Eczema Blues

This is another 4-part series, focusing on elderly. For those of you who have been following this blog, you know I’ve been passionately persevering in bringing you information for eczema children. This month, however, I’m inspired to focus on elderly because (i) I see a desire among elderly ladies in the eczema support group meeting to care for their skin and (ii) I am ashamed that I can’t convince my own elderly parents of the right skincare. Hopefully, with this series, elderly who surf the internet and found this blog will find the series useful and adult kids (yes, you and me included!) will be empowered to help their aged parents with the correct skincare. So here we go!

So far we have covered stasis dermatitis (at the lower extremity), incontinence associated dermatitis (at the genital area up to upper thigh) and for the last part of this series, we will explore asteatotic eczema, another common elderly skin condition affecting the lower leg.

What is Asteatotic Eczema?

Also known as xerosis (abnormal dryness), cracked skin eczema or eczema craquele, it is a scaly, flaky, cracked skin condition due to dry skin. The symptoms are scales, cracks, fissures, redness, dryness and itch. If the skin is cracked deeply to injure the capillaries, bleeding fissures may be seen. These symptoms usually present at the lower leg but may also affect the arms, thighs, hands and lower back.

Asteatotic eczema is most prevalent in elderly, above age 65.

What Causes Asteatotic Eczema?

As discussed in the very first post of this series, elderly skin has weaker ability to retain moisture, thus more likely to have dry skin. Less oil and sweat glands also contribute to skin dryness. Their skin is also thinner. The dryness is worsened during winter or cold air-conditioning where the humidity is low (below 50). Other possible factors that contribute to dry skin are long, hot showers, rubbing to towel dry (instead of dab dry), harsh soaps and lack of moisturizing. Dehydration and malnutrition may also play a role, for instance not drinking enough fluids and lacking essential fatty acids and zinc.

Other causes include underactive thyroid, severe weight loss and lymphoma. Medications such as retinoids, diuretics and protein kinase inhibitors may also cause asteatotic eczema.

Complications of Asteatotic Eczema

As with all dry, itchy skin conditions that lead to chronic scratching, infection can occur. Lesions may form and overtime rubbing causes skin discoloration. Also possible are thickened skin (lichenification) or red patches of skin. With damaged skin barrier, the potential for allergic and irritant contact dermatitis increase.

Prevention of Asteatotic Eczema

Good Skincare Routine – Refer to these videos on skincare (shower, moisturizing), with the few basics below:

1. Avoid harsh soap and products with top irritants, like fragrance
2. Lukewarm shower, keep it short and for elderly who do not sweat much/head outdoors, daily shower is sufficient (or wet wipe the body on few days/week)
3. Moisturize after shower
4. Have humidifier if bedroom’s humidity is below 50.
5. Dab dry and not rub dry after shower
6. Do not use products that increase friction to skin, e.g. exfoliating bits found in facial wash or wool/scratching material
7. Frequent change of towel, and use softer material towels

Treatment of asteatotic eczema may include a combination of keratolytics (able to soften, loosen and facilitate exfoliation of upper skin cells), moisturizers and topical steroids (again, use with care given the already thin skin of elderly and higher potential for irritant dermatitis from chemicals in creams).

While looking up asteatotic eczema, I realized that there isn’t much written on it including research in Pubmed. I wonder if it’s because it seems not as serious as other skin conditions, or that research is often more focused on children and adults (or difficulty to conduct studies). In any case, we should not forget the skin health of our elderly family members and that’s what this entire past 4 weeks have been about! Share and support each other in our elderly skincare!

This is another 4-part series, focusing on elderly. For those of you who have been following this blog, you know I’ve been passionately persevering in bringing you information for eczema children. This month, however, I’m inspired to focus on elderly because (i) I see a desire among elderly ladies in the eczema support group meeting to care for their skin and (ii) I am ashamed that I can’t convince my own elderly parents of the right skincare. Hopefully, with this series, elderly who surf the internet and found this blog will find the series useful and adult kids (yes, you and me included!) will be empowered to help their aged parents with the correct skincare. So here we go!

Last week, we covered a very common skin condition affecting elderly, Stasis Dermatitis. For those of you with aged parents with hyper-pigmented, itchy, swollen/ulcerated skin on the legs, coupled with varicose vein condition, read more in last week’s post. This week, we’re covering another common skin condition affecting elderly with incontinence issue who have to wear adult ‘diapers’. They may be too embarrassed to share with you their skin problem at the genital area, so it’s good to know so that you can ask gently about it.

What is Incontinence Associated Dermatitis (IAD)?

It is an inflammatory skin condition that affects elderly who wear absorptive products to manage their urinary or fecal incontinence issues. Incontinence associated dermatitis is also known as perineal dermatitis. Its prevalence range from 5% to as high as over 20% in various studies. It is characterized by skin damage, inflammation and erythema (skin redness).

Is it Eczema? If not, what causes IAD?

Eczema is atopic dermatitis, meaning there is atopy/allergic reaction involved that triggered the skin reaction. In the case of incontinence associated dermatitis, it is the constant contact to the urine/stool in the adult diaper that damages the skin. This skin damage weakens the skin barrier and leads to deteriorating skin functions, mainly protective and moisture retention functions.

The skin barrier becomes less protective and more susceptible to penetration of irritants (urine/stool), thus more likely to suffer from irritant dermatitis (vs atopic dermatitis).

The skin barrier’s ability to retain moisture already weakens with age and further exposure to urine/liquid stool/sweat increases the rate of this water loss (known as trans-epidermal water loss TEWL).

Skin damage via friction with absorptive products is higher in elderly with IAD and it is possible that the constant exposure to urine raises the skin pH level which makes it more susceptible to damage from friction/pressure.

For elderly with both urine and fecal incontinence (known as double incontinence), there is higher likelihood of skin damage as the liquid stools/stools mixed with urine, leads to higher volume of digestive enzymes that breakdown the fats and proteins of the skin layer.

Just the genital area?

No, incontinence associated dermatitis can extend beyond the genital area to the buttocks and upper thighs.

Complications of Incontinence Associated Dermatitis

A frequent complication of skin inflammation is skin infection. The other complication is candidiasis (fungal infection from yeast called Candida albicans) that appears like a red/brownish red rash with ‘satellite’ lesions. Incontinence associated dermatitis should be differentiated from skin ulcers, which is pressure ulcer/deep tissue damage from pressure (sometimes at area of bone prominence).

Prevention of IAD

• Minimize time wearing absorptive products, for instance use of hand-held urinal or catheter
• Frequent change of the adult diapers to minimize the amount of time the skin comes into contact with urine
• If there is diarrhea or liquid stools, be sure to change adult diaper frequently
• Daily proper cleaning (without using harsh soap) of genital area at each change of absorptive products and protection with moisturizer (non-fragrance and without common irritants). An ointment containing zinc oxide, similar to baby diaper cream/ointment can also be used to protect against irritant/urine/stool.
• Similar to baby skin care, frequent washing, use of hot water, rubbing dry with towel should be avoided to minimize drying and wear and tear of skin.

Other methods to manage the incontinence issue can be explored, such as diet/fluid management, pelvic muscle and bladder training and toileting technique. Surgical procedure is often presented as an option, but the pros and cons have to be weighed properly given that no surgical procedure is 100% risk-free. Particularly for an elderly, being subject to a surgical procedure so as not to have to wear ‘diaper’ may end up with more complications (This is outside the scope of this skin post, but more can be read here and here).

For those of us with elderly family members with continence issue, maybe tactfully drop reminder of extra skincare when they are wearing the absorptive products. Share your experience in the comments too, we all need support!

This is another 4-part series, focusing on elderly. For those of you who have been following this blog, you know I’ve been passionately persevering in bringing you information for eczema children. This month, however, I’m inspired to focus on elderly because (i) I see a desire among elderly ladies in the eczema support group meeting to care for their skin and (ii) I am ashamed that I can’t convince my own elderly parents of the right skincare. Hopefully, with this series, elderly who surf the internet and found this blog will find the series useful and adult kids (yes, you and me included!) will be empowered to help their aged parents with the correct skincare. So here we go!

Last week, we talked about the elderly skin differences and the loss of skin functions. This week is on stasis dermatitis, very likely if you start noticing, you’d see many elderly with this skin condition.

Stasis dermatitis is a common inflammatory skin condition that occurs on the lower extremities (our body from the hip to the toes, including also the knee, ankle joints, the thigh, leg and foot). Stasis dermatitis is also known by various names, such as varicose eczema, venous eczema, venous dermatitis and gravitational dermatitis.

Its prevalence is about 7% in elderly persons above the age of 50 and can be up to 20% for those above age 70. The main cause of stasis dermatitis is venous insufficiency, which has been reported to affect more than 50% of elderly above age 50 internationally (thus, making stasis dermatitis a common skin condition for elderly).

What Causes Stasis Dermatitis?

Venous insufficiency is the main cause – a term that you’d see being commonly mentioned.

Venous insufficiency refers to the poor blood circulation, commonly due to weakening of the valvular function with age. The malfunction allowed a backflow of the blood from deep venous system into the superficial venous system, creating venous hypertension.

It is hypothesized that this increased pressure leads to the dermal capillaries being more permeable. This results in the leaking out of macromolecules (fibrinogen) that eventually polymerized and form a cuff (fibrin cuff) that reduces oxygen to the skin cells. White blood cells that help the body to fight inflammation becomes activated and trapped in the fibrin cuff resulting in a hyper state of inflammation.

Who gets Stasis Dermatitis?

Typically middle-aged and elderly patients, from age 50s onward

Patients with venous insufficiency due to surgery, trauma or thrombosis (blood clot)

Women, due to increased stress on the lower extremity venous system from pregnancy

Patients with health conditions such as high blood pressure (hypertension with diastolic dysfunction) and congestive heart failure

Patients taking medications such as antihypertensive medication, e.g. amlodipine

Sedentary lifestyle and Obesity

Symptoms of Stasis Dermatitis

Symptoms may show at area at the lower leg and around the ankle, such as

• Itch
• Hyperpigmentation/discoloration, usually reddish-brown skin
• Atrophic skin patches (small/white scarred skin that is decreasing/thinning)
• Edema (swelling from excess fluids, e.g. blood pooling from faulty varicose veins)
• Dilated superficial veins
• Infection with honey-colored crust over infected area
• Pain
• Slow healing of open sores
• Lichenification (thickening of skin from repeated scratching)

 Complications of Stasis Dermatitis

Chronic stasis dermatitis where the skin is inflamed severely for prolonged period can lead to weeping patches, plaques (solid, raised lesion), on-healing venous ulcers and higher likelihood of contact dermatitis. It can also aggravate into other conditions such as:

Cellulitis – Streptococcus or staphylococcus bacteria entering through a break in the skin, causing infection that can spread quickly from a reddened skin to lymph nodes/blood stream

Lipodermatosclerosis – Underlying fat necrosis (degeneration of fat cells), with appearance of “inverted champagne bottle” on the inner leg

Prevention of Stasis Dermatitis

To prevent stasis dermatitis, measures can be taken to reduce venous insufficiency. This can be prompt treatment of varicose veins, treatment of health conditions, management of venous insufficiency and preventing deep vein thrombosis.

1. Leg elevation – above the heart when lying down to improve blood circulation and reduce swelling
2. Compression socks – also improve circulation
3. Not standing for long periods
4. Taking regular walks
5. Moisturizing (avoiding harsh soaps and perfumed products)
6. Protecting from further injury (e.g. knocks or falls)

Treatment of Stasis Dermatitis

Treating the cause of the venous insufficiency is one part of treating the skin condition. Avoid scratching and follow the nurse’s instruction for wound care. Antibiotics may be prescribed, either topically or orally, if there is infection. Topical steroid may be prescribed but since the skin is already thin, talk to the doctor about alternative non-steroid options or be careful to apply only the low potency for limited time.

As I look through the pictures of stasis dermatitis, I really feel very sad. It’s an age-related problem and the thought that our parents who bore the hard work to raise us have to bear this pain is very heart-breaking. The irony is that they don’t quite believe in skincare or compression stocking – encourage one another to stay positive in helping our parents!

This is another 4-part series, focusing on elderly. For those of you who have been following this blog, you know I’ve been passionately persevering in bringing you information for eczema children. This month, however, I’m inspired to focus on elderly because (i) I see a desire among elderly ladies in the eczema support group meeting to care for their skin and (ii) I am ashamed that I can’t convince my own elderly parents of the right skincare. Hopefully, with this series, elderly who surf the internet and found this blog will find the series useful and adult kids (yes, you and me included!) will be empowered to help their aged parents with the correct skincare. So here we go!

How does Skin Age?
It is obvious that our skin ages as we age – even if we don’t look into the mirror or care to look at our own skin, the number of anti-ageing, whitening and anti-wrinkle products remind us that our skin grow old. Aging can be intrinsic (i.e. genetics) and extrinsic, with the main factor being sun exposure, although lifestyle (smoking, alcohol, obesity, diet, exercise) and pollution also play a role.

We have covered skin functions in this blog, so below explains how our skin age and loses its ability to perform its functions.

Differences in Elderly Skin

1. Thinner skin that appears more transparent, due to loss of epidermis (surface layer of skin)
2. Decreasing and increasingly fragmented collagen, thus less supple skin
3. Wrinkles, from sagging of elastic fibres and more reasons here
4. More fragile skin due to flattening of skin cells, prone to blisters, burns and tears
5. Loss of elasticity (from less fibroblasts), thus ‘loose’ skin
6. Fewer Langerhans cells, which are immune cells of skin
7. Reduced lipids within skin
8. Reduced sebum (oil) production, leading to dry/itchy skin
9. Reduced cutaneous blood flow
10. Reduced sweat glands, from shrinkage of eccrine glands
11. Reduced pigment cells
12. Photaging, due to sun exposure
13. Lower cell replacement
14. Less acidic pH of epidermis
15. Thinner blood vessel walls at the dermis, thus easier to bruise

Skin Function Loss for Elderly

With the above skin changes, there is associated loss of skin function:

• Weakening of the skin barrier function, more permeable to irritants
• Less able to regulate temperature, due to loss in fats and sweat glands
• Less able to protect against sun
• Less able to retain water in skin (stratum corneum)
• Less able to repair the skin and heal wound, aggravated by health conditions that reduce healing such as diabetes
• More susceptible to infection (from fewer AND less responsive Langerhans cells)
• More susceptible to injury due to reduced ability to sense pressure and temperature, and thinner blood vessel walls

With the skin changes in elderly, there are numerous skin conditions that affect them. Most of the skin disorders have signs of skin inflammation and itch (pruritus). General itch without an underlying skin disorder is very common and mainly due to the breakdown of skin barrier, thus normally tolerated soaps and detergents start to trigger rash and itch (i.e. increasing risk of contact dermatitis). Atopic dermatitis is also common because of increased penetration of allergens via the defective skin barrier. As eczema, contact dermatitis and itch has been discussed in this blog (type into search box for all related posts), this series won’t cover these skin conditions despite being very common in elderly (as well as kids!).

For this series, I’m covering 3 skin disorders which are common and that I see in elderly around me (aka Singapore). These are Statis Dermatitis (affecting varicose vein area), Incontinence Associated Dermatitis (from exposure to urine or stools) and Asteatotic eczema (cracked skin). Older people may also have health conditions where either the condition itself predisposes them to skin disorders (atherosclerosis, diabetes, HIV, congestive heart failure) or the medication might. For instance, non-enzymatic metabolites, diuretics and calcium blockers affect the skin. So take time to Google, research and ask the doctor for elderly in your family about potential side effects of the medication they are taking. Elderly who are immobile (i.e. always on the chair or bed) or live in homes are also at higher risk of skin disorders.

Catch up next week on Statis Dermatitis and meanwhile, drop me a comment if you have a condition for elderly skin that you’d like me to look into!