4.05 Ageing Skin

Presented by:

Dr Iain Wilkinson (Consultant Geriatrician East Surrey Hospital)

Dr Jo Preston  (Consultant Geriatrician St George’s Hospital)


Dr Bernard Ho, Dermatology Clinical Fellow

Sip of MDTea

PDF version of infographic here

Broadcast Date: 10th October 2017

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Show notes

PDF version here

Learning Outcomes


  • To understand normal physiology of the skin and how it changes in older adults
  • To develop an understanding of how to manage dry skin in older adults
  • To understand causes of itchy skin as a presenting complaint


  • To be able to recognise different emollients and how emollients they should be used


  • Recognise dermatological issues can be a manifestation of an underlying systemic medical problem
  • To consider visual assessment in those falling, with delirium and as part of a CGA



  • Xerosis – skin that is dry to touch, due to lack of moisture in the outer layer of the skin (stratum corneum), resulting in cracked skin
  • Pruritus – itchy skin or unpleasant sensation that provokes the desire to scratch

Key Points from Discussion

Ageing skin physiology

See also Series 3 episode 3 for discussion of ageing skin physiology

  • Protection:
    • Accumulation of UV damage as people age
    • Cell aging via loss of telomere ends
  • Barrier:
    • Decreased sebum protection
    • Epidermal thinning; flattening of dermo-epidermal junction;
  • Pain receptor:
    • Dermal thinning → reduction in nerve endings ➔ decreased sensation
    • Neuropathic pain increases
  • Thermoregulation
    • Dermal thinning → reduced function to thermoregulate: hypothermia more common
    • Reduced moisture retention
    • Reduced ability to vasodilate in the capillary bed ➔ prone to heat retention
  • Endocrine function (Vit D, melanin)
    • Decreased ability to synthesis vit D ➔ prone to vit D deficiency/reduced bone density
    • Decreased ability to synthesis melanin ➔ prone to skin cancers (in addition to photodamage done in previous years)
  • Communication/Visual appearance
    • Wrinkling/Sagging of skin
    • Loss of demarcation between chin and neck in males

Dry skin

  • Causes:
    • Genetic: Ichthyosis
    • Age related changes
    • Dry environment, low humidity
    • Drugs: retinoids, diuretics, EGFR inhibitors
    • Postmenopausal
    • Medical causes: hypothyroidism, CKD, malnutrition, dermatitis/eczema
  • Complication:
    • Eczema, infection (through cracks in skin allowing infection in), contact allergy
  • Management
    • Emollients, emollients, emollients
    • Things to consider:
      • Severity of the dryness
      • Tolerance
      • Personal preference
      • Cost and availability
    • Avoid aqueous cream as an emollient choice
  • Further reading:

Itchy skin 

  • Causes:
    • Systemic:
      • Renal: Chronic renal failure – buildup of urea and waste materials
      • Liver: Cholestatic – buildup of bilirubin
      • Endocrine/metabolic: DM; hyperthyroidism; hypoparathyroidism
      • Hematological: IDA; polycythaemia; leukaemia; lymphoma
      • Neurological: neuropathic pruritus
      • Psychogenic: skin picking; depression; anxiety; delusional parasitosis
      • Oncological: can precede underlying malignancy such as lymphoma by many years
    • Skin diseases:
      • Psoriasis, Urticaria, Allergic contact dermatitis, Dry skin, Dermatitis herpetiformis, Scabies, Mycosis fungoides
    • Exposure-related:
      • Allergens/irritants – check contacts and exposures
      • Insects/infestations (i.e. bed bugs)
      • Medication (i.e opioids as side effect)
  • Pruritus screen
    • Bloods can look for signs of the systemic diseases above
    • Consider:
      • Antimitochondrial antibody – autoimmune conditions
      • CXR
      • Immunoglobulins
      • Plasma electrophoresis
  • Management: Treat underlying cause; Emollients, emollients, emollients

Elderly Hospitalised Patients – The Impact of Itch and Its Prevalence. Teoh et al, 2016. Annals of Academic Medicine Singapore

Prevalence of skin diseases in hospitalized geriatric patients: Association with gender, duration of hospitalization and geriatric assessment. Makrantonaki et al 2017

Cutaneous Vasculitis 

This is a complex collection of conditions with many different causes. Vasculitides are classified by the size of the vessels affected; small, medium or large.

  • Older people are most likely to get small vessel vasculitis
    • Presents with raised palpable purple areas called purpura, or occasionally ulcers
  • Diagnosis
    • Biopsy – histology shows inflamed blood vessels
  • Reactive vasculitis
    • E.g. Secondary to acute infection
    • Tends to settle in 6-8 weeks
    • Supportive measures- emollients, topical steroids, light compression
  • Vasculitis secondary to underlying inflammatory process
    • May be more severe and persistent
    • Need to manage underlying condition

Further reading:


Blistering conditions

Autoimmune basis

Usually require immunosuppression with steroids +/- steroid sparing agent


Videos of how to apply emollients, and topical steroids.


Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

NHS Knowledge Skills FrameworkSuitable to support staff at the following levels:


  • Personal and People Development: Levels 1-2
  • Service Improvement: Level 1
Foundation curriculumSection







Patient centred care

Self directed learning

Support for patients with long term conditions

Core Medical TrainingCommon competences:


  • The patient as central focus of care
  • Managing long term conditions and promoting patient self-care

System specific competences:

  • Dermatology
  • Geriatric medicine
GPVTS programSection 3.05 – Managing older adults


  • Core Competence: Managing medical complexity

Section 3.21 – Care of people with skin problems

  • Core competence: clinical management
  • Core competence: managing medical complexity
ANP (Draws from KSF)Section 6 Clinical Examination


Section 7.31 Problems with Skin

Section 20 Patient as central focus of care

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