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General Principles in Older Adults

Aging skin is subject to both intrinsic aging processes, as well as many years of environmental assault. With increasing age, skin’s barrier function declines, making it much more difficult to maintain moisture. Thus, dry skin in older adults is almost inevitable. This has multiple consequences, the most common being pruritus. Dry skin is also more susceptible to environmental insults, which can cause eczematous dermatitis because of an irritant or an allergen.

After many years of being subject to oxidative damage from environmental pollution and radiation, skin cells have accumulated many mutations. Thus skin cancers are prevalent in the older population.

Aberrant responses of the immune system increase with age; consequently, autoimmune skin diseases as well as allergic contact dermatitis become more common. As normal function of the immune system declines, certain infectious diseases are also more common, such as herpes zoster and onychomycosis.

Certain benign tumors are extremely common in older adults. These include acrochordons, seborrheic keratoses, and cherry angiomas. Although a frequent cause of alarm in a patient, they only require reassurance. On the other hand, benign nevi are extremely uncommon in this age group, and any new mole should raise a suspicion of melanoma.

Seborrheic Keratosis

Essentials of Diagnosis

  • Seborrheic keratosis is the most common benign epithelial tumor of adulthood.

  • The trunk is affected more than the extremities, head, and neck.

  • Primary lesions are 5–20-mm light brown to dark brown–black papules and plaques with a rough, warty surface (Figure 49–1).

  • Differential diagnosis includes: solar lentigo, melanocytic nevus, verruca vulgaris, and lentigo maligna melanoma.

Figure 49–1.

Seborrheic keratoses. Waxy, stuck-on papules and plaques, with varying shades of brown and a verrucous surface. (Reproduced with permission from Neill Peters, MD.)

Complications

Friction, pressure, and trauma to these lesions may cause irritation or inflammation.

Treatment

Irritated or inflamed lesions can be treated with cryotherapy (Box 49–1), curettage, or shave removal. Lesions on cosmetically sensitive areas are best treated with light electrodessication to minimize scarring and dyspigmentation.

Box 49–1. Cryotherapy

  1. Indications

    • Liquid nitrogen can be used to treat

      • Actinic keratosis

      • Seborrheic keratosis (irritated)

      • Warts

  2. Dipstick technique

    1. Roll extra cotton over the tip of the cotton applicator.

    2. Dip tip into liquid nitrogen.

    3. Apply tip of applicator to lesion until 1–2 mm of normal surrounding skin turns white.

    4. Wait until lesion completely thaws back to normal color.

    5. Repeat (number of freeze–thaw cycles depends on the lesion being treated).

  3. Open-spray technique

    (Requires hand-held nitrogen unit and C-tip aperture.)

    1. Nozzle should be 1–2 cm from target lesion and perpendicular to it.

    2. Squeeze trigger to emit continuous burst of spray.

    3. The lesion and not more than 1 mm of surrounding normal skin should ...

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