Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2022;12(3):e2022145 1 Dermatology Practical & Conceptual Retrospective Analysis of Dermatological Diseases in Geriatric Patients During Dermatology Outpatient Department Visits Gulhan Aksoy Sarac1, Mehmet Ali Can Emeksiz1, Onur Acar2, Ersin Nazlican3, Efsun Tanacan1, Tufan Nayir4 1 Department of Dermatology and Venereology, Ufuk University Hospital, Ankara, Turkey 2 Ağrı Provincial Health Directorate, Republic of Turkey Ministry of Health, Ağrı, Turkey 3 Department of Public Health, Faculty of Medicine, Çukurova University, Adana, Turkey 4 Republic of Turkey Ministry of Health, Ankara, Turkey Key words: geriatrics, elderly, skin diseases, dermatology, epidemiology Citation: Aksoy Sarac G, Emeksiz MAC, Acar O, Nazlican E, Tanacan E, Nayir T. Retrospective analysis of dermatological diseases in geriatric patients during dermatology outpatient department visits. Dermatol Pract Concept. 2022;12(3):e2022145. DOI: https://doi.org/10.5826/dpc.1203a145 Accepted: December 23, 2021; Published: July 2022 Copyright: ©2022 Akoy Sarac et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Onur Acar, MD, Ağrı Provincial Health Directorate, Republic of Turkey Ministry of Health, Ağrı, Turkey, E-mail: dronuracar@yandex.com Introduction: The elderly population is vulnerable to experience a great number of dermatological diseases thanks to the intrinsic and extrinsic process of aging. Objectives: The aim of this study is to retrospectively investigate the prevalence of dermatological diseases in geriatric patients, their distribution by age and gender, and to provide a reference for studies on aging and skin problems. Methods: In the present study, patients who reported to the dermatology outpatient clinic between January 1 2019, and January 1 2021, were evaluated retrospectively. As a result of examining the re- cords of patients, 887 patients over the age of 65 who met the study protocol were included. Results: The three most common diseases in all geriatric patients were fungal infections, eczematous dermatitis, and pruritus. Fungal infections were frequent in males and the 65-74 age group. In the males, the more frequent were precancerous lesions and malignant neoplasms, whereas in the females it was ur- ticaria and adverse drug reactions. In the logistic regression model, the risk of fungal infection in geriatric patients was increased by being male (odds ratio 1.55, P = 0.006) and being in the range of 65-74 years old (odds ratio 1.46, P = 0.025). Male patients were at significantly higher risk for precancerous and ma- lignant lesions (OR:2.81 P < 0.001) and actinic keratosis (odds ratio 3.26, P < 0.001) in this disease group. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2022;12(3):e2022145 Introduction Due to technological advancements and improved living conditions/standards, life expectancy in Turkey as in other parts of the world is increasing on a daily basis. According to the Turkish Statistical Institute, life expectancy at birth increased from 78.0 for the 2013-2015 period to 78.6 for the 2017-2019 period. Similarly, life expectancy at age 65 for both sexes was 17.8 years in the 2013-2015 period, while it was 18 years in the 2017-2019 period [1]. In the last five years, the proportion of the elderly population, which in- cludes individuals aged 65 and over, increased from 8.2% to 9.5%. It is estimated that the proportion of the elderly population will increase to 11% in 2025, 12.9% in 2030, and 16.3% in 2040[(2]. The geriatric population consists of individuals aged 65 and over. Aging is a continuous biological process. During the aging process, many functions such as regeneration ca- pacity, chemical cleaning capacity, DNA repair capacity, sensory perception, mechanical protection and immune re- sponse of cells forming organs, and tissues decline. Due to the effect of these changing cellular functions, the skin struc- ture is adversely affected as in all other organs and systems. The effects of aging on the skin are evaluated under two different pathways as intrinsic and extrinsic pathways. In- trinsic aging is considered the unavoidable and unstoppable physiological regression of the functions of cells and tissues. Extrinsic aging on the other hand, is both preventable and avoidable. It occurs as a result of exposure to environmen- tal influences such as sunlight and ultraviolet radiation. The effects of extrinsic aging on the skin include not only physi- ological but also morphological changes. As a result of these aging mechanisms, there is dryness, wrinkles, flabbiness, and loss of flexibility of the skin and many benign neoplasms also occur in the skin due to aging [3]. Objectives Due to the physiological and morphological effects of aging on the skin and the increase in the number of the elderly in the population over time, dermatological diseases associated with aging have become an important field of study. The aim of this study is to retrospectively investigate the prevalence of dermatological diseases in geriatric patients, their distri- bution by age and gender, and to provide a reference for studies on aging and skin problems. Methods In this study, patients who reported to the dermatology out- patient clinic between January 1 2019, and January 1 2021, were evaluated retrospectively. The records of 887 patients over the age of 65 were examined; 485 (54.7%) of them were females and 402 (45.3%) of them were males. The participants were grouped by gender and by age groups of 65-74 years and 75 years or older. According to the diagnoses, skin diseases and disorders were categorized into 12 groups viral infections, bacterial infections, fungal infections, eczematous dermatitis, papulosquamous diseases, vesiculobullous diseases, precancerous lesions and malignant neoplasms, benign neoplasms, xerosis cutis, pruritus, urti- caria and adverse drug reactions and other diseases (cuta- neous lymphomas, pigmentation disorders, connective tissue diseases, vascular diseases, metabolic skin diseases, acne and related diseases, hair disorders, nail disorders, skin ulcers). Data analysis was performed using SPSS 23.0 statistical program. Descriptive statistical parameters were used for the prevalence of skin diseases. Chi-square analysis was used to determine whether there was a significant difference in the prevalence of skin diseases according to gender and age group. A logistic regression model was established for each of the diseases that were significant in the chi-square analy- sis. A value of P < 0.05 was accepted as significant in the en- tire analysis. Ethics committee approval was obtained from the university ethics committee. Results All the 887 patients whose records were examined were geriatric patients aged 65 and over. Of these patients, 485 (54.7%) were females and 402 (45.3%) were males. The mean age was 73.34 ± 7.24 (65-101) for women, 73.75 ± 7.08 (65-94) for men, and 73.53 ± 7.16 (65-101) years for all participants. Five hundred and thirty-nine (60.8%) of the participants were in the age group of 65-74 years and 348 (39.2%) were in the age group of 75 years and over. Of the individuals in the 65-74 age group, 304 (56.4%) were females and 235 (43.6%) were males. One hundred and eighty-one (52.0%) of the individuals in the 75 years and over age group were females and 167 (48%) were males. Diseases seen during the entire study period are re- corded as; fungal infections (23.0%), eczematous derma- titis (17.1%), pruritus (10.8%), papulosquamous diseases Conclusions: Men are more vulnerable to life-threatening skin diseases. It is important to determine risk factors for individuals who are more sensitive to environmental factors in terms of increasing the quality of life and protection from diseases. Original Article | Dermatol Pract Concept. 2022;12(3):e2022145 3 (8.1%), viral infections (7.8%), precancerous lesions and malignant neoplasms (7.2%), benign neoplasms (5.3%), xerosis cutis (4.7%), urticaria and adverse drug reactions (3.2%), bacterial infections (2.5%), vesiculobullous diseases (0.9%) and other diseases (9.1%) (Tables 1 and 2). Fungal infections were most common in men and women between the ages of 65 and 74, and the incidence in this age range was between 72.6% and 62.4%. Fungal infections in both sexes; tinea ungium (63.7%), tinea pedis (23.5%), tinea cruris (5.9%), tinea corporis (5.4%) and candida stomati- tis (1.5%). Eczematous dermatitis, which is the second most com- mon dermatologic disease in the geriatric population, was most common in men and women between the ages of 65 and 74, with a prevalence of 64.4% and 54.8% in this age Table 1. Distribution of diagnosed skin diseases by gender and results of chi-square analysis Dermatologic Diseases Females N = 495 (%) Males N = 402 (%) Total N = 887 (%) P value X2 Fungal infections 95 (19.6) 109 (27.1) 204 (23.0) 0.008 7.032 Eczematous dermatitis 90 (18.6) 62 (15.4) 152 (17.1) 0.218 1.520 Pruritus 52 (10.7) 44 (10.9) 96 (10.8) 0.915 0.011 Papulosquamous diseases 38 (7.8) 34 (8.5) 72 (8.1) 0.735 0.114 Viral infections 40 (8.2) 29 (7.2) 69 (7.8) 0.567 0.327 Precancerous lesions and malignant neoplasms 20 (4.1) 44 (10.9) 64 (7.2) < 0.001 15.278 Benign neoplasms 26 (5.4) 21 (5.2) 47 (5.3) 0.928 0.008 Xerosis cutis 28 (5.8) 14 (3.5) 42 (4.7) 0.110 2.557 Urticaria and Adverse drug reactions 24 (4.9) 4 (1.0) 28 (3.2) 0.001 11.238 Bacterial infections 11 (2.3) 11 (2.7) 22 (2.5) 0.655 0.199 Vesiculobullous diseases 5 (1.0) 3 (0.7) 8 (0.9) 0.655 0.199 Table 2. Distribution of diagnosed skin diseases by age groups and results of chi-square analysis Dermatologic Diseases 65-74 years N = 539 (%) 75 years and over N = 348 (%) Total N = 887 (%) P value X2 Fungal infections 137 (25.4) 67 (19.3) 204 (23.0) 0.033 4.538 Eczematous dermatitis 92 (17.1) 60 (17.2) 152 (17.1) 0.947 0.004 Pruritus 53 (9.8) 43 (12.4) 96 (10.8) 0.238 1.395 Papulosquamous diseases 41 (7.6) 31 (8.9) 72 (8.1) 0.488 0.480 Viral infections 39 (7.2) 30 (8.6) 69 (7.8) 0.452 0.565 Precancerous lesions and malignant neoplasms 33 (6.1) 31 (8.9) 64 (7.2) 0.117 2.451 Benign neoplasms 34 (6.3) 13 (3.7) 47 (5.3) 0.095 2.789 Xerosis cutis 20 (3.7) 22 (6.3) 42 (4.7) 0.074 3.197 Urticaria and Adverse drug reactions 20 (3.7) 8 (2.3) 28 (3.2) 0.240 1.379 Bacterial infections 11 (2.0) 11 (3.2) 22 (2.5) 0.295 1.097 Vesiculobullous diseases 4 (0.7) 4 (1.1) 8 (0.9) 0.531 0.393 range. Eczematous dermatitis was seen in both sexes; aller- gic contact dermatitis (27.0%), irritant contact dermatitis (9.9%), nummular dermatitis (6.6%), lichen simplex chron- icus (6.6%), and erythema intertrigo (3.9%). Papulosquamous diseases were most common in women (60.5%) and men (52.9%) in the 65-74 years group. Papu- losquamous diseases seen in both sexes; psoriasis Vulgaris (44.4%), seborrheic dermatitis (37.5%), lichen planus (11.1%), prurigo nodularis (2.8%), lichen sclerosis et atro- phicus (2.8%), and parapsoriasis (1.4%). Viral infections were more common in women (52.5%) aged 75 and over, and in men (69.0%) in the 65-74 years age group. Viral infections seen in both sexes; zona zoster (94.3%), molluscum contagiosum (4.3%) and anogenital warts caused by human papilloma virus (1.4%). 4 Original Article | Dermatol Pract Concept. 2022;12(3):e2022145 Precancerous and malignant lesions were most common in women (55%) aged 75 years and above, while in men (54.5%) they were most common in the group of 65-74 years. Precancerous and malignant neoplasms seen in both sexes; actinous keratosis (78.1%), squamous cell carcinoma (10.9%), mycosis fungoides (6.3%), basal cell carcinoma (3.1%), and lentigo maligna (1.6%). Benign neoplasms were most common in women (69.2%) and men (76.2%) in the 65-74 years age group. Be- nign neoplasms were seen in both sexes; seborrheic keratosis (27.7%), skin tag (23.4%), epidermal cyst (14.9%), melano- cytic nevus (14.9%) and keloid scar (4.3%). When the prevalence of skin diseases was analyzed by gender; fungal infections (p=0.008) and precancerous and malignant neoplasms (P < 0.001) were more common in males than females. Among the precancerous and malignant neoplasms, actinic keratosis (P < 0.001) was more common in males than females. When skin diseases were considered according to the distribution among age groups; Fungal in- fections were seen more frequently in the 65-74 age group (P = 0.033, significant) compared to the other age group. Tinea corporis (P = 0.039, significant) among fungal infections and allergic contact dermatitis among eczematous dermatitis (P = 0.046, is significant) were seen more frequently in the 65-74 age group compared to the other age group (Tables 1 and 2). A logistic regression model was established to analyze the extent to which the parameters with significant differences in the chi-square test increased the risk of developing skin dis- eases. According to the established logistic regression model, the risk of fungal infection in geriatric patients was increased by being male (odds ratio [OR] 1.55, P = 0.006) and being in the range of 65-74 years old (OR 1.46, P = 0.025). Male pa- tients were at significantly higher risk for precancerous and malignant lesions (OR 2.81, P < 0.001) and actinic keratosis in this disease group (OR 3.26, P < 0.001) (Table 3). Conclusions While the average life expectancy in the world increases on one hand, on the other hand, efforts to take preventive mea- sures on the health problems of geriatric patients, provide early diagnosis and necessary medical treatment not only improve their living conditions, but also reduce costs for countries [4,5]. According to 2020 data, 9.5% of Turkey’s population consists of individuals aged 65 and over [6]. In our study, 15% of the total number of patients who reported to the outpatient clinic were over 65 years old. In this study, fungal infections, eczematous dermatitis, pruritus, papulosquamous diseases, and viral infections in order of the most prevalent to the least, constitute the first five most common dermatological diseases groups in the geriatric population. Bilgili et al. In a study conducted in an Eastern city in Turkey where winter conditions are severe, it is stated that in order of prevalence, the most common dermatological diseases are eczematous dermatitis, fungal infections, pruritus, urticaria-angioedema and bacterial in- fections. It is stated that viral infections and papulosqua- mous diseases are seen less frequently [7]. In another study conducted in Turkey, eczematous dermatitis, pruritus, fungal infections, precancerous and malignant lesions, and bacterial infections are listed as the most common dermatological dis- eases [8]. When we look at the studies conducted in Turkey related to the subject of the study, it is seen that the order of the most common dermatological disease groups changes according to geographical and climatic differences, but it is seen that eczematous dermatitis, fungal infections, pruritus disease group generally ranks high in the studies and main- tains its significance. In this study, fungal infections constitute the most com- mon disease group in the geriatric population. In addition, fungal infections were 1.55 times more common in men and 1.46 times more common in the 65-74 age group. Similarly, in a study conducted by Yalçın et al in Turkey, fungal in- fections were reported to be more common in males (18%) and in the 65-74 years age group (16.7%) [9]. Age, gender, personal care, epidermal turn-over and decreased immuno- logical functions may be responsible in the frequent occur- rence of fungal infections in the geriatric population [10]. It is widely accepted that the fact that men are exposed to physical causal factors more than women and that they do not consider skin care as important as women, results in fun- gal infections being more common in men. This may be the reason why the prevalence of this disease was higher in males in our study too [9]. In this study, eczematous dermatitis constituted the sec- ond most common disease group in the geriatric population. Table 3. Logistic regression model established for the estimation of risk factors leading to skin diseases Dermatologic Diseases Risk Factor B P value Odds Ratio 95% Confidence Interval Fungal infection Male 0.442 0.006 1.555 1.134 - 2.132 65-74 years 0.380 0.025 1.462 1.050- 2.036 Precancerous and malignant lesion Male 1.036 < 0.001 2.819 1.631 - 4.871 Actinic keratosis Male 1.184 < 0.001 3.267 1.735 -6.152 Original Article | Dermatol Pract Concept. 2022;12(3):e2022145 5 Eczematous dermatitis is more common in the 65-74 years age group in both men and women. In addition, among ec- zematous dermatitis, contact dermatitis is the most common disorder. Similarly, in the study conducted by Yaldız et al, it is stated that allergic contact dermatitis (44.5%) and irritant contact dermatitis (33.2%) are the most common diseases among eczematous dermatitis [4]. The fact that eczematous dermatitis is more common in early geriatric ages and con- tact dermatitis is more common than others can be explained by the increased exposure to many environmental and phys- ical extrinsic factors in the development of eczematous der- matitis. It is thought that it will continue to be seen more frequently in the coming years due to the changing climatic conditions, increasing exposure to sunlight and increasing chemical exposure. In this study, pruritus was the third most common der- matological disease. Although it is seen at the same rate in women and men, it is of significance that it is seen at a higher rate in the 75 and over age group. Similarly, in a study conducted in Turkey, pruritus (12.8%) was the third most common disease and it was seen to increase from a rate of 12.2% in the 65-74 age group, to 14.3% in the 75-84 age group, and 16.9% in the 85 and over age group [11]. In a study conducted with 46 people staying in a nursing home in Denmark, the pruritus rate was reported as 28.9% [12]. It is acknowledged that the incidence of pruritus increases with age. Dry skin, nervous degeneration and weakening of immunity due to aging predispose the aged to pruritus [13]. Among the causes of diseases such as pruritus, it is important to have preventable or intervening measures in order to re- duce this very common disease in later ages. For this reason, it can be said that patient information activities to be carried out in dermatology outpatient clinics and the study of pre- ventive medicine by health professionals will be beneficial in reducing these diseases. In this study, papulosquamous diseases was the fourth most common dermatological disease group. In this group of diseases, psoriasis vulgaris, seborrheic dermatitis and lichen planus, in order of prevalence, are the three most common diseases. In a study by Darjani et al in Iran, it was reported that papulosquamosis patients were seen in 31.6% of geriat- ric patients, and seborrheic dermatitis (15.4%) and psoriasis (7.3%) were the first two in this group [14]. In a study by Kandwal et al in India, it was reported that papulosquamous diseases (40%) and psoriasis (9.4%) as a constituent of this group were most common in individuals over 60 years of age [15]. In this study, precancerous and malignant lesions were seen in 7.2% of the geriatric population. Similar to our study, the prevalence of precancerous and malignant lesions was re- ported as 5.2% by Yalçın et al, 9.6% by Polat et al, and 9.7% by Yaldız et al [4,8,9]. Among these lesions, actinic keratosis, squamous cell carcinoma and mycosis fungoides in decreas- ing order of prevalence constitute the three most common lesions. When evaluated as a group, these lesions are 2.81 times more frequent in male subjects compared to female subjects. In this study, the prevalence of actinic keratosis was 5.6%. In addition, the risk of developing actinic keratosis, which is a common premalignant lesion, is 3.26 times higher in men. Prevalence of actinic keratosis has been reported as 29.3% by Kılıç et al, 22.3% by Cvitanovic et al, and 21.1% by Akdeniz et al [16-18]. Likewise, in the study of Akdeniz et al., it was emphasized that actinic keratosis was significantly more common in men [18]. Actinic keratosis usually presents as red or brown papules 3-6 mm in diameter on sun-exposed body parts in fair-skinned individuals [19]. The fact that men are exposed to sunlight more frequently in working and so- cial life is acknowledged as one of the important factors that cause it to be more common in men. The average life expectancy in most of the world is get- ting to continues to increase due to preventive approaches and improving treatment options. 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