Introduction

Many common skin conditions affect younger and older adults equally. However, certain inflammatory diseases, infections, and neoplasms of the skin increase in prevalence with age. Inflammatory skin reactions that may occur in the elderly include drug-induced eruptions, erythema multiforme, toxic epidermal necrolysis, and anticonvulsant hypersensitivity syndrome (see Table 123-1). Benign skin tumors that are common in the elderly include seborrheic keratoses, acrochordons, keratoacanthomas, and cherry angiomas (see Table 123-2).

Management Principles

The elderly patient who presents with a skin condition should be asked about use of potential irritants, such as rubbing alcohol and detergents. The patient's concept of the skin condition and expectations for therapy should also be discussed.

Maximizing compliance: The prescribed treatment regimen should be as simple as possible and should be tailored to the patient's physical capabilities. For example, a patient who has difficulty applying a topical medication because of neurologic impairment or arthritis may need a back scratcher-like applicator for hard-to-reach dematoses. In some situations, the assistance of a visiting nurse may be necessary.

The elderly are 2 to 3 times more likely to experience adverse reactions to antihistamines and corticosteroids, which are frequently used to treat skin disorders. These drugs, therefore, should be prescribed reluctantly and always with clear written instructions. The physician must also consider that regimens that are virtually trouble-free for younger patients, such as adding oil to bathwater, may pose a danger to the elderly.

Choosing the drug formulation: Most dermatologic agents are applied topically in the form of ointments, creams, lotions, powders, soaks, compresses, or gels (see Table 123-3). The amount of medication prescribed should suffice for a complete course of therapy or should at least last until the next physician visit. About 30 g of ointment or cream is required to cover the entire body once. The "rule of nines" can be used to estimate the proportion of body surface area involved and hence the amount of the preparation needed for each application (see Figure 123-1). The palm of the hand (which represents 1% of body surface) can also serve as a rough guide. Hence, twice-daily applications of an ointment to both palms requires about 4 × 0.25 g, or 1 g daily, and a 30-g tube or jar should last 1 month. This dosing information should be shared with patients to guide their usage rate.