If treatment is delayed, these hyperkeratotic disorders can erode and form ulcers [6]. About 30% of foot ulcers in the elderly can be caused by eroded hyperkeratosis [1]. Initial treatment involves changing the patient’s shoes to decrease unnecessary pressure and friction. Modification of the patient’s gait is important in preventing further
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deterioration of the foot [1,2]. Surgery can be performed if conservative treatment fails to remit after conservative treatment [6]. Digital deformities of the feet result from the degenerative changes that occur in the feet as the body ages [5]. Common digital deformities include hallux valgus (bunion); hallux limitus; and hammer toe contractures [6]. Bunions are a result of constant irritation, pressure, and lateral deviation of the great toe [2,6]. Bunions develop as a little sac at the first metatarsal head [2,6]. A predisposing factor for the development of a bunion is excessive pronation while standing [6]. Pain over the first metatarsal joint and difficulty wearing shoes are some of the early signs of bunion formation [2]. Bunion treatment primarily consists of modifying the shoes to accommodate the bunion deformity, along with extra shoe padding to alleviate some of the pain. Joint surgery remains a viable option if conservative treatment is not effective [2]. Hallux limitus is a disorder caused by an inability to dorsiflex at the first metatarsophalangeal joint of the great toe [7]. As a result the first metatarsal head becomes enlarged and the great toe hyperextends [5]. The first metatarsophalangeal joint is restricted during gait making it hard for the foot to move over the hallux when the forefoot is on the ground [7]. Arthritis of the metatarsophalangeal joint is a common underlying condition causing hallux limitus [7,8]. Symptomatic relief, such as using insoles to realign the foot and redistribute weight away from the painful joint, can treat hallux limitus [5]. Hammer toes, mallet toes, and claw toes are caused by contraction of one or more toe joints [9]. Improper shoes and stockings along with biomechanical problems cause the toes to contract and curl. Many people experience pain from toe contractions when they are wearing uncomfortable shoes. Hammer toes are more common in women, as a result of poor shoe choices. Genetics also plays a role in developing toe contractions. Conservative treatments include moleskin, corn pads, toe splints, emollition, and comfortable opentoed shoes; however, the best results usually occur after surgery [6]. Careful attention to specific foot complaints allows for early detection and prevention of many common disorders of the foot [5]. Lichen planus of the skin is a relatively common disease that can last for months to years [10]. Initially, it presents as a pruritic, slightly purplish, papular eruption with a polygonal shape [10,11]. The extent of pruritus is associated with the type and location of the lesion [10]. Hypertrophic lesions, which are found mostly on the lower legs, are very pruritic. This disease occurs most often in men and women between
the ages of 30 and 70 years and tends to favor the inner wrists and ankles [12]. One case study suggests that lichen planus – like eruptions may be a variation of late-onset lupus erythematosus, and elderly patients with lichen planus – like eruptions should be followed carefully until a diagnosis clearly can be made [13]. In the United States, lichen planus is reported in about 1% of all new patients with a slightly higher incidence in between December and January [10]. Most cases involving the skin resolve within 18 months but there have been reports of cases lasting as long as 5 years. Long-standing lichen planus lesions have a propensity to develop into squamous cell carcinomas (SCCs) [14]. The cause of lichen planus is not known but it is believed to be an autoimmune disease, possibly from a viral infection [10,11]. Those with the disease usually have a positive family history and an increased risk of being reinfected. Although there is no cure for lichen planus, most symptoms can be treated with antihistamines and topical steroids [10]. Other helpful measures include soothing baths and application of wet dressings to the affected areas to help reduce the itching [10,11]. As the disease heals, brown discolorations left from the lesions eventually fade away. Nail changes, such as nail plate thinning and ridging, can also be observed in some lichen planus cases [10]. Nongenital warts are estimated to affect about 7% to 12% of the population [15]. Warts present as hard, benign, skin proliferations, caused by one or more of the 150 identified types of human papillomavirus (HPV). Common warts are found more frequently on the hands and knees and are known as ‘‘verruca vulgaris.’’ These warts range in size from 1 mm to over 1 cm and are most commonly caused by HPV types 2 and 4. Filiform warts are long narrow, growths on or around the face. Deep palmoplantar warts are caused mostly by HPV type 1 and they appear as small, shiny papules with a well-defined border and a rough surface. These warts tend to grow deep and cause a lot of pain in the weight-bearing areas of the body, such as the ball of the foot and heel. Flat warts are called verruca plana because they are only slightly elevated with a flesh colored, smooth surface. They can range from 1 to 5 mm and can develop as groups of warts on the hands and shins from HPV types 3, 10, and 28. Butcher’s warts are similar to common warts but they are typically seen on the hands of those who handle meat frequently. Mosaic warts are plaques of warts seen on the palms and soles of the feet. Cystic warts or plantar cysts are caused by HPV type 60. These warts present as smooth nodules with defined ridges and like the deep palmoplantar warts, they appear on weight-bearing areas of the body. The
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diagnosis of warts is based primarily on clinical findings, although a biopsy can be performed if any there is any doubt in the initial diagnosis. A case study involving an elderly man showed that a lesion that was clinically described as a cutaneous horn was actually confirmed to be a viral wart after a biopsy was performed [16]. There are a multitude of ways to treat warts. Topical agents are not very expensive or painful and are used most often [15]. Topical agents, like salicylic acid, can be bought over the counter and applied at home to treat warts. Other topical agents can be used to treat warts in the office setting; one commonly used agent is cantharidin, which is an extract from the blistering beetle. Prescription medications, such as cidofovir, imiquimod, and podophyllotoxin, have also been used to treat warts, usually genital warts and some recurrent warts that are resistant to other therapies. Warts are resistant to conventional therapies in many immunodeficient patients; in these cases alternative medications should be used [17,18]. Oral acitretin has been shown greatly to improve large, painful, palmoplantar warts but it has been linked with hair loss in some patients [17]. Intralesional injections have proved to be successful in treating some persistent warts, although side effects can occur [15]. Grafting should not be performed on plantar warts or other lesions of the foot because the vascular and neural structure of the foot can be disturbed causing keratotic lesions and ulcers [19]. Cryosurgery and lasers are two very successful surgical methods that can be performed to remove warts, although they can be painful and leave scars depending on the location and size of the wart [15]. Cryosurgery may have to be repeated over several weeks or months for effective wart removal [35]. Research has shown that recalcitrant warts can be treated effectively with topical immunotherapy using diphenylcyclopropanone [20]. Treatment with diphenylcyclopropanone does not cause scarring or pain during its application, and it should be considered first when trying to remove recalcitrant warts.
Infections Defective host defenses in the elderly compromise their ability to ward off infectious agents [6]. Consequently, infections are one of the most common reasons for diabetic patients to be admitted to the hospital [1]. Ulcers and underlying peripheral neuropathy are among the most important risk factors for developing foot infections [21]. Sensory neuropathy
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in the diabetic foot develops from increases in plantar pressure [5]. About 55% of the amputations caused by diabetes occur in patients older than 65 years of age [25]. Prevention of peripheral neuropathy through aggressive glycemic control may be the most important primary control measure for foot infections [22]. Treatments of diabetic foot infections include elevation of the foot at rest, tissue debridement, and broad-spectrum antibiotics [1]. Tinea pedis (athlete’s foot) is a fungal infection of the foot that typically starts in the last web space [5]. It is characterized by inflamed scales and ulcerations [2]. Tinea pedis can also occur on the sole of the foot, interdigitally, and less commonly on the dorsum of the foot [2,5]. Hot, humid weather and occlusive footwear promote the transmission of athlete’s foot [23]. A secondary bacterial infection can result from severe and prolonged fungal infections [2,5]. A green colonization within the web spaces may indicate a bacterial invasion by Pseudomonas pyocyanea [5]. Treatments include oral terbinafine, itraconazole, or fluconazole, or topical imidazole [2]. Low-potency corticosteroids should be used up to 7 days to control the inflammation because prolonged use causes skin atrophy [23].
Age-associated nail changes Nail abnormalities are increasing because of a variety of factors, including the aging patient populations [22]. One study evaluated over 200 elderly patients admitted to a geriatric medical unit over a 3-month period and found that 70% of these individuals had a nail disorder [3]. The ability to diagnose and manage onychologic needs of the elderly can be enhanced by understanding and learning about the nail changes commonly seen in the aging patient. In the elderly, fingernails tend to soften, whereas toenails seem to become tougher. Longitudinal ridging, horizontal layering, and roughness of the nail surface characterize brittle nails. Treatment involves good nutrition and moisturizing [6]. Nail trauma also contributes to the development of brittle nails, so it is important to keep the nails short. Shoe-induced biomechanical abnormalities can eventually result in toenail trauma and onychodystrophy [3]. Onychauxis is a local hypertrophic area of the nail plate and onychogryphosis is a toenail abnormality that normally causes the entire great toenail plate to enlarge [5]. Onychauxis and onychogryphosis both develop from high shoe pressure [3]. Onycholysis may occur in patients whose nails en-
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dure the trauma from walking in poorly fitting shoes. Onychoclavus (subungual corns) can develop from an anatomic abnormality or change in foot function, for example by wearing poorly fitting shoes [3,5]. Onychocryptosis (ingrown toenails) can be caused by cutting the nails too short [3]. Onychophosis refers to hyperkeratotic tissue developing on the lateral folds of the nails; this normally affects the first or fifth toe [6]. Treatments should be directed at correcting the underlying bony abnormality, wearing properly fitting shoes, and undergoing routine foot care screening. Onychomycosis, a fungal infection caused by dermatophytes, yeasts, or molds, is one of the most common diseases of the nails [24]. Onychomycosis can become a social impediment and cause significant morbidity, especially in the elderly [22,24]. Prevalence rates for onychomycosis can range from 1% to over 25% in family practice and dermatology offices [22]. The dermatophyte, tinea unguium, accounts for about 90% of onychomycosis infections. Onychomycosis can be classified into four subtypes: (1) distal subungual onychomycosis, (2) white superficial onychomycosis, (3) proximal subungual onychomycosis, and (4) candidal onychomycosis. All four subtypes cause thickening of the nails [25]. Distal subungual onychomycosis is the most common subtype; it presents as a yellow or white discoloration toward the end of the nail and works its way up the nail. White superficial onychomycosis forms white patches on the superficial layer of the nail and then the nail begins to crumble. Proximal subungual onychomycosis also forms large, white patches but it is found in immunocompromised patients, usually affecting their finger nails and toenails equally. Candidal onychomycosis is seen in patients with traumatized nails and those infected with Candida infections. Onychomycosis can be diagnosed by using a potassium hydroxide preparation or by obtaining a fungal culture of the nail plate. The most accurate way to diagnose onychomycosis is to obtain an acid-Schiff – stained biopsy of the nail. Onychomycosis does not normally affect all the nails, and it does not cause pitting like psoriasis. Treatment options range from topical and systemic antifungals to surgery. Initial treatments include trimming and debridement [22]. Systemic drugs include oral griseofulvin, fluconazole, itraconazole, and terbinafine. Topical antifungals, such as ciclopirox nail lacquer 8% solution, take a longer time period to become effective. In more severe cases nail avulsion may be necessary. Elderly patients may be taking other medications that may be contraindicated with antifungal medications [25]. It is important to know the patient’s past medical history and current medications before prescribing treatment.
Cutaneous malignancies The prevalence and incidence of cancer are age related; increased life expectancy increases the number of elderly patients with cancer [26]. Statistics show that the most skin cancer deaths occur in the elderly population and more than half of those people develop cancer after the age of 65. Persistent dermatologic problems contribute to the development of malignancies [27]. In addition, older individuals also have a decrease in cellular proliferation, which causes the cells to have an increased susceptibility to other carcinogens [26]. Many risk factors influence the development of skin cancer, such as immunosuppression, multiple nevi, occupational exposure to products that affect DNA repair, and light-colored skin with freckles. The most preventable factor is extensive sun exposure [15]. Basal cell carcinoma (BCC) is the most common form of skin cancer, causing about 80% of morbidity and mortality [15,27]. It generally tends to develop in older individuals, although it may occur in young adults and children [28]. Clinically, it can present as an open sore, or as a growth with an elevated border and central indentation. Most causes of BCC are a result of chronic sun exposure, although burns, radiation exposure, and other diseases, such as stasis dermatitis, can lead to BCC formation. Those who develop a BCC are more likely to develop other ones; regular skin screenings are essential to catch any new skin developments before they destroy surrounding tissue. The most common modalities of treatment for BCC and other nonmelanoma skin cancers are curettage surgery, excisional surgery, and Mohs’ surgery [27]. Photodynamic therapy is a therapeutic alternative for treatment of BCCs [29]. It is a noninvasive method, in which a photosensitizing agent activated by light is used to destroy tumor cells. A persistent, reoccurring pruritus after the removal of a carcinoma usually indicates that the removal was not complete or another hidden malignancy is developing [30]. Squamous cell carcinoma is less common than BCC but it has the ability to metastasize to distant tissues; this often occurs in chronically inflamed skin or mucous membranes [27]. Some SCCs grow rapidly, because of immunosuppression or viral manifestations; lesions should be treated aggressively [31]. SCCs have been linked to nonresponsive prurigo nodularis lesions [32]. Malignant melanoma is the least common, but most severe form of skin cancer [27]. It begins on the surface of the skin, but it can eventually grow down into deeper layers of the skin and reach blood and lymphatic vessels causing lifethreatening disease. In addition, medications causing
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immunosuppression may lead to SCC formation. SCC appears as flesh-colored eruptions with crusted surfaces that bleed when they are bothered. Verrucous carcinoma (VC) is a low-grade variant of SCC characterized by slow, continuous local growth [33]. VC most commonly occurs in patients between the ages of 55 and 65 years, and primarily affects men. The lesion develops at sites of irritation or inflammation and can penetrate to deeper tissues. Palmoplantar VC usually infects the skin over the first metatarsal head, but it can occur in other areas of the foot, such as the toes or heel, causing pain, ulceration, and bleeding. The HPV is thought to be the cause of VC; reports have shown that HPV type 2 is not only associated with palmoplantar warts but also VC of the foot [33,34]. A skin biopsy should be performed for definite diagnosis of VC [33]. Treatments are aimed at excising the VC, although radiation therapy can be performed over areas of soft tissue [33,36]. VC can be prevented if effective treatment for areas of inflammation and trauma are administered early [33].
Leg dermatoses Xerosis (dry skin) occurs most frequently on the legs of elderly patients [36]. The decreased activity of sebaceous and sweat glands in the elderly is one of the main contributing factors causing dryness. Other contributing causes are altered skin thickness caused by inappropriate desquamation and decreased hydration. Xerotic legs have the appearance of cracked porcelain; the cracks arise from loss of water from the epidermis. Xerotic skin disrupts the desquamation process; powdery flakes develop and become visible on the surface of the skin. In the winter, when the humidity is lower, xerosis tends to be more severe; natural emollients of the skin must be replaced after showering. The management of dry skin is a process that can be introduced into the patient’s everyday care [37]. For example, mild soaps and bath oils can be used when showering to preserve the natural oils of the skin and various moisturizers can be applied to damp skin to increase its moisture. Research has shown that ammonium lactate 12% lotion is also very effective in reducing the effects and severity of xerotic skin [36]. Pruritus is a perceived itching sensation that is commonly brought on by xerosis; it eventually leads scratching, which causes inflammation, and then excoriations. In addition, pre-existing skin disease, such as atopic dermatitis, can persist into old age and cause itching. Various underlying metabolic and psychogenic disorders also cause pruritus; treatment
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should be tailored to the specific etiology to prevent reoccurrence [36]. A complete medical history, physical examination, and laboratory tests are needed to determine the specific cause of the pruritus. Symptoms can be relieved with topical treatments including ammonium lactate moisturizers, emollients, and corticosteroids. It is important to remember that corticosteroid atrophy occurs faster in aged skin so they should not be used for extended periods of time. Asteatotic dermatitis commonly occurs in the shins of elderly patients, but it has been noted to have occurrences in other areas of the body [38]. It presents clinically as dry, pruritic, scaling skin with some bleeding from dermal capillaries. Patients can have a localized eruption or a more spread out eruption that may indicate that it is associated with other diseases. The localized, asteatotic dermatitis can be divided into four types of presentations. The first is cracked erythema, caused by harsh soaps and detergents. The second one occurs in areas where corticosteroid therapy was previously used. The next type occurs along with certain neurologic disorders. The last type results from aging skin and occurs frequently in the lower extremities of elderly patients. The decreased amount of water and sweat grand activity in the epidermis of most elderly patients makes them most susceptible to asteatotic dermatitis. The decrease in water causes epidermal cells to shrink leading to a decrease in skin elasticity and fissure development. Skin inflammation leads to further stretching, which can lead to ruptured dermal capillaries, bleeding, and infection. Primary lesions are scaly and red, whereas secondary lesions develop as erythematous patches with mild bleeding. Asteatotic dermatitis is most prevalent in the winter months in northern environments where humidity is lowered indoors by heaters. Older men are affected more commonly than women. Prevention measures aim at educating the public about the controllable factors that contribute to the dermatitis. These factors include the amount of showers, types of cleansers, diet, medications, and indoor temperature. The elimination of irritative soaps, detergents, and hot showers or baths can help reduce the effects of the dermatitis. Humidifiers, short-term use of corticosteroids, and the application of lotion after showering also greatly reduce the effects of asteatotic dermatitis. Scabies is an infectious disease commonly seen in the institutionalized elderly; cramped facilities contribute to the frequent spread of disease to staff and patients [39,40]. Sarcoptes scabiei is the itch mite responsible for causing this infection that affects millions of people every year [39]. Transmission requires direct skin-to-skin contact, although sharing
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of infected towels or clothing can also facilitate the spread. If it is not diagnosed and treated early it can lead to widespread infestations, especially in nursing homes where patients require lots of assistance from the hospital staff. The diagnostic feature of scabies infection is burrows seen under the skin and a tiny vesicle over the area where the female mite is located. The burrows are seen within the folds of the body, such as between the fingers, at the waist, the external genitalia of men, and the lower buttocks of women. Diagnosis is confirmed by revealing the mite in skin scrapings. This involves putting a drop of oil on the lesion, scraping the skin, and then transferring it to a glass slide for viewing under a microscope. Alternative approaches include the burrow ink test, superficial shave biopsy, and a new technique that uses epiluminescence microscopy. Patients with severe xerosis tend to scratch themselves and leave marks from their fingernails that resemble the burrows in scabies infections; identification of burrows alone is not enough to confirm an infection [41]. Oral ivermectin is a simple and effective way to treat scabies [42,43]. Crusted scabies is a form of hyperinfection with hundreds of mites, caused by the altered immune response of the host [39]. This type of scabies occurs mostly in immunocompromised and elderly patients. Scabies can be treated easily with prescription medications; the best-known treatment is 5% permethrin cream, which is applied at night and washed off the next morning. Sometimes the patient needs a second treatment before the infection resolves. In addition, they may experience some mild burning depending on the severity of the infection. Other treatments involve lindane lotion or oral ivermectin for severe cases. Irritative contact dermatitis in the elderly is commonly caused by topical medications [44]. It develops as a response to chemical damage to the skin’s epidermal cells and presents as an inflammation of the skin with varying degrees of edema and scaling. Irritative contact dermatitis does not spread beyond the initial area of contact [45]. Irritative contact dermatitis can be divided into two groups: strong irritants, which produce immediate reactions, and mild irritants, which need longer exposure before a reaction develops [44]. Initial symptoms include burning and stinging along with general discomfort. The inflammatory skin reactions are initiated by the release and response of cytokines by keratinocytes. Cutaneous irritants, like detergents and solvents, remove essential oils from the skin and make it more susceptible to the effects of previously tolerated products. In the United States, irritative contact dermatitis is common in those who constantly expose their skin to water or other irritants and it is seen more frequently in women,
probably from cleaning products. There are no diagnostic tests available for irritative contact dermatitis, so diagnosis is based on ruling out other cutaneous diseases. This can be accomplished by obtaining a detailed history of the exposure to the affected site. In addition to a detailed history, patch testing can be used in severe cases to rule out allergic contact dermatitis. A skin biopsy can also be done to exclude other disorders, such as psoriasis. Irritative contact dermatitis responds well to bland, topical corticosteroids like amcinonide (Cyclocort) and fluocinolone. Unresponsive contact dermatitis in elderly patients indicates systemic disease. Secondary infections can occur, particularly with Staphylococcus aureus, and those patients who are under severe stress can develop neurodermatitis (lichen simplex chronicus). Hyperpigmentation or hypopigmentation can occur following infection, particularly in those who have more pigmented skin. Recovering patients must learn to avoid the cutaneous irritants; otherwise they redevelop the dermatitis and possibly other more complicating secondary infections. Stasis dermatitis affects a large portion of the elderly population [45]. It is estimated to affect 15 to 20 million patients over the age of 50 years in the United States. Stasis dermatitis can develop from poorly treated xerosis and pruritus. Patients present with pruritus on the medial ankle; it then spreads to the foot and calf, eventually causing leg edema. Chronic stasis dermatitis appears lichenified and hyperpigmented and can eventually lead to the ‘‘inverted champagne bottle’’ appearance of the leg. This skin disease commonly affects the lower legs bilaterally [46]. It is usually the sequelae of venous insufficiency and can eventually lead to ulcerations of the legs. Alteration of the function of the deep venous plexus of the leg causes blood to backflow to the superficial venous system causing venous hypertension and cutaneous inflammation. Stasis dermatitis is often misdiagnosed as cellulitis and generally affects women at a higher rate than men because of the fact that pregnancy puts extra stress on the lower legs [45]. Treatment is aimed at lessening the impact of the venous insufficiency. Venous Doppler studies should be considered to determine if vascular surgery is needed. Compression therapy can be administered to control the amount of pressure on the legs. Support stockings, elastic wraps, and Unna’s boots are examples of devices that can be used to even out the pressure on the affected legs. Elevating the legs 6 in above the heart has also been proved to be an effective treatment measure along with engaging in regular exercise. Topical corticosteroids used to treat stasis dermatitis can cause infections if the patient has open
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excoriations. Topical antibiotics, such as bacitracin and Polysporin, should also be used. Leg ulcers are becoming a severe problem in the United States, with about 600,000 new cases per year [47]. The etiologic causes are usually linked to venous or arterial insufficiencies. It is important to determine the exact cause of the ulcer to provide the proper treatment for the patient [48]. Venous insufficiency is a dysfunction of the venous system that causes high venous pressure in the legs [47]. It can be caused by outflow obstruction, thrombosis, or incompetent valves in the legs [48]. Characteristics of venous insufficiency ulcers include reddish brown color, shallow depth, irregular margins, and minimal pain [47]. The elevated pressure is a result of faster circulation times and higher oxygen content. Most leg ulcers develop from high venous pressure in the legs. Burn scars and chronic infections are some of the predisposing factors for their development. Case reports have shown that venous leg ulcers are more common in women and the rate increases with advancing age [48]. Standard venous ulcer treatment involves elevation of the leg, compression therapy, and topical therapy to absorb the exudate and maintain a moist wound environment [49]. General prevention measures aim at keeping the feet clean and dry, controlling glucose levels, and maintaining optimal venous return by not standing for long periods of time. Arterial insufficiency causes only about 5% to 10% of leg ulcers [47]. Causes of arterial insufficiency include atherosclerosis and vasculitis, which are common in people with hypertension, diabetes, and other circulatory diseases. Arterial ulcer lesions occur more frequently over bony prominences and they gradually increase in size. Leg ulcers caused by arterial insufficiencies are much more painful than those caused by venous insufficiency and elevation of the ulcerated leg tends to make the symptoms worse. Erosive pustular dermatosis of the leg is a rare disorder that can affect the lower limbs of elderly patients who present with chronic venous insufficiency or stasis dermatitis [50]. Clinical features of the disease include pustule formation and moist eroded lesions on the leg. SCCs are also known to cause leg ulcers, especially in elderly patients with poor general health [47] Regular physical examinations are necessary to determine if any changes are occurring that may lead to ulcer formation.
Psychologic disorders Psychologic diseases in the elderly are often associated with diseases involving the skin [51]. Lichen
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simplex chronicus, prurigo nodularis, neurotic excoriations, and delusions of parasitosis are some of the conditions affecting many elderly patients. Lichen simplex chronicus (neurodermatitis) is a troublesome, itchy dermatosis that is commonly seen in patients with obsessive-compulsive behaviors. These patients present with inflamed, pruritic plaques over areas of their body that eventually become lichenified from the constant scratching and rubbing. Treatment involves topical steroids, along with behavior changes that identify and eliminate triggering factors [51,52]. Topical aspirin solution with dichloromethane has been shown to be an effective antipruritic treatment [53]. Those patients with severe lesions may need more intense treatment, such as fluocinonide or clobetasol solution [51]. Prurigo nodularis is an eruption of excoriated nodules caused by intense pruritus. The nodules are hard and hyperpigmented, occurring all over the extremities. Like lichen simplex chronicus, prurigo nodularis can also be treated with mild corticosteroids or stronger steroids like betamethasone. Topical capsaicin has been shown to interfere with the perception of pruritus by eliminating neuropeptides in cutaneous sensory nerves [54]. In addition, it has been tested and proved to be an effective and safe treatment option for clearing the skin lesions associated with prurigo nodularis [54]. Neurotic excoriations are the most common psychologically induced skin disorder [51]. Patients usually start to compulsively pick their skin after an insect bite or another mild irritation; this progresses until larger lesions and ulcerations form. Patients who complain of a crawling sensation all over their body are said to have delusions of parasitosis; these patients may also have other disorders, such as psychoneurosis and drug addictions. Antipsychotics and treatments geared toward the specific underlying problem are the best methods of treatment for this disorder.
Summary Routine care of the legs and feet in the elderly is important in helping to prevent infections, malignancies, and further deterioration [1]. The lower extremities are of particular interest because of the increasing amount of diseases and disorders involving the legs and feet. Foot disorders in the elderly are associated with poor choices in footwear, structural changes, brought on by aging, and inadequate knowledge about prevention and treatment [4]. Conservative treatments along with gait modification provide positive longterm results, although sometimes surgery is necessary
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for severe foot disorders. Onychomycosis and other nail disorders commonly infect the elderly despite the wide variety of treatment options [22,25]. The increase in malignancy formation in the elderly is caused by the increase in the elderly population and inadequate treatment of leg ulcers and other chronic lesions [26,28]. Aging is associated with many dermatologic changes; many of the disorders and diseases of the lower extremities can be managed if detected and treated early. Proper awareness of the signs, symptoms, and care is important [41].
[15]
[16] [17]
[18]
[19]
References [20] [1] Alam M, Scher K, Schneiderman PI. Leg, foot and nail disease in the elderly. Geriatr Dermatol 2001;5: 65 – 81. [2] Strauss H, Spielfogel WD. Foot disorders in the elderly. Clinical Geriatrics 2003;52:595 – 602. [3] Cohen PR, Scher RK. The nail in older individuals. In: Scher RK, Daniel CR, editors. Nails: therapy, diagnosis, surgery. 2nd edition. Philadelphia: WB Saunders; 1990. p. 127 – 50. [4] Markinson BC. Podiatry: three-step approach to inoffice assessment of the geriatric foot. Geriatrics 2001; 56:48 – 52. [5] Dawber R, Bristow I, Turner W. Skin disorders. In: Dunitz M, editor. Text atlas of podiatric dermatology. Malden, MA: Blackwell Science; 2001. p. 31 – 76. [6] Laine W. Foot problems. In: Newcomer VD, Young EM, editors. Geriatric dermatology clinical diagnosis and practical therapy. Tokyo: Igaku-Shoin Medical Publishers; 1989. p. 459 – 76. [7] Gurnick K. Prescribing foot orthoses for hallux limitus. Valencia, CA: KLM Orthotics: KLM Laboratories; 1998. [8] Wulker N. Hallux rigidus. Derleme/ Review 2000;11: 95 – 103. [9] Brown C. Mallet toe. E Medicine 2003. Available at: www.emedicine.com/orthoped/topic516.htm. Accessed July 27, 2003. [10] Chuang TY. Lichen planus. E Medicine 2002. Available at: www.emedicine.com/DERM/topic233.htm. Accessed July 21, 2003. [11] Walling AD. Clinical Information from the International family medicine literature. Australian Family Physician 1999. p. 369. [12] Michael JA. Dermatitis, contact. E Medicine 2002. Available at: www.emedicine.com/EMERG/topic131. htm. Accessed July 17, 2003. [13] Koga T, Kubota H, Kiryu J, et al. Late onset systemic lupus erythematosus with lichen planus-like eruption and cardiac tamponade. Eur J Dermatol 2000;8: 620 – 2. [14] Ardabili M, Gambichler T, et al. Metastatic cutaneous squamous cell carcinoma arising from a previous area
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of chronic hypertrophic lichen planus. Dermatol Online J Feb 2003;9:10. Rinker MH. Warts, nongenital. E Medicine 2001. Available at: www.emedicine.com/DERM/topic457.htm. Accessed July 21, 2003. Dyall-Smith D, Mason G. Plantar wart presenting as a cutaneous horn. Aust J Dermatol 1995;36:214 – 5. Anthony FC, Webster ADB, Bain MD, Harland CC. Recalcitrant palmoplantar warts associated with adultonset adenosine deaminase deficiency. Br J Dermatol 2002;147:180 – 95. Asadullah K, Renz H, et al. Verrucosis of hands and feet in a patient with combined immune deficiency. J Am Acad Dermatol 1998;38:850 – 2. Hautkr Z. Problems in surgery of the sole of the foot. Medline 1990;65:550 – 2. Upitis JA, Krol A. The use of diphenylcyclopropanone in the treatment of recalcitrant warts. J Cutan Med Surg 2002;6:214 – 7. Gregory J. Geriatrics: foot and ankle secrets. Philadelphia: Hanley and Belfus; 1998. Werschler P, Smith SA, Bondar GL. Treatment of onychomycosis in the elderly. Clin Geriatr 2002;10(4): 19 – 30. Goldstein AO, Smith KM, Ives TJ, Goldstein B. Mycotic infections: effective management of conditions involving the skin, hair and nails. Geriatrics 2000;55: 40 – 52. Pierard G. Onychomycosis and other superficial fungal infections of the foot in the elderly: a pan-European survey. Dermatology 2001;202:220 – 4. Jones ED. Onychomycosis: current treatment options. J Am Acad Nurse Pract 2003;15:165 – 8. Dutcher JP, Wiernik PH. Oncologic disorders in older adults. 2003;45:501 – 15. Available at: www.pubmed. gov. Keywords: Malignancy in older adults. Adam JE. Skin cancer: a review. Geriatrics and Aging 2002;5:14 – 6. Greenway HT, Peterson CM. Treatment guidelines for basal cell carcinoma. The Skin Cancer Foundation Journal 1998;16:16 – 7. Zeitouni NC, Oseroff AR, Shieh S. Photodynamic therapy for nonmelanoma skin cancers: current review and update. Mol Immunol 2003;39:1133 – 6. Cormia FE. Pruritus, an uncommon but important symptom of systemic carcinoma. Arch Dermatol 1965;92: 36 – 9. Billingsley EM, Davis N, Helm KF. Rapidly growing squamous cell carcinoma. J Cutan Med Surg 1999;3: 193 – 7. Al-Waiz MM, Maluki AH. Squamous cell carcinoma complicating prurigo nodularis. Saudi Med J 2000; 21:300 – 1. Mohsin A. Verrucous carcinoma. E Medicine 2002. Available at: www.emedicine.com/derm/topic452.htm. Accessed July 21, 2003. Noel JC, Peny MO, et al. Demonstration of human papillomavirus type 2 in a verrucous carcinoma of the foot. Dermatology 1993;187:58 – 61.
A. Theodosat / Dermatol Clin 22 (2004) 13–21 [35] Yeh CJ. Treatment of verrucous hyperplasia and verrucous carcinoma by shave excision and simple cryosurgery. Int J Oral Maxillofac Surg 2003;32: 280 – 3. [36] Norman RA. Causes and management of xerosis and pruritus in the elderly. Annals of Long-term Care 2001; 9:35 – 40. [37] Murray S. Dry skin in the elderly patient. Geriatrics and Aging 2002;5:20 – 2. [38] Anderson CK. Asteatotic eczema. E Medicine 2002. Available at: www.emedicine.com/derm/topic538.htm. Accessed July 24, 2003. [39] Stone SP. Scabies and pediculosis. Geriatr Dermatol 2001;7:95 – 104. [40] Meltzer E. Ivermectin and the treatment of outbreaks of scabies in medical facilities. Harefuah 2002;141: 948 – 52. [41] Palmissano C, Norman RA. Geriatric dermatology in chronic care and rehabilitation. Dermatol Nurs 2000; 12:116 – 23. [42] Badiane C. Ivermectin: new indication. Oral treatment of scabies: simple and effective. Prescrire Int 2002;11: 137 – 40. [43] Millership S, Readman R, Bracebridge S. Use of Ivermectin, given orally, to control scabies in homes for the elderly mentally ill. Commun Dis Public Health 2002;5:144 – 6. [44] Hogan D. Contact dermatitis, irritant. E Medicine
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2002. Available at: www.emedicine.com/DERM/ topic85.htm. Accessed July 16, 2003. Flugman SL. Stasis dermatitis. E Medicine 2002. Available at: www.emedicine.com/DERM/topic403.htm. Accessed July 3, 2003. Goodheart HP. Eczema. Part 9: Stasis dermatitis. Women’s Health in Primary Care 2001;4:703 – 5. Bowman PH, Hogan DJ. Leg ulcers: a common problem with sometimes uncommon etiologies. Geriatrics 1999;54:43 – 53. Margolis DJ, Bilker W, Santanna J, et al. Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol 2002;46:381 – 6. Venous stasis ulcers. Tyco Healthcare. St. Mansfield, MA. Brouard MC, et al. Erosive pustular dermatosis of the leg: report of three cases. Br J Dermatol 2002;147: 765 – 9. Norman RA. Geriatric dermatology. Clin Geriatr 2003; 35:367 – 90. Senti G, Wuthrich B. Therapy of neurodermatitis (atopic dermatitis). Ther Umsch 2001;58:304 – 8. Yosipovitch G, et al. The effect of topically applied aspirin on localized circumscribed neurodermatitis. J Am Acad Dermatol 2001;45:910 – 3. Stander S, Luger T, Metze D. Treatment of prurigo nodularis with topical capsaicin. J Am Acad Dermatol 2001;44:471 – 8.
Skin diseases of the lower extremities in the elderly Athena Theodosat, MPH, MSII 350 Blackwood-Clementon Road, Apartment 106, Pine Hill, NJ 08021, USA
About 50% of older individuals rely on family and health care personnel to provide routine foot care [1]. Recent research has shown that older individuals are also at a high risk for developing foot disease and that they benefit from the same foot screenings and follow-up as patients with diabetes [1]. Even though the incidence of foot disease is high in the elderly population, many health care professionals give little attention to patient’s feet during office visits [2]. Some of the common problems affecting the geriatric patient’s feet include hyperkeratotic lesions, such as calluses and corns, and digital deformities, such as hallux valgus, hallux limitus, and hammer toe contractures [1,2]. Elderly patients also experience diseases of the toenails that stem from infections and previous trauma [3]. Infections and ulcerations can develop from untreated feet and diseases [2]. Onychologic infections involving the feet usually start on the nail plate and then spread to the web spaces and other areas of the foot [1]. Leg dermatoses in the elderly include but are not limited to xerosis, pruritus, stasis dermatitis, and venous ulcers [1,2]. This article focuses on skin diseases of the lower extremities, which is the second most common site of problems in elderly patients [1,2].
Foot dermatoses As people age, they begin to experience changes in the structure and physiology of their feet [2]. Most of the time, these changes in the feet result in unnecessary pain and discomfort [2]. Treatment is
E-mail address: [email protected]
available and effective, but most patients are unaware of their options [4]. Many age-related conditions are discovered as a result of careful inspection of the patient’s feet. Managing foot problems early can prevent a decrease in mobility and quality of life for the elderly patient. Conservative treatment can resolve a variety of foot problems but surgery may be necessary to treat severe foot conditions [4]. Hyperkeratosis, which presents as a thickening of the outermost layer of the epidermis, is one of the most common disorders affecting the foot [5]. Mechanical forces and hereditary factors contribute to the development of hyperkeratosis. The rate of basal cell division generates new epidermal cells and determines how thick the skin becomes. Hyperkeratotic lesions occur over bony prominences of the body and places in the body that experience increased friction. When normal skin is exposed to pressure it can become hyperkeratotic; it is considered to be a disorder when symptoms develop [5]. Tylomata (calluses) and helomata (corns) are common hyperkeratotic disorders affecting the feet [6]. A corn is defined as a painful, well-demarcated callosity found over a bony prominence of the foot. Soft corns between the toes can lead to maceration and cellulitis. A callus is a broad plaque normally affecting the sole of the foot. The ball of the foot and margins of the heel are more susceptible to hyperkeratotic lesions. Both types of lesions are characterized by their degree of cornification, and can be found almost anywhere on the feet. If treatment is delayed, these hyperkeratotic disorders can erode and form ulcers [6]. About 30% of foot ulcers in the elderly can be caused by eroded hyperkeratosis [1]. Initial treatment involves changing the patient’s shoes to decrease unnecessary pressure and friction. Modification of the patient’s gait is important in preventing further
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deterioration of the foot [1,2]. Surgery can be performed if conservative treatment fails to remit after conservative treatment [6]. Digital deformities of the feet result from the degenerative changes that occur in the feet as the body ages [5]. Common digital deformities include hallux valgus (bunion); hallux limitus; and hammer toe contractures [6]. Bunions are a result of constant irritation, pressure, and lateral deviation of the great toe [2,6]. Bunions develop as a little sac at the first metatarsal head [2,6]. A predisposing factor for the development of a bunion is excessive pronation while standing [6]. Pain over the first metatarsal joint and difficulty wearing shoes are some of the early signs of bunion formation [2]. Bunion treatment primarily consists of modifying the shoes to accommodate the bunion deformity, along with extra shoe padding to alleviate some of the pain. Joint surgery remains a viable option if conservative treatment is not effective [2]. Hallux limitus is a disorder caused by an inability to dorsiflex at the first metatarsophalangeal joint of the great toe [7]. As a result the first metatarsal head becomes enlarged and the great toe hyperextends [5]. The first metatarsophalangeal joint is restricted during gait making it hard for the foot to move over the hallux when the forefoot is on the ground [7]. Arthritis of the metatarsophalangeal joint is a common underlying condition causing hallux limitus [7,8]. Symptomatic relief, such as using insoles to realign the foot and redistribute weight away from the painful joint, can treat hallux limitus [5]. Hammer toes, mallet toes, and claw toes are caused by contraction of one or more toe joints [9]. Improper shoes and stockings along with biomechanical problems cause the toes to contract and curl. Many people experience pain from toe contractions when they are wearing uncomfortable shoes. Hammer toes are more common in women, as a result of poor shoe choices. Genetics also plays a role in developing toe contractions. Conservative treatments include moleskin, corn pads, toe splints, emollition, and comfortable opentoed shoes; however, the best results usually occur after surgery [6]. Careful attention to specific foot complaints allows for early detection and prevention of many common disorders of the foot [5]. Lichen planus of the skin is a relatively common disease that can last for months to years [10]. Initially, it presents as a pruritic, slightly purplish, papular eruption with a polygonal shape [10,11]. The extent of pruritus is associated with the type and location of the lesion [10]. Hypertrophic lesions, which are found mostly on the lower legs, are very pruritic. This disease occurs most often in men and women between
the ages of 30 and 70 years and tends to favor the inner wrists and ankles [12]. One case study suggests that lichen planus – like eruptions may be a variation of late-onset lupus erythematosus, and elderly patients with lichen planus – like eruptions should be followed carefully until a diagnosis clearly can be made [13]. In the United States, lichen planus is reported in about 1% of all new patients with a slightly higher incidence in between December and January [10]. Most cases involving the skin resolve within 18 months but there have been reports of cases lasting as long as 5 years. Long-standing lichen planus lesions have a propensity to develop into squamous cell carcinomas (SCCs) [14]. The cause of lichen planus is not known but it is believed to be an autoimmune disease, possibly from a viral infection [10,11]. Those with the disease usually have a positive family history and an increased risk of being reinfected. Although there is no cure for lichen planus, most symptoms can be treated with antihistamines and topical steroids [10]. Other helpful measures include soothing baths and application of wet dressings to the affected areas to help reduce the itching [10,11]. As the disease heals, brown discolorations left from the lesions eventually fade away. Nail changes, such as nail plate thinning and ridging, can also be observed in some lichen planus cases [10]. Nongenital warts are estimated to affect about 7% to 12% of the population [15]. Warts present as hard, benign, skin proliferations, caused by one or more of the 150 identified types of human papillomavirus (HPV). Common warts are found more frequently on the hands and knees and are known as ‘‘verruca vulgaris.’’ These warts range in size from 1 mm to over 1 cm and are most commonly caused by HPV types 2 and 4. Filiform warts are long narrow, growths on or around the face. Deep palmoplantar warts are caused mostly by HPV type 1 and they appear as small, shiny papules with a well-defined border and a rough surface. These warts tend to grow deep and cause a lot of pain in the weight-bearing areas of the body, such as the ball of the foot and heel. Flat warts are called verruca plana because they are only slightly elevated with a flesh colored, smooth surface. They can range from 1 to 5 mm and can develop as groups of warts on the hands and shins from HPV types 3, 10, and 28. Butcher’s warts are similar to common warts but they are typically seen on the hands of those who handle meat frequently. Mosaic warts are plaques of warts seen on the palms and soles of the feet. Cystic warts or plantar cysts are caused by HPV type 60. These warts present as smooth nodules with defined ridges and like the deep palmoplantar warts, they appear on weight-bearing areas of the body. The
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diagnosis of warts is based primarily on clinical findings, although a biopsy can be performed if any there is any doubt in the initial diagnosis. A case study involving an elderly man showed that a lesion that was clinically described as a cutaneous horn was actually confirmed to be a viral wart after a biopsy was performed [16]. There are a multitude of ways to treat warts. Topical agents are not very expensive or painful and are used most often [15]. Topical agents, like salicylic acid, can be bought over the counter and applied at home to treat warts. Other topical agents can be used to treat warts in the office setting; one commonly used agent is cantharidin, which is an extract from the blistering beetle. Prescription medications, such as cidofovir, imiquimod, and podophyllotoxin, have also been used to treat warts, usually genital warts and some recurrent warts that are resistant to other therapies. Warts are resistant to conventional therapies in many immunodeficient patients; in these cases alternative medications should be used [17,18]. Oral acitretin has been shown greatly to improve large, painful, palmoplantar warts but it has been linked with hair loss in some patients [17]. Intralesional injections have proved to be successful in treating some persistent warts, although side effects can occur [15]. Grafting should not be performed on plantar warts or other lesions of the foot because the vascular and neural structure of the foot can be disturbed causing keratotic lesions and ulcers [19]. Cryosurgery and lasers are two very successful surgical methods that can be performed to remove warts, although they can be painful and leave scars depending on the location and size of the wart [15]. Cryosurgery may have to be repeated over several weeks or months for effective wart removal [35]. Research has shown that recalcitrant warts can be treated effectively with topical immunotherapy using diphenylcyclopropanone [20]. Treatment with diphenylcyclopropanone does not cause scarring or pain during its application, and it should be considered first when trying to remove recalcitrant warts.
Infections Defective host defenses in the elderly compromise their ability to ward off infectious agents [6]. Consequently, infections are one of the most common reasons for diabetic patients to be admitted to the hospital [1]. Ulcers and underlying peripheral neuropathy are among the most important risk factors for developing foot infections [21]. Sensory neuropathy
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in the diabetic foot develops from increases in plantar pressure [5]. About 55% of the amputations caused by diabetes occur in patients older than 65 years of age [25]. Prevention of peripheral neuropathy through aggressive glycemic control may be the most important primary control measure for foot infections [22]. Treatments of diabetic foot infections include elevation of the foot at rest, tissue debridement, and broad-spectrum antibiotics [1]. Tinea pedis (athlete’s foot) is a fungal infection of the foot that typically starts in the last web space [5]. It is characterized by inflamed scales and ulcerations [2]. Tinea pedis can also occur on the sole of the foot, interdigitally, and less commonly on the dorsum of the foot [2,5]. Hot, humid weather and occlusive footwear promote the transmission of athlete’s foot [23]. A secondary bacterial infection can result from severe and prolonged fungal infections [2,5]. A green colonization within the web spaces may indicate a bacterial invasion by Pseudomonas pyocyanea [5]. Treatments include oral terbinafine, itraconazole, or fluconazole, or topical imidazole [2]. Low-potency corticosteroids should be used up to 7 days to control the inflammation because prolonged use causes skin atrophy [23].
Age-associated nail changes Nail abnormalities are increasing because of a variety of factors, including the aging patient populations [22]. One study evaluated over 200 elderly patients admitted to a geriatric medical unit over a 3-month period and found that 70% of these individuals had a nail disorder [3]. The ability to diagnose and manage onychologic needs of the elderly can be enhanced by understanding and learning about the nail changes commonly seen in the aging patient. In the elderly, fingernails tend to soften, whereas toenails seem to become tougher. Longitudinal ridging, horizontal layering, and roughness of the nail surface characterize brittle nails. Treatment involves good nutrition and moisturizing [6]. Nail trauma also contributes to the development of brittle nails, so it is important to keep the nails short. Shoe-induced biomechanical abnormalities can eventually result in toenail trauma and onychodystrophy [3]. Onychauxis is a local hypertrophic area of the nail plate and onychogryphosis is a toenail abnormality that normally causes the entire great toenail plate to enlarge [5]. Onychauxis and onychogryphosis both develop from high shoe pressure [3]. Onycholysis may occur in patients whose nails en-
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dure the trauma from walking in poorly fitting shoes. Onychoclavus (subungual corns) can develop from an anatomic abnormality or change in foot function, for example by wearing poorly fitting shoes [3,5]. Onychocryptosis (ingrown toenails) can be caused by cutting the nails too short [3]. Onychophosis refers to hyperkeratotic tissue developing on the lateral folds of the nails; this normally affects the first or fifth toe [6]. Treatments should be directed at correcting the underlying bony abnormality, wearing properly fitting shoes, and undergoing routine foot care screening. Onychomycosis, a fungal infection caused by dermatophytes, yeasts, or molds, is one of the most common diseases of the nails [24]. Onychomycosis can become a social impediment and cause significant morbidity, especially in the elderly [22,24]. Prevalence rates for onychomycosis can range from 1% to over 25% in family practice and dermatology offices [22]. The dermatophyte, tinea unguium, accounts for about 90% of onychomycosis infections. Onychomycosis can be classified into four subtypes: (1) distal subungual onychomycosis, (2) white superficial onychomycosis, (3) proximal subungual onychomycosis, and (4) candidal onychomycosis. All four subtypes cause thickening of the nails [25]. Distal subungual onychomycosis is the most common subtype; it presents as a yellow or white discoloration toward the end of the nail and works its way up the nail. White superficial onychomycosis forms white patches on the superficial layer of the nail and then the nail begins to crumble. Proximal subungual onychomycosis also forms large, white patches but it is found in immunocompromised patients, usually affecting their finger nails and toenails equally. Candidal onychomycosis is seen in patients with traumatized nails and those infected with Candida infections. Onychomycosis can be diagnosed by using a potassium hydroxide preparation or by obtaining a fungal culture of the nail plate. The most accurate way to diagnose onychomycosis is to obtain an acid-Schiff – stained biopsy of the nail. Onychomycosis does not normally affect all the nails, and it does not cause pitting like psoriasis. Treatment options range from topical and systemic antifungals to surgery. Initial treatments include trimming and debridement [22]. Systemic drugs include oral griseofulvin, fluconazole, itraconazole, and terbinafine. Topical antifungals, such as ciclopirox nail lacquer 8% solution, take a longer time period to become effective. In more severe cases nail avulsion may be necessary. Elderly patients may be taking other medications that may be contraindicated with antifungal medications [25]. It is important to know the patient’s past medical history and current medications before prescribing treatment.
Cutaneous malignancies The prevalence and incidence of cancer are age related; increased life expectancy increases the number of elderly patients with cancer [26]. Statistics show that the most skin cancer deaths occur in the elderly population and more than half of those people develop cancer after the age of 65. Persistent dermatologic problems contribute to the development of malignancies [27]. In addition, older individuals also have a decrease in cellular proliferation, which causes the cells to have an increased susceptibility to other carcinogens [26]. Many risk factors influence the development of skin cancer, such as immunosuppression, multiple nevi, occupational exposure to products that affect DNA repair, and light-colored skin with freckles. The most preventable factor is extensive sun exposure [15]. Basal cell carcinoma (BCC) is the most common form of skin cancer, causing about 80% of morbidity and mortality [15,27]. It generally tends to develop in older individuals, although it may occur in young adults and children [28]. Clinically, it can present as an open sore, or as a growth with an elevated border and central indentation. Most causes of BCC are a result of chronic sun exposure, although burns, radiation exposure, and other diseases, such as stasis dermatitis, can lead to BCC formation. Those who develop a BCC are more likely to develop other ones; regular skin screenings are essential to catch any new skin developments before they destroy surrounding tissue. The most common modalities of treatment for BCC and other nonmelanoma skin cancers are curettage surgery, excisional surgery, and Mohs’ surgery [27]. Photodynamic therapy is a therapeutic alternative for treatment of BCCs [29]. It is a noninvasive method, in which a photosensitizing agent activated by light is used to destroy tumor cells. A persistent, reoccurring pruritus after the removal of a carcinoma usually indicates that the removal was not complete or another hidden malignancy is developing [30]. Squamous cell carcinoma is less common than BCC but it has the ability to metastasize to distant tissues; this often occurs in chronically inflamed skin or mucous membranes [27]. Some SCCs grow rapidly, because of immunosuppression or viral manifestations; lesions should be treated aggressively [31]. SCCs have been linked to nonresponsive prurigo nodularis lesions [32]. Malignant melanoma is the least common, but most severe form of skin cancer [27]. It begins on the surface of the skin, but it can eventually grow down into deeper layers of the skin and reach blood and lymphatic vessels causing lifethreatening disease. In addition, medications causing
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immunosuppression may lead to SCC formation. SCC appears as flesh-colored eruptions with crusted surfaces that bleed when they are bothered. Verrucous carcinoma (VC) is a low-grade variant of SCC characterized by slow, continuous local growth [33]. VC most commonly occurs in patients between the ages of 55 and 65 years, and primarily affects men. The lesion develops at sites of irritation or inflammation and can penetrate to deeper tissues. Palmoplantar VC usually infects the skin over the first metatarsal head, but it can occur in other areas of the foot, such as the toes or heel, causing pain, ulceration, and bleeding. The HPV is thought to be the cause of VC; reports have shown that HPV type 2 is not only associated with palmoplantar warts but also VC of the foot [33,34]. A skin biopsy should be performed for definite diagnosis of VC [33]. Treatments are aimed at excising the VC, although radiation therapy can be performed over areas of soft tissue [33,36]. VC can be prevented if effective treatment for areas of inflammation and trauma are administered early [33].
Leg dermatoses Xerosis (dry skin) occurs most frequently on the legs of elderly patients [36]. The decreased activity of sebaceous and sweat glands in the elderly is one of the main contributing factors causing dryness. Other contributing causes are altered skin thickness caused by inappropriate desquamation and decreased hydration. Xerotic legs have the appearance of cracked porcelain; the cracks arise from loss of water from the epidermis. Xerotic skin disrupts the desquamation process; powdery flakes develop and become visible on the surface of the skin. In the winter, when the humidity is lower, xerosis tends to be more severe; natural emollients of the skin must be replaced after showering. The management of dry skin is a process that can be introduced into the patient’s everyday care [37]. For example, mild soaps and bath oils can be used when showering to preserve the natural oils of the skin and various moisturizers can be applied to damp skin to increase its moisture. Research has shown that ammonium lactate 12% lotion is also very effective in reducing the effects and severity of xerotic skin [36]. Pruritus is a perceived itching sensation that is commonly brought on by xerosis; it eventually leads scratching, which causes inflammation, and then excoriations. In addition, pre-existing skin disease, such as atopic dermatitis, can persist into old age and cause itching. Various underlying metabolic and psychogenic disorders also cause pruritus; treatment
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should be tailored to the specific etiology to prevent reoccurrence [36]. A complete medical history, physical examination, and laboratory tests are needed to determine the specific cause of the pruritus. Symptoms can be relieved with topical treatments including ammonium lactate moisturizers, emollients, and corticosteroids. It is important to remember that corticosteroid atrophy occurs faster in aged skin so they should not be used for extended periods of time. Asteatotic dermatitis commonly occurs in the shins of elderly patients, but it has been noted to have occurrences in other areas of the body [38]. It presents clinically as dry, pruritic, scaling skin with some bleeding from dermal capillaries. Patients can have a localized eruption or a more spread out eruption that may indicate that it is associated with other diseases. The localized, asteatotic dermatitis can be divided into four types of presentations. The first is cracked erythema, caused by harsh soaps and detergents. The second one occurs in areas where corticosteroid therapy was previously used. The next type occurs along with certain neurologic disorders. The last type results from aging skin and occurs frequently in the lower extremities of elderly patients. The decreased amount of water and sweat grand activity in the epidermis of most elderly patients makes them most susceptible to asteatotic dermatitis. The decrease in water causes epidermal cells to shrink leading to a decrease in skin elasticity and fissure development. Skin inflammation leads to further stretching, which can lead to ruptured dermal capillaries, bleeding, and infection. Primary lesions are scaly and red, whereas secondary lesions develop as erythematous patches with mild bleeding. Asteatotic dermatitis is most prevalent in the winter months in northern environments where humidity is lowered indoors by heaters. Older men are affected more commonly than women. Prevention measures aim at educating the public about the controllable factors that contribute to the dermatitis. These factors include the amount of showers, types of cleansers, diet, medications, and indoor temperature. The elimination of irritative soaps, detergents, and hot showers or baths can help reduce the effects of the dermatitis. Humidifiers, short-term use of corticosteroids, and the application of lotion after showering also greatly reduce the effects of asteatotic dermatitis. Scabies is an infectious disease commonly seen in the institutionalized elderly; cramped facilities contribute to the frequent spread of disease to staff and patients [39,40]. Sarcoptes scabiei is the itch mite responsible for causing this infection that affects millions of people every year [39]. Transmission requires direct skin-to-skin contact, although sharing
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of infected towels or clothing can also facilitate the spread. If it is not diagnosed and treated early it can lead to widespread infestations, especially in nursing homes where patients require lots of assistance from the hospital staff. The diagnostic feature of scabies infection is burrows seen under the skin and a tiny vesicle over the area where the female mite is located. The burrows are seen within the folds of the body, such as between the fingers, at the waist, the external genitalia of men, and the lower buttocks of women. Diagnosis is confirmed by revealing the mite in skin scrapings. This involves putting a drop of oil on the lesion, scraping the skin, and then transferring it to a glass slide for viewing under a microscope. Alternative approaches include the burrow ink test, superficial shave biopsy, and a new technique that uses epiluminescence microscopy. Patients with severe xerosis tend to scratch themselves and leave marks from their fingernails that resemble the burrows in scabies infections; identification of burrows alone is not enough to confirm an infection [41]. Oral ivermectin is a simple and effective way to treat scabies [42,43]. Crusted scabies is a form of hyperinfection with hundreds of mites, caused by the altered immune response of the host [39]. This type of scabies occurs mostly in immunocompromised and elderly patients. Scabies can be treated easily with prescription medications; the best-known treatment is 5% permethrin cream, which is applied at night and washed off the next morning. Sometimes the patient needs a second treatment before the infection resolves. In addition, they may experience some mild burning depending on the severity of the infection. Other treatments involve lindane lotion or oral ivermectin for severe cases. Irritative contact dermatitis in the elderly is commonly caused by topical medications [44]. It develops as a response to chemical damage to the skin’s epidermal cells and presents as an inflammation of the skin with varying degrees of edema and scaling. Irritative contact dermatitis does not spread beyond the initial area of contact [45]. Irritative contact dermatitis can be divided into two groups: strong irritants, which produce immediate reactions, and mild irritants, which need longer exposure before a reaction develops [44]. Initial symptoms include burning and stinging along with general discomfort. The inflammatory skin reactions are initiated by the release and response of cytokines by keratinocytes. Cutaneous irritants, like detergents and solvents, remove essential oils from the skin and make it more susceptible to the effects of previously tolerated products. In the United States, irritative contact dermatitis is common in those who constantly expose their skin to water or other irritants and it is seen more frequently in women,
probably from cleaning products. There are no diagnostic tests available for irritative contact dermatitis, so diagnosis is based on ruling out other cutaneous diseases. This can be accomplished by obtaining a detailed history of the exposure to the affected site. In addition to a detailed history, patch testing can be used in severe cases to rule out allergic contact dermatitis. A skin biopsy can also be done to exclude other disorders, such as psoriasis. Irritative contact dermatitis responds well to bland, topical corticosteroids like amcinonide (Cyclocort) and fluocinolone. Unresponsive contact dermatitis in elderly patients indicates systemic disease. Secondary infections can occur, particularly with Staphylococcus aureus, and those patients who are under severe stress can develop neurodermatitis (lichen simplex chronicus). Hyperpigmentation or hypopigmentation can occur following infection, particularly in those who have more pigmented skin. Recovering patients must learn to avoid the cutaneous irritants; otherwise they redevelop the dermatitis and possibly other more complicating secondary infections. Stasis dermatitis affects a large portion of the elderly population [45]. It is estimated to affect 15 to 20 million patients over the age of 50 years in the United States. Stasis dermatitis can develop from poorly treated xerosis and pruritus. Patients present with pruritus on the medial ankle; it then spreads to the foot and calf, eventually causing leg edema. Chronic stasis dermatitis appears lichenified and hyperpigmented and can eventually lead to the ‘‘inverted champagne bottle’’ appearance of the leg. This skin disease commonly affects the lower legs bilaterally [46]. It is usually the sequelae of venous insufficiency and can eventually lead to ulcerations of the legs. Alteration of the function of the deep venous plexus of the leg causes blood to backflow to the superficial venous system causing venous hypertension and cutaneous inflammation. Stasis dermatitis is often misdiagnosed as cellulitis and generally affects women at a higher rate than men because of the fact that pregnancy puts extra stress on the lower legs [45]. Treatment is aimed at lessening the impact of the venous insufficiency. Venous Doppler studies should be considered to determine if vascular surgery is needed. Compression therapy can be administered to control the amount of pressure on the legs. Support stockings, elastic wraps, and Unna’s boots are examples of devices that can be used to even out the pressure on the affected legs. Elevating the legs 6 in above the heart has also been proved to be an effective treatment measure along with engaging in regular exercise. Topical corticosteroids used to treat stasis dermatitis can cause infections if the patient has open
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excoriations. Topical antibiotics, such as bacitracin and Polysporin, should also be used. Leg ulcers are becoming a severe problem in the United States, with about 600,000 new cases per year [47]. The etiologic causes are usually linked to venous or arterial insufficiencies. It is important to determine the exact cause of the ulcer to provide the proper treatment for the patient [48]. Venous insufficiency is a dysfunction of the venous system that causes high venous pressure in the legs [47]. It can be caused by outflow obstruction, thrombosis, or incompetent valves in the legs [48]. Characteristics of venous insufficiency ulcers include reddish brown color, shallow depth, irregular margins, and minimal pain [47]. The elevated pressure is a result of faster circulation times and higher oxygen content. Most leg ulcers develop from high venous pressure in the legs. Burn scars and chronic infections are some of the predisposing factors for their development. Case reports have shown that venous leg ulcers are more common in women and the rate increases with advancing age [48]. Standard venous ulcer treatment involves elevation of the leg, compression therapy, and topical therapy to absorb the exudate and maintain a moist wound environment [49]. General prevention measures aim at keeping the feet clean and dry, controlling glucose levels, and maintaining optimal venous return by not standing for long periods of time. Arterial insufficiency causes only about 5% to 10% of leg ulcers [47]. Causes of arterial insufficiency include atherosclerosis and vasculitis, which are common in people with hypertension, diabetes, and other circulatory diseases. Arterial ulcer lesions occur more frequently over bony prominences and they gradually increase in size. Leg ulcers caused by arterial insufficiencies are much more painful than those caused by venous insufficiency and elevation of the ulcerated leg tends to make the symptoms worse. Erosive pustular dermatosis of the leg is a rare disorder that can affect the lower limbs of elderly patients who present with chronic venous insufficiency or stasis dermatitis [50]. Clinical features of the disease include pustule formation and moist eroded lesions on the leg. SCCs are also known to cause leg ulcers, especially in elderly patients with poor general health [47] Regular physical examinations are necessary to determine if any changes are occurring that may lead to ulcer formation.
Psychologic disorders Psychologic diseases in the elderly are often associated with diseases involving the skin [51]. Lichen
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simplex chronicus, prurigo nodularis, neurotic excoriations, and delusions of parasitosis are some of the conditions affecting many elderly patients. Lichen simplex chronicus (neurodermatitis) is a troublesome, itchy dermatosis that is commonly seen in patients with obsessive-compulsive behaviors. These patients present with inflamed, pruritic plaques over areas of their body that eventually become lichenified from the constant scratching and rubbing. Treatment involves topical steroids, along with behavior changes that identify and eliminate triggering factors [51,52]. Topical aspirin solution with dichloromethane has been shown to be an effective antipruritic treatment [53]. Those patients with severe lesions may need more intense treatment, such as fluocinonide or clobetasol solution [51]. Prurigo nodularis is an eruption of excoriated nodules caused by intense pruritus. The nodules are hard and hyperpigmented, occurring all over the extremities. Like lichen simplex chronicus, prurigo nodularis can also be treated with mild corticosteroids or stronger steroids like betamethasone. Topical capsaicin has been shown to interfere with the perception of pruritus by eliminating neuropeptides in cutaneous sensory nerves [54]. In addition, it has been tested and proved to be an effective and safe treatment option for clearing the skin lesions associated with prurigo nodularis [54]. Neurotic excoriations are the most common psychologically induced skin disorder [51]. Patients usually start to compulsively pick their skin after an insect bite or another mild irritation; this progresses until larger lesions and ulcerations form. Patients who complain of a crawling sensation all over their body are said to have delusions of parasitosis; these patients may also have other disorders, such as psychoneurosis and drug addictions. Antipsychotics and treatments geared toward the specific underlying problem are the best methods of treatment for this disorder.
Summary Routine care of the legs and feet in the elderly is important in helping to prevent infections, malignancies, and further deterioration [1]. The lower extremities are of particular interest because of the increasing amount of diseases and disorders involving the legs and feet. Foot disorders in the elderly are associated with poor choices in footwear, structural changes, brought on by aging, and inadequate knowledge about prevention and treatment [4]. Conservative treatments along with gait modification provide positive longterm results, although sometimes surgery is necessary
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for severe foot disorders. Onychomycosis and other nail disorders commonly infect the elderly despite the wide variety of treatment options [22,25]. The increase in malignancy formation in the elderly is caused by the increase in the elderly population and inadequate treatment of leg ulcers and other chronic lesions [26,28]. Aging is associated with many dermatologic changes; many of the disorders and diseases of the lower extremities can be managed if detected and treated early. Proper awareness of the signs, symptoms, and care is important [41].
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