Skin Disorders in Older Adults: Age-Related Changes in Quality and Texture

Photo Essay
Focus on Signs and Symptoms 

The skin is transformed as we age; its hue and texture evolve with time and with disease. These changes are important to understand so that we can distinguish the pathologic from the normal in the elderly.

In this second part of my 2-part series, I will review changes in the quality and texture of the skin that occur with aging. In a previous issue (CONSULTANT, June 2011, page 381), I discussed age-related changes in skin pigmentation.

ATROPHY
The collagen content of the skin decreases by 1% per year after age 20, and the collagen fibers become more thick and brittle.¹ Ground substance and elastin fibers also decrease with aging, and the dermis and epidermis become thinner. These structural changes clinically manifest as cutaneous atrophy—skin that appears to lack underlying structures (Figure 1) and that has a wrinkled or “cigarette-paper” surface (Figure 2).

EDEMA
Decreased cardiovascular function in the elderly can impair the return of blood and lymph from the extremities. This impairment in lymphatic return manifests as edema in the arms and legs, which gives the skin an indurated but distensible quality (Figure 3). Edema sometimes is “tacked down” by the hair follicles, in which case it is referred to as peau d’orange skin. The edema is described as pitting when the application of point pressure leaves behind an indentation for a time.



STRIAE
Striae distensae occur when the skin is subjected to continuous and progressive stretching. They are characterized by a thinning of connective tissue stroma, which produces a linear, atrophic appearance of the skin. Histopathologic examination supports the view that striae distensae are scars. There is no evidence that they form by stress-induced rupture of the connective tissue.² In the elderly, they are most commonly related to weight gain or loss and excessive adrenocortical activity.

Early striae present as flat, thin, linear, wrinkled (cigarette paper–like) depressed patches, which can be white, gray, pink, red, or purple. Gradually, these patches lengthen and widen. Red and purple striae are referred to as striae rubra. Mature striae are white, depressed, atrophic, wrinkled, irregularly linear plaques (Figure 4). Their long axis is parallel to the lines of skin tension, and they range from 1 to 10 cm in length and 1 to 10 mm in width. Pink or red striae can be faded with tretinoin or laser therapy, but they cannot be eliminated altogether.<sup>3

KERATOLYSIS EXFOLIATIVA</sup>
Keratolysis exfoliativa is an idiopathic condition characterized by chronic palmar and occasionally plantar peeling. It can be exacerbated by environmental factors, and it may be misdiagnosed as chronic contact dermatitis.⁴ Exfoliative keratolysis is more common during the summer. It most often occurs in young adults but can occur in the elderly. Keratolysis exfoliativa can manifest with expanding collarettes of scale and circular or oval, tender, peeling patches (Figure 5). These peeling patches lack a normal barrier function and may become red, dry, and cracked. However, they are not usually pruritic. 

The diagnosis of keratolysis exfoliativa is made on the basis of the history and the results of the physical examination. The diagnosis is supported by (and in fact requires) negative patch and potassium hydroxide fungal test results. Treatment with lactic acid 12% usually resolves this condition.

PIEZOGENIC PAPULES
Piezogenic papules are pressure-induced; they probably occur as a result of the herniation of fat tissue caused by the degeneration of dermal collagen. The papules manifest as compressible skin-colored lumps on the marginal sides of the heel and are typically only evident with pedal weight bearing (Figure 6). They can be solitary. Painful piezogenic papules occur when a fragment of nerve is extruded with the fat. 

There is no treatment. A piezogenic papule will disappear when the patient sits down and pressure is removed from the soles of the feet. If the papules are painful, relief can be obtained by the placement of orthopedic padding in the patient’s shoes.⁵ ■