Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 1 A Retrospective Review of Chronic Non-Communicable Dermatoses Among Older Adults at a Tertiary Healthcare Facility in Southwestern Nigeria Atinuke Arinola Ajani1, Fatai Olatunde Olanrewaju1, Ademola Enitan1, Olufikemi Fabusuyi2, Mufutau Oripelaye1, Olumayowa Abimbola Oninla1, Olayinka Olasode1 1 Department of Dermatology and Venereology, Obafemi Awolowo University, Ile-Ife, Nigeria 2 Department of Medicine, University of Medical Science Teaching Hospital Complex, Akure, Nigeria Key words: geriatric, aged, skin diseases, non-infectious, chronic disease Citation: Ajani AA, Olanrewaju FO, Enitan A, et al. A Retrospective Review Of Chronic Non-Communicable Dermatoses Among Older Adults At A Tertiary Healthcare Facility In Southwestern Nigeria. Dermatol Pract Concept. 2023;13(4):e2023262. DOI: https:// doi.org/10.5826/dpc.1304a262 Accepted: June 23, 2023; Published: October 2023 Copyright: ©2023 Ajani 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: Ajani Atinuke Arinola, Consultant Dermatologist & Genitourinary Physician, Department of Dermatology and Venereology, Obafemi Awolowo University, Ile-Ife, Phone: +2348025559295 Email: daraolu@yahoo.com Introduction: Aging is a ubiquitous human trait that predisposes older persons to chronic diseases. Compared with systemic non-communicable diseases, a significant gap exists in literature on the burden of non-communicable dermatoses (NCDs) amongst older adults particularly in low and middle-income countries. Objectives: The aim of this study was to document the epidemiology and clinical pattern of non- communicable skin diseases among older adults at a tertiary healthcare facility in Southwestern Nigeria. Methods: We conducted a retrospective review of medical records of ambulant adults aged ≥60 years referred for dermatological care at a teaching hospital in ile-ife, South-Western Nigeria between February 2017 and February 2022. The frequency and pattern of NCDs were recorded for descriptive statistical analysis using SPSS 20 statistics software. The level of statistical significance was set at 0.05. Results: A total 553 medical records were reviewed with a female: male ratio of 1.3:1 The mean age of the study population was 68.85 ±7.87. Six out of every 10 patients (60.6%) had at least one chronic NCD. The incidence of chronic NCDs declined with increasing age. Chronic eczemas (22.4%), pigmentary dermatoses (9.4%) and skin tumors (8.7%) were the most frequent chronic ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 Introduction The human population is experiencing a major demographic shift with an unprecedented growth in the number of older adults (60 years and older) [1,2]. This change in the world population characteristic is most profound in lower- and middle-income countries where majority of the world’s older adults reside [3]. Currently, over 1 billion adults are 60 years or older. It is expected that this figure will double by 2050 and by then, 80% of older adults will be resident in less de- veloped countries [2,3]. Although longevity is desirable, it comes with social, economic and health consequences. As such, the gains of increased life expectancy are overshadowed by additional years of poor health and dependency [2]. This can be at- tributed to inevitable, age-related non-linear decline in the human body. As one ages, the structural and functional in- tegrity of various organ-systems are gradually compromised. Physiological and immunological processes progressively become less efficient, and there is a corresponding increase in susceptibility to a wide variety of diseases, particularly non-communicable diseases. Studies have demonstrated an increasing burden of chronic diseases with increasing age and an evolution of the pattern of these diseases over time [4–6]. Chronic morbidities in older adults tend to be multiple with over 30% of older persons having co-morbid chronic health problems[4–6]. Additionally, adults with chronic health problems have sig- nificantly worse health-related quality of life, higher costs and increased risk of death when compared with adults without chronic health conditions [7,8]. Chronic dermatological conditions contribute to the burden of non-communicable diseases in the older adults [9–12]. A significant association has been demonstrated between chronic inflammatory skin diseases such as psoria- sis, atopic dermatitis and immunobullous skin diseases and long standing systemic and psychiatric disorders including cardiovascular diseases, renal diseases, metabolic problems as well as extra-cutaneous malignancies [11–14]. Unfor- tunately, compared with systemic non-communicable dis- eases, a significant gap exists in literature on the burden of non-communicable dermatoses amongst older adults. Studies evaluating chronic health problems of older persons rarely report on the burden of skin diseases in them[4–6,15,16]. Nevertheless, there is a high burden of non-communicable dermatoses (NCDs) in lder adults with significant impact on morbidity, mortality and quality of life [11,17–21]. Objectives We conducted a 5-year review of the medical records of all new patients aged 60 years and above attending the derma- tology outpatient clinic to determine the frequency and dis- tribution of chronic, non-communicable dermatoses across various age sub-groups of older adults with skin complaints. Methods This sub-study is the retrospective arm of a larger study in- vestigating dermatoses of senescence among adults at a ter- tiary health care facility in Southwestern Nigeria. A review of the health records of older adult who received care at the outpatient dermatology clinic of Obafemi Awolowo Univer- sity Teaching Hospitals Complex, Ile-Ife, Nigeria between February 2017 and February 2022 was conducted with ap- proval from the institutional ethics and research committee. The medical records of all new patients aged 60 years and older seen during the study period were retrieved and infor- mation regarding their age, sex and clinical diagnosis were recorded in a data proforma for subsequent transfer to a digital data spread sheet for coding and analysis. Only case records with conclusive clinical diagnosis were documented while those with inconclusive diagnosis were excluded from the study. All documented dermatologic diagnosis were made by a consultant dermatologist after appropriate clinical and laboratory evaluation. Grouping and Categorization of Skin Diseases Cases with a clinical diagnosis of non-communicable (non-infectious) dermatoses were selected for further cate- gorization and analysis. The NCDs were sub-categorized as non-communicable dermatoses recorded. Older males had a significantly higher incidence of chronic eczemas while chronic urticarias and skin tumors demonstrated significant female preponderance. Conclusions: There is a high burden of chronic NCDs with significant gender disparities among older adults with skin problems in Nigeria. Pre-emptive planning and resource allocation towards specialist geriatric-dermatology services are needed to address skin-health needs of the growing geriatric pop- ulation. Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 3 acute or chronic NCDs, based on the duration of presenting complaints and/or clinical propensity for relapse. Chronic NCDs were defined as non-relapsing dermatoses of non- infectious etiology with a duration of symptoms greater than or equal to six months or non-infectious dermatosis with a chronic remitting and relapsing course lasting greater > 3 months. As such, subjects with acute NCDs such as irritant contact dermatitis, acute adverse drug reactions and acute ur- ticaria were eventually excluded from the final data analysis. Patients presenting with multiple chronic NCDs condi- tions were noted with each diagnosis coded separately under each case for further analysis as multiple response set. Those who developed new co-morbid chronic non-communicable diagnosis at a separate time during the period under review were included separately as new cases. Statistical analysis was performed using IBM SPSS Sta- tistics (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0). Continuous variables are presented as means ± standard deviation (SD). Comparison of means was done using Student T test. Categorical variables are pre- sented as tables and charts and comparison between groups done with chi square test. The level of statistical significance was set at 0.05. Ethical Consideration The study protocol complied with the Declaration of Hel- sinki. The study was approved by the Ethics and Research Committee of the Obafemi Awolowo University Teaching Hospitals Complex with a national registration number: NHREC/17/03/2021 and an international registration num- ber: IRB/IEC/0004553. The need for informed consent for the retrospective arm of the study was waived by institu- tional ethics and research committee as this arm of the study did not require direct contact with patients and the clinical data used was anonymized. Results Five hundred and fifty-three patients comprising of 316 fe- males (57.1%) and 237 males (42.9%) within the age range of 60-98 years were treated for skin problems during the period of review. More than half (58.2%) of the study pop- ulation were in their 7th decade, with a mean age of 68.85 ±7.87 years. The male patients were significantly older than the females in this study (P = 0.00) and had a significantly lower incidence of non-communicable dermatoses compared with females (P = 0.011). Three hundred and sixty-four (60.6%) patients had at least one non-communicable dermatosis (NCD), majority (92.0%) of whom had chronic NCDs. Most patients with chronic NCDs were in their 7th decade while those with acute NCDs were significantly older and predominantly in their 8th decade of life (Table 1). A progressive decline in proportion of chronic NCDs was observed with advancing age. Conversely, an up-ward trend occurred in the incidence of acute NCDs with age (Figure 1). Female sex was signifi- cantly associated with a diagnosis of chronic NCDs. Though no gender differences occurred in the incidence of acute NCDs, females with acute NCDs were significantly older than those with chronic NCD (P < 0.05) (Table 1). Frequency of Chronic NCDs Amongst Study Subjects A diverse spectrum of chronic NCDs (Tables 2-5) was re- corded in the study population. Eczemas (22.4%) consti- tuted the highest overall burden of chronic NCDs followed rather remotely by pigmentary disorders (9.4%) and skin tumors (8.7%). The three most common diagnosis in fe- males were eczemas, pigmentary dermatoses and skin tu- mors while in males, eczemas, cutaneous pain syndromes and papulo-squamous disorders were most frequent. The Table 1. Age and sex comparison of NCDs in the study population. Acute NCDs N (%) Chronic NCDs N (%) NCDsa N= 553 (%) P value Gender Female 18(3.25) 204 (36.9) 222 (40.1) 0.534 Male 11(2.0) 131(23.7) 142 (25.7) Total 29 (5.2) 335(60.6) 364(65.8) Mean age Female 72.94 ±11.86 68.04 ±7.85 68.44 ±8.32 0.02 Male 73.00 ±5.53 70.20 ±7.56 70.42 ±7.44 0.14 Total 72.97 ±9.82 68.89 ±7.80 69.21 ±8.04 0.037 NCD =† = Non communicable dermatoses aNCDs‡ = includes both acute and chronic NCDs 4 Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 Figure 1. Incidence of acute and chronic non communicable derma- toses. The incidence of acute non communicable dermatoses (blue line) increased with age while chronic non communicable (red line) diseases showed progressive decline with advancing age. Linear by linear association = 6.44, P = 0.011. Table 2. Gender differences in the incidence of various groups of chronic NCDs in older adults. % of total populationa N = 553 Total NCDsb N = 335 (%) Female N = 204 (%) Males N = 131 (%) P value Eczemas 124(22.4) 124(37.0) 66 (32.4) 58 (44.3) 0.03 Pigmentary 52(9.4) 52(15.5) 37(18.1) 15(11.5) 0.10 Skin tumours 48(8.7) 48(14.3) 37(18.1) 11(8.4) 0.02 Papulosquamous dermatoses 34(6.1) 34(10.1) 19(9.3) 15(11.5) 0.53 Chronic cutaneous pain syndromes 31(5.6) 31(9.3) 15(7.4) 16(12.2) 0.14 Miscellaneous 18(3.1) 18(5.4) 11(5.4) 7(5.3) 0.96 Chronic Urticaria/ reactive dermatoses 17(3.1) 17(5.1) 15 (7.4) 2(1.5) 0.02 Erythroderma 14(2.5) 14(4.2) 7(3.4) 7(5.3) 0.40 Cutaneous manifestation of systemic disorders 11(2.0) 11(3.3) 4(2.0) 7(5.3) 0.09 Autoimmune & Immunobullous dermatoses 8(1.4) 8(2.4) 5(2.5) 3(2.3) 0.61 Multiple skin diseases 45(8.1) 45(13.4) 26 (12.7) 19 (14.5) 0.65 NDCs = non communicable dermatoses. atotal population of older adults seen during the period of reviewbtotal number of adults with chronic non communicable dermatoses proportion of males with eczemas was significantly more than females (P < 0.05) (Table 2). Unlike eczemas, Chronic urticaria/reactive inflammatory skin diseases and skin tumors demonstrated significant female preponderance (P < 0.05). Chronic urticaria occurred 4.9 times more frequently in fe- males than males. The disparity in incidence of skin tumors widened between both sexes with increasing age (Figure 2). The incidence of co-morbid communicable skin diseases was 8.1% and was mainly due to fungal infections in females and parasitic and viral diseases in male (Figure 3). Conclusions The skin is not immune to the impact of aging on health and in fact, may be the first or most severely affected organ by the consequences of aging. The spectrum of cutaneous manifestations in the aging skin is wide, with diverse patho- physiological mechanisms. In this study, we documented a high incidence (65.8%) of non-communicable skin diseases (NCDs) in older adults with dermatological complaints in the hospital setting. This is similar to an incidence of 61.38% reported by Jha in Nepal[22]. Although communicable der- matoses have been previously reported as the most frequent dermatologic problem in developing and tropical countries [23–27], a closer look at many of these studies reveals that the incidence of NCDs is higher when comparison is done as a collective group. In addition, many recent studies corrobo- rate a predominance of NCDs in older adults as well as the general population adult population both in developing and developed economies [28–32]. Chronic NCDs (60.6%) occurred 11.5 times more fre- quently than acute NCDs and were significantly more fre- quent in older females in this study. The true incidence of chronic NCDs as a collective group of dermatoses in older adults is unknown. Nevertheless, a similarly high prevalence can be inferred from previous works on individual dermato- ses that constitute this spectrum in older adults [18,33–36]. In a study by Gaber et al. [32], four out of the five most fre- quent groups of skin diseases in elderly patients were chronic non communicable skin diseases, diagnosed in 56.5% of the study population [32, 40]. Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 5 Table 3. Comparison of non communicable dermatoses across different age groups. Diagnostic Group 60-69 years N = 194 (%) 70-79 years N = 91 (%) ≥80 years N = 50 (%) P value Eczemas 64 (33.0) 38 (41.8) 22(44.0) 0.20 Pigmentary dermatoses 30(15.5) 16(17.6) 6(12.0) 0.68 Skin tumours 29 (14.9) 12 (13.2) 7(14.0) 0.92 Papulosquamous disorders 18(9.3) 11(12.1) 5(10.0) 0.76 Chronic cutaneous pain syndromes 19(9.8) 6(6.6) 6(12.0) 0.94 Miscellaneous 13(6.7) 3(3.3) 2(4.0) 0.29 Chronic urticaria and reactive dermatoses 13 (6.7) 4 (4.4) 0(0.0) 0.06 Erythroderma 6(3.1) 4(4.4) 4(8.0) 0.14 Cutaneous manifestation of systemic disorders 7(3.6) 3(3.3) 1(2.0) 0.60 Autoimmune & Immunobullous dermatoses 5(2.6) 2(2.2) 1(2.2) 0.79 Multiple skin diseases 22(11.3) 16(17.6) 7(14.0) 0.351 Linear by linear association used to test association between variables when Chi2 assumptions were violated. Table 4. Spectrum of chronic inflammatory non communicable dermatoses in study population. Diagnosis No of patients Percentage (%) (N= 335) Inflammatory NCDs 197 ‘58.8 Eczemas 124 37.1 Asteatotic eczema 35 10.4 Seborrheic dermatitis 27 8.1 Lichen simplex 20 6.0 Atopic dermatitis 10 3.0 Chronic hand and foot eczema 9 2.7 Photodermatitis 5 1.5 Stasis eczema 4 1.2 Nummular eczema 4 1.2 Prurigo nodularis 4 1.2 Allergic contact dermatitis 3 0.9 Periorbital dermatitis 2 0.6 Pompholyx 1 0.3 Autoimmune & Immunobullous dermatoses 8 2.4 Diagnosis No of patients Percentage (%) (N= 335) Bullous pemphigoid 3 0.90 Cutaneous lupus 2 0.60 Bechets disease 1 0.30 Scleroderma 1 0.30 Vasculitis 1 0.30 Papulo-squamous disorders 34 10.1 Psoriasis 21 6.3 Lichen planus 12 3.6 Lichen sclerosus et atrophicus 1 0.3 Chronic urticaria and reactive dermatosis 17 5.1 Chronic urticaria 12 3.6 Pyoderma gangrenosum 2 0.6 Papular urticaria 2 0.6 Erythema nodosum 1 0.3 Erythroderma 14 4.2 NCDs = non communicable dermatoses. The high incidence of chronic NCDs in older adults can be attributed in part to age-related deterioration in the skin functional and structural integrity caused by intrinsic and extrinsic aging as well as age-related co-morbid systemic conditions. Intrinsic aging is characterized by decreased skin thickness, increased permeability to chemical substances and diminished vascular support [37]. These changes lead to increased skin susceptibility to injury, irritation, inflam- mation, along with reduced propensity for repair and re- generation therefore, establishing a foundation for the 6 Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 Table 5. Spectrum of chronic non-inflammatory non communicable dermatoses in study population. Diagnosis No of patients Percentage (%) (N = 335) Non inflammatory NCDs 160 47.8 Pigmentary skin diseases 52 15.5 Vitiligo 33 9.9 Idiopathic guttate hypomelanosis 8 2.4 Exogenous ochronosis 6 1.8 Other pigmentary disorders 5 1.5 Cutaneous manifestations of systemic disorders 11 3.3 Pruritus due to systemic disorders 7 2.1 Paraneoplastic dermatoses 2 0.6 Other cutaneous manifestations of systemic disorders 2 0.6 Cutaneous dysesthesias 31 9.3 Post-herpetic neuralgia 26 7.8 Cutaneous sensory disorders 5 1.5 Skin tumors 48 14.3 Benign skin tumors 41 12.2 Dermatofibroma 2 0.6 Cherry angioma 1 0.3 Acrochordon 3 0.9 Keloids 14 4.2 Syringoma 4 1.2 Seborrheic keratosis 16 4.8 Pre-malignant and malignant skin tumors 7 2.1 Actinic keratosis 2 0.6 Squamous cell carcinoma 1 0.3 Melanoma 1 0.3 Other malignant skin tumors 3 0.9 Miscellaneous 18 5.4 Hair disorders 2 0.6 Chronic adverse cutaneous drug reactions 6 1.8 Keratoderma 5 1.5 Chronic ulcer 3 0.9 Nutritional dermatosis 1 0.3 Sarcoidosis 1 0.3 NCDs = non communicable dermatoses. Figure 2. Incidence of skin tumors in female and male patients. The incidence of skin tumors increased with age in females in contrast to the decline observed in males. The difference in incidence of skin tumors widened with increasing age between the two sexes. pathogenesis of most chronic NCDs. Extrinsic aging, mainly due to ultraviolet exposure also plays a significant role in the pathogenesis of NCDs in advanced age. Chronic ultraviolet exposure causes cellular DNA damage, accelerates intrinsic skin aging [37,38] increases skin fragility [37], and depletes the skin cutaneous immune cell population predisposing to skin tumorigenesis [37,38]. In addition, hormonal factors, diet, psychosocial problems, systemic co-morbid conditions and treatments for these conditions also contribute to the pathogenesis of chronic non-communicable skin diseases in old age. Inflammatory NCDs affect about 20 – 25% of the world population[39]. The incidence amongst older adults in this study was higher (35.6%). Chronic inflammatory dermato- ses especially eczemas are often reported as one of the most frequent skin findings in older adults [18,32,40]. Eczemas (37.0%) were the most frequently diagnosed chronic NCDs amongst older adults in this study. A similar finding of high prevalence of eczemas amongst older persons was reported by Wang et al [41] in China as well as several other research- ers in different geographical regions [18,22,35,42–44]. The etiology of inflammatory NCDs including eczemas in older persons is multifactorial. Age-related physiological dete- rioration in epidermal barrier function with correspond- ing decline in skin barrier homeostasis, stratum corneum hydration and increased skin pH appear to play a central role [41,45]. Impaired epidermal barrier function is asso- ciated with increased cutaneous cytokine expression and chronic low grade cutaneous and systemic inflammation [45–48]. Other endogenous factors including, reduced epi- dermal synthesis of natural moisturizing factors, lipids and Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 7 differences in the incidence of late-onset vitiligo as well as age-related differences in the etiopathogenesis, morpholog- ical variant and clinical course of the disease. In Nigeria, older adults account for 5.8% of dermatology consulta- tions for vitiligo [54], while in Singapore and Kuwait, up to 14% of subjects with vitiligo have late onset vitiligo [55,56]. Lower incidences were reported in India [20,57], Egypt [32] and Tanzania [18]. Vitiligo with onset in late adult hood is often more rapidly progressive and tends to be frequently associated with other autoimmune disorders [58,59]. Other pigmentary disorders occurred infrequently in our study population. We documented a much lower inci- dence of idiopathic guttate hypomelanosis (2.4%) compared with values as high as 9 - 70% reported in previous studies [26,53,60]. It is known that genetics and environmental fac- tors play major roles in the pathogenesis of idiopathic gut- tate hypomelanosis with the disease being more frequent in individuals with lighter ethnic skin tones. The low incidence of idiopathic guttate hypomelanosis among older adults in this study may therefore be related to the predominantly darker skin tone of our study population. Skin tumors were the third most frequent group of chronic NCDs diagnosed in the study. The overall incidence sebum as well as exogenous factors such as drugs contribute to the pathogenesis of eczemas and cutaneous inflammation in the elderly [49,50]. Given that the deterioration in epidermal barrier func- tion progresses relative to age [51,52], the substantial male preponderance of eczemas in this study may be due to the significant age difference between male and female patients in the study. Age-related decline in epidermal barrier func- tion may also be responsible for the observed increase in in- cidence of acute NCDs (comprising predominantly of acute eczemas such as contact dermatitis) with advancing age in this study. Cutaneous aging is associated a variety of divergent pig- mentary changes ranging from mottled hyperpigmentation in sun-exposed areas to hypopigmented macules of guttate hy- pomelanosis in relatively less exposed skin. Pigmentary der- matoses consisting predominantly of vitiligo and idiopathic guttate hypomelanosis occurred in 9.4% of older adults and were the second largest group of chronic non communicable dermatoses in this study. Vitiligo (9.9%) was the most fre- quent pigmentary disorder. A similar finding was reported by Raveendra in India [53]. Overall, vitiligo in older adults is not uncommon. However, there are racial and geographical Figure 3. Co-morbid infectious dermatoses in the study population. The incidence of concomitant infectious dermatoses was highest in the seventh decade. Fungal skin infections followed by parasitic skin diseases were the most frequent in female and male patients respectively. 8 Original Article | Dermatol Pract Concept. 2023;13(4):e2023262 grouped under their respective causes. The true incidence of chronic idiopathic erythroderma in older adults is unknown, however, a significant preponderance in elderly men has been previously documented [72]. We found a higher incidence of CIEs in males that was not statistically significant (P > 0.05). The incidence of co-morbid communicable dermatoses was surprisingly low (8.1%) in the study population. The spectrum of infectious dermatoses was dominated by fun- gal infections in females and parasitic and viral infections in males. This was a healthcare facility-based study, and as such findings of this research reflect predominantly chronic skin conditions in older adults warranting specialist care. Older adults with minor or less severe skin conditions that may otherwise present to the general practitioner or remain un- treated are therefore not captured by this study. This study establishes a high burden of chronic non communicable dermatoses with significant gender dispari- ties among older adults receiving dermatological care at a tertiary healthcare facility in Southwestern Nigeria. With increasing longevity, a corresponding rise in the prevalence these chronic skin conditions is foreseeable, and the demand for specialist geriatric skin care is bound to grow. Healthcare providers therefore need to be proactive in planning and al- locating resources, to ensure that specialized geriatric skin care services are available to meet the skin health needs of the growing elderly population. References 1. Luebberding S, Krueger N, Kerscher M. Skin physiology in men and women: In vivo evaluation of 300 people including TEWL, SC hydration, sebum content and skin surface pH. Int J Cosmet Sci 2013;35:477–83. 2. World Health Organization (WHO). Aging and health 2022. https://www.who.int/news-room/fact-sheets/detail/ageing-and- health (accessed September 27, 2022). 3. World Health Organization (WHO). UN Decade of Healthy Ageing 2022. https://www.who.int/initiatives/decade-of-healthy -ageing (accessed September 1, 2022). 4. Boersma P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev Chronic Dis 2020;17. 5. da Silva DSM, de Assumpcao D, Fransisco PM, Yassuda MS, Neri AL, Borim FS. 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The gender gap in skin tumors widened with increasing age (Figure 2) due to a steep increase in the proportion of females with skin tumors with age. Although a higher prevalence of skin tumors in older adult females compared with males has been previously documented [63,64], this opposing trend in inci- dence as well as a statistically significant gender difference in incidence of skin tumors has not been previously reported. Seborrheic keratosis was the most common skin tumor diagnosed in 4.8% of the patients and comprised of 33.3% of all skin tumors in this study. This incidence is lower than reports from other parts of the world [62,63,65] most likely due to differences in skin phototype of the population stud- ied. Studies from other parts of Africa report Kaposi sar- coma[18] and keloids[66] as the most frequent skin tumors encountered in older adults. In our study, keloids (4.2%) ranked second highest in the tumor category constituting less than a third of the total number of skin tumors. The differences in incidence and pattern of skin tumors in vari- ous studies may be related to genetic factors, other prevail- ing co-morbid conditions such as HIV infection, as well as the influence of environmental and cultural factors on per- ception of skin diseases. Although seborrheic keratoses are benign in nature and often considered a cutaneous mani- festation of extrinsic skin aging, they are worth mentioning particularly in older adults as their occurrence may herald more sinister diagnosis of internal malignancies particularly when eruptive [37,67]. Other frequently diagnosed chronic NCDs amongst older adults in this study were: papulo-squamous dermato- ses, cutaneous dysesthesias and urticaria/reactive dermatoses in decreasing order of frequency. 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