Dermatoses in the Elderly Within a Duodecennial Era at Rivers State University Teaching Hospital (RSUTH): A Retrospective Review

¹Dermatology Unit, Department of Internal Medicine, Rivers State University & Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria

²Dermatology in Clinical Practice, University of South Wales, UK

³Community Medicine Department, Rivers State University & Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria

⁴Nursing Services Department, Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria

*Corresponding author: Ekechi Stella Amadi, Dermatology Unit, Department of Internal Medicine, Rivers State University & Rivers State University Teaching Hospital, Port Harcourt, Rivers State, Nigeria & Dermatology in Clinical Practice, University of South Wales, UK, Phone: 08032790394; Email: [email protected]

Received Date: October 27, 2024

Publication Date: December 14, 2024

Citation: Amadi ES, et al. (2024). Dermatoses in the Elderly Within a Duodecennial Era at Rivers State University Teaching Hospital (RSUTH): A Retrospective Review. Dermis. 4(4):23.

Copyright: Amadi ES, et al. © (2024).

ABSTRACT

Background: The population of older adults have been rising steadily across the globe. This increase is even noticed in the rural areas. Aging is associated with a lot of skin changes that predisposes older persons to skin diseases. Skin care in older adults is of importance contrary to the poor perception that older adults are not concerned about their skin. Aim: The aim of this study is to examine the various dermatoses that affected the older adults who visited the skin clinic under the period stated. The various causes would be evaluated and literature review with special focus on Africa would be discussed as well. Methods and Materials: Data which includes the socio-demographics and diagnoses for those aged 60 years and above were taken from the new patient registers of the dermatology clinic. The data was entered into a data spread sheet and was analysed. The frequencies were represented in tables for better visualization. Result: Those aged 60 years and above consisted of 9.4% of the total patients who attended the dermatology clinic of RSUTH over the twelve year period. The proportion of males was 38.8% and that of females was 61.2%. The age range was 60-92 years. Those who visited from the rural areas constituted 10.4% of the older population. The commonest dermatoses found within this group were eczemas including allergic skin reactions and photodermatitis; Tinea infections, vitiligo, ulcers, generalized pruritus, lichenoid eruptions, urticarias and dermatosis papulosa nigra in a descending order. Conclusion: A variety of dermatoses were seen among the older adults. The findings are similar to other studies done within the same region.

Keywords: Dermatoses, Elderly, Rivers State University Teaching Hospital

INTRODUCTION

The population of older adults have been rising steadily across the globe. This increase is even noticed in the rural areas [1]. Aging is associated with a lot of skin changes that predisposes older persons to skin diseases [2]. Skin care in older adults is of importance contrary to the poor perception that older adults are not concerned about their skin [3]. The aim of this study is to explore the incidence and types of dermatoses seen in older age group in this tertiary clinic which were made clinically except in few cases that were confirmed histologically.

METHODS AND MATERIALS

The study site was initially called Braithwaite Memorial Specialist Hospital with only one dermatologist as at 2011. Full scale dermatology clinic began in 2012. The name changed to Rivers State University Teaching Hospital (RSUTH) in 2018 when it was upgraded to become the centre for training medical students for the Rivers State University that began a medical school. In 2020, another dermatology lecturer was employed. The materials used in retrieving the data were the medical out patient records kept by the nurses and the new patient registers kept by residents and consultants. Socio-demographic data including hospital number, age, sex, address and occupation were retrieved. The treatment received prior to hospital visits, diagnoses, investigations, treatment received from clinic and follow up care were also noted if documented. The data was entered into a data spread sheet and was analysed. The frequencies were represented in tables for better visualization.

RESULTS

Those aged 60 years and above consisted of 9.4% of the total patients who attended the dermatology clinic of RSUTH over the twelve year period. The proportion of males was 38.8% and that of females was 61.2%. The male: female ratio was (1:1.5). The age range was 60-92 years. There were 207 dermal diagnoses made amongst 183 geriatric patients; 164 patients had just one skin diagnosis, 15 had two skin diagnoses, 3 had three skin diagnoses and 1 patient had 4 skin diagnoses. The incidence of geriatric dermatoses is seen in Table 1. The modal age group was the young old age group in this study as reflected in Table 2. The commonest dermatoses found within this group were eczemas including allergic contact dermatitis and photodermatitis, Tinea infections and vitiligo. Ulcers, generalized pruritus, lichenoid eruptions, urticarias and dermatosis papulosa nigra in a descending order were other common lesions. This is displayed in table 3. Those who visited from the rural areas constituted 10.4% of the older population as seen in Table 4. Hypertension was the commonest indicated chronic medical condition (9.8%), followed by diabetes (3.8%) and metastatic skin cancer from breast cancer (3.8%). Five older adults had both hypertension and diabetes (2.7%) as table 5 displays. Two older patients (1.1%) were diagnosed with leprosy and 75% of the muco-cutaneous ulcers were seen in those with diabetes. The cases seen within the skin clinic were managed with the appropriate treatment such as antifungals, antibacterial and anti- viral agents; topical corticosteroids, emollients and other specific agents. A few cases particularly those who had tumours, had to be referred to the surgical clinic.

Table 1. Incidence of geriatric dermatoses

Table 2. Age group distribution

Table 3. Variety of dermatoses (Top 20 diagnoses)

Table 4. Area of Residence

Table 5. Existing Chronic Medical Conditions

DISCUSSION

Studies carried out in Africa show the varying proportions of the elderly with dermatoses. Amadi et al at the dermatology outpatient clinic of the University of Port Harcourt Teaching Hospital (DOPC–UPTH, 2017) had a prevalence of 3.1%, [4] Bell-Gam et al in that same centre during an audit in 2018 had a proportion of 2.7% [5] and Otike-Odibi in a private health facility had the frequency of geriatric dermatoses to be 3.3% [6]. Otike-Odibi et al examined older adults in different wards of UPTH which showed a much higher frequency of geriatric dermatoses; 51.4% of the patients had at least one skin lesion [7]. Ikpae et al had 2.7% of the older adults in rural area in upland Rivers State having a skin complaint [8]. Ayanlowo et al at the clinic of Lagos University Teaching Hospital (LUTH) had a proportion of 4.8% in those who visited the clinic to be older than 60 years and above [9]. Ajani et al showed that 60.6% of the elderly patient seen in Ile-Ife had at least one chronic non-communicable dermatosis [10]. In Ghana, Addo at the dermatology outpatient clinic of the Korle Bo Teaching Hospital had those 60 years and above to be 4.2% [11]. In a study in a rural riverine area of Liberia had 16.7% of those with skin complains to be older adults [12]. Amadi et al in a study at UPTH showed that only 9.5% of the elderly sought for care for their dermatological lesions despite majority of them having a cutaneous disease [3]. Some were lower than the proportion found in this study while others were much higher this can be explained by the site where the older adults were attended to. Several of these studies were done at the clinic where the older adults make complaints of what bothers them which may not fully reflect all the problems they have if a physician carries out full body examination.

Studies that showed female preponderance like this study include Ayanlowo et al at LUTH (1:1.3), Amadi et al at UPTH (1:1.1) and Otike-Odibi at a private health facility (1:1.5) Studies done in Tunisia, Libya and Egypt showed a variety of skin lesions in older adults with a higher proportion of females [13-15]. Male preponderance was seen in other studies such as that done by Otike-Odibi et al and Mponda & Masenga. Otike-Odibi et al had a M: F ratio of 1.3:1 amongst admitted older adults at the UPTH while Mponda & Masenga in Tanzania showed more than half of the participants to be males [7,16].

 The studies carried out by Otike-Odibi in a private health facility and Otike- Odibi et al at UPTH showed the modal age group to be 65-74 just as this study shows [6,7]. Ayanlowo et al at LUTH clinic had 60-69 age group with the highest numbers; Elfaituri et al in Libya also had majority of elderly patients within this group (65-74) Ajani et al had 58% of older adults in the 7th decade and Bell-Gam et al had 60-65 as the modal group in their study [5,9,10,14]. This is not surprising as the younger old age group is higher in proportion across the globe.

Dermatitis (eczema) is a common skin manifestation in several studies just as this study has showed. It was top most in the study carried out by Ayanlowo et al; who showed also in that study papulosquamous disorders, tumors, pruritus, and prurigo nodularis were amongst the top five skin disorders [9]. Amadi et al at DOPC- UPTH had eczema, fungal infections, vitiligo, urticaria, herpes zoster, keloids, lichen planus and generalized pruritus as some of the top most diagnoses just as this study also reflects [4]. Otike-Odibi et al showed xerosis was the most common skin disorder [7]. Amadi at Kakata, Liberia had chronic stasis dermatitis as the commonest manifestation amongst the elderly who attended an outreach clinic [12]. Dermatitis (eczema) comprised of 45% of the dermatoses seen in the elderly population in the study by Addo in Ghana [11]; however, Souissi et al had fungal infections as the most common in their study in Tunisia which was attributed to the very hot weather [13]. Kaposi sarcomas was the commonest malignant tumour seen in this study similar to the finding in studies done by Ayanlowo et al unlike the study done by Elfatuiri et al in Libya that showed basal cell carcinoma to be the highest [9,14]. This difference can be explained by the different Fitzpatrick skin types seen across Africa. Those in Libya have lighter skin pigments (Type I-III) with a sunnier climate. Kaposi sarcoma is common in Africa and the emergence of retroviral disease has increased its prevalence also.

 Hypertension was the commonest chronic medical condition seen amongst the elderly in this study which is similar to the studies done by Amadi in Liberia, Otike-Odibi et al in UPTH, and Mponda &Masenga in Tanzania [7,12,16]. This is not surprising as age related hypertension is common in the elderly. There is increasing evidence of skin Na⁺ retention in hypertension which chronic skin diseases such as eczema and psoriasis may be predisposing risk [17,18]. Diabetes was the second most common chronic condition seen in this study. Diabetes and skin diseases have been well established [19]. This study clearly showed that ulcers are common in diabetic patients. This finding however is not unique to this age group alone, despite age being a confounding factor for both chronic skin diseases and diabetes [19]. There are many skin diseases associated with diabetes including ulcers, generalized pruritus, onchomycosis and ichthyosis that fall into the top diagnoses in this study. This study showed metastatic skin cancer with primaries from the breast. The dermatologist certainly sees cases of metastatic skin disease which can affect any part of the body [20]. There could also be other primary skin malignancies that can manifest on the breast [20]. Breast cancers can mimic skin lesions such as allergic contact dermatitis, Paget’s disease, herpes zoster and intertrigo necessitating visit to the skin clinic [20]. Malignant tumours are not so common in the dark skinned African however when it is diagnosed it would most likely have metastasized. Risk factors include sunlight, genetic skin diseases like albinism and xeroderma pigmentosum; chronic wounds and use of skin lightening creams [21]. Approximately 90 % of persons living with HIV develop skin changes and symptoms at some stage during the course of their disease [22]. Retroviral disease is also known to manifest in older adults regardless of the perception that it is not common in the elderly [23]. Older adults can still engage in risky sexual behaviour need to be counselled [23]; however, with the advent of highly active antiretroviral therapy (HAART) younger persons with HIV/AIDS can live longer reaching advanced age [24]. Tuberculosis and rheumatoid arthritis have been well established to have cutaneous signs [25]. The rheumatoid arthritis patient presented with pyoderma gangerosum which was published as a case report [26]. Peptic ulcer disease has not been associated with established cutaneous signs but the causative organism Helicobacter pylori has been implicated in causing an increase in some chronic skin diseases such as chronic spontaneous urticaria, psoriasis, rosacea and generalised itching [27]. Hansen’ s disease was one of the top ten disorders in a tertiary health facility within the same state done by Amadi et al, unlike this study that had fewer persons with the disease. This difference might be due to the location of the health facility and the improvement of diagnosing Hansen’s disease over time. The long incubation of the mycobacterium may also affect the prevalence.

SUMMARY

This study showed the incidence of dermatoses in the elderly at RSUTH over a 12 year period (2012-2023) to be 9.4%. The commonest skin lesion was non-specified dermatitis from records retrieved. Kaposi sarcoma was the highest malignant tumour seen amongst the elderly. Hypertension and diabetes were the two most common chronic medical diseases seen amongst this age group.

CONCLUSION

A variety of dermatoses were seen among the older adults. The findings are similar to other studies done within the same region.

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