Dermatology has long fought to prevent and reverse the cutaneous signs of aging, but the truth exists that aging is inevitable. It is time to adapt the specialty to improve care for skin disease in older patients.
Aging and dermatology have a complicated history. The perception that the field is built on “antiaging” unfortunately diminishes the true experience of all patients, who will inevitably age. It also minimizes the role of dermatologists as critical members in the care of aging adults. Normalizing aging with an expert understanding of its implications is critical for our field. Dermatologists are in a unique position of managing both the pathology and cosmesis of aging. This dual role can make it difficult to answer the question what is healthy aging? The true answer to this question is different for every patient but should always be rooted in the honesty that all people will continue to age regardless of intervention or effort. Helping someone look younger with preventive measures and interventions does not neglect this truth, but instead addresses a specific manifestation in the context of a normal process. Adapting our field to the inevitability of aging does not deny the tremendous skills the field has developed through cosmetic and laser procedures. To this end, geriatric dermatology builds on the current paradigm to best convey the true reality of aging.
Who Is Geriatric Dermatology?
A man in his 90s walked into my office last month, accompanied by his daughter and wife. He had a persistent itch for years that was getting worse, explaining that the itch was constant but worsened at night. He was treated for scabies many times without improvement, as was his asymptomatic wife who sleeps in the same bed. He brought a plastic bag of topical steroids he had used over the years but reported that he did not like to use them because they ruin his clothes and only work for a few hours after application. He spends most of his day taking care of his wife who has advanced dementia. He admitted that it was difficult to take his medications and use his creams because he was so fatigued taking care of her. This patient worried that the stress was worsening his skin, making the itch so severe that it wakes him up at night. His inability to sleep only worsens the stress, creating a frustrating cycle.
Examination revealed a mix of red papules and eczematous plaques on the trunk, scantily appearing on the extremities. Neither morphology was dominant. The skin changes were less notable than the extent of his symptoms. While looking over his skin, there were two or three lesions concerning for basal cell carcinoma.
The heaviness of the room was palpable. The patient and his family waited to hear the answer as to what was going on and how we could easily and safely make it go away. I had run well over the 15-minute allotted appointment time, and the next two patients were waiting.
The challenge of this patient’s plight in the context of a busy clinical environment is not something novel for me or any other dermatologist. This fact, however, does not make this commonality easier.
I have questions about the diagnosis, and there are concerns about the appropriate treatments. Significant time is needed to discuss the risks and benefits of each treatment option as well as to address the social challenges to adherence for treatments and future appointments.
This is the reality of complex older adult care in dermatology. The model is challenged at every level—clinical, educational, and investigational—with older patients. These patients, with medical complexity and social nuance similar to my patient, are seen in dermatology clinics around the world. It is always challenging to meet their needs adequately, but rather than throwing up our hands and stamping these situations as “difficult,” there opens innumerable opportunities for the field of dermatology to grow. We can make these situations easier for our systems, our patients, and our specialty.
What Is Geriatric Dermatology?
What is geriatric dermatology? From a purely definitional standpoint, it refers to the practice of dermatology for older adult patients. However, this simplified statement does not capture the breadth or facets of this new field. The marrow of the specialty is in its diverse set of goals and practices, which range from the basic science of aging, to diseases commonly seen in older adults, and then beyond pathophysiology to the health care system barriers to optimal care and social determinants of health that uniquely impact older individuals. Similar to pediatric dermatology, geriatric dermatology is a deviation from common disease-specific models in dermatology. While not built on a single disease, the field relies on our ability to take a step back and appreciate the multitude of factors that contribute to the skin health of older adults.
What is the basic science of aging skin? There are unique physiologic differences of aging skin that lead to known, ubiquitous pathology. It is widely accepted that there are intrinsic age-related changes in barrier function and the systemic immune system. Moreover, patients are exposed to a variety of extrinsic elements that, over time, uniquely impact the skin, most famously sun exposure. The accumulation of intrinsic and extrinsic aging factors is widely accepted in the field, and they confer the platform needed to build the field of geriatric dermatology. While some of these concepts are held and studied by the dermatology community, others can be found elsewhere in medicine and have not made their way into the dermatology infrastructure. For example, the concept of immunosenescence refers to age-related changes of the immune system. While it is taught in medical schools, it is not a common discussion for many older patients with immunologic disease. Another example is the idea of inflammaging, which refers to age-related increases in the levels of proinflammatory markers in the blood and tissues. This concept is widely accepted as a risk factor for many common diseases in older individuals, such as chronic kidney disease, cognitive impairment, and even certain age-related cancers. However, no known skin condition has ever been implicated. With the rich knowledge of aging that extends beyond the current dogmas of our field, dermatology is well positioned to be included in the broader discussion.
What is the clinical reality of geriatric dermatology? Dermatologists are a major part of the care of older adults. While the basic science informs the basis of the diseases we see in older patients, an overwhelming reality exists: older adults are ubiquitous in most dermatology clinics throughout the world. The National Ambulatory Medical Care Survey of 2000 showed that 4.4% of all ambulatory visits for patients older than 65 years were to their dermatologist.1 Of specialists, this was only below ophthalmology and nearly equivalent to orthopedics, cardiology, and urology. Moreover, the same survey showed dermatology had the largest increase in visits between 1980 to 2000 of all specialties for patients older than 65 years. This fact, while unlikely surprising to dermatologists, does convey the need for dermatology to continue to be a vocal, contributing, and leading presence in the care of older adults.
What is the landscape of geriatric specialties across medicine? The aforementioned specialties who see geriatric patients at higher or equal frequency than dermatology each have established “geriatric” subspecialties, further highlighting an opportunity for dermatology to grow using the templates of other specialties. The Geriatrics for Specialists Initiative (GSI), spearheaded by the American Geriatrics Society, has cultivated specialists who are interested in aging within their practice.2 The geriatrics community recognized that there would never be enough geriatricians to meet all the needs of older adults, so they began to reach out and develop leaders in specialties that commonly care for older patients. This group currently includes the specialties of anesthesiology, colon and rectal surgery, emergency medicine, general surgery, gynecology, ophthalmology, orthopedic surgery, otolaryngology, physical medicine and rehabilitation, trauma surgery, and urology. Through deliberate research, career development, and financial backing, GSI has changed the framework of many specialties. Perhaps, the best example is in emergency medicine where clinical and research focuses have led to initiatives and changes within emergency room infrastructure, including the creation of geriatric emergency rooms and accreditation by the American College of Emergency Physicians.3 Beyond just infrastructure enhancements, this deliberate focus has resulted in actionable guidelines and proven improvements in patient outcomes.
What do we know about older patients in dermatology’s flagship diseases? With the support of our science, experience in clinic, and paradigms of colleagues across medicine, we must shine a light on our own practices and diseases. Unfortunately, that light shows a clear omission of geriatric nuance across dermatology. Regarding to directed research as well as clinical and educational efforts, there is a dearth of knowledge of dermatology’s flagship diseases as they relate to our older patients. We must ask how presentations, pathophysiology, workups, treatments, and outcomes differ for older adults. The answers to these questions will not come easily and will take tremendous effort from our field. Yet, to date, there are examples of how asking these questions can powerfully reframe the scope of diseases. For example, in a study evaluating age and comorbidities in patients with pyoderma gangrenosum, patients aged 65 years or older were more likely to have a malignant neoplasm, whether solid organ or hematologic.4 This finding had never been previously reported. Other dermatologic diseases have well-established geriatric cohorts, including pruritus,5 keratinocyte carcinomas,6 and vesiculobullous disease.7 As we continue to ask more questions, we can continue to illuminate the nuances and best practices that will allow us to provide the best possible care.
What is the present and future of geriatric dermatology? Necessary changes will require alterations to dermatology’s long-standing schematics and a scientific approach to rebuilding them. This requires true self-reflection and a willingness to address limitations in the current infrastructure that have hampered our understanding and care of this population, such as the exclusion of older adults from clinical trials. This is a phenomenon seen across medicine, but it was recently highlighted in two of dermatology’s most high-profile diseases: atopic dermatitis8 and psoriasis.9
Exclusion from clinical trials is just one example of a built-in barrier, unrealized until the field deliberately brought focus to this population. In order to combat these barriers and continue to bring attention to this group, we need efforts for advocacy across the specialty through research, education, and clinical care. In 2018, the American Academy of Dermatology supported the creation of the first Geriatric Dermatology Expert Resource Group, bringing together providers, both medical and surgical, who are interested in understanding and improving care for these patients. Since its inception, clinical and research initiatives have sprouted, such as the Geriatric Dermatology Clinic at the San Francisco Veterans Health Administration Hospital and the UCSF Aging Skin Collaborative, respectively. The latter includes basic science, epidemiologic, and clinical researchers. We hope programs like these can be replicated by any physician who struggles (as many do) when searching for answers about best practices in this patient population.
The Practice of Geriatric Dermatology
Returning back to the patient, anxious and itchy, he sat eagerly with his family awaiting my evaluation. With the weight of a system ill equipped to support us, I told them I did not have the perfect diagnosis for them. I explained I have had countless patients with near identical presentations, and while there are several treatment options, many of the medications have never been trialed or reported on a large scale in older adults. With the mix of nomenclature confusion and treatment nuances, I felt the skepticism enter the room. This feeling is felt by patients and providers alike in these daily interactions. In each of these encounters, the field is left naked, with a rigid system and without an abundance of scientific support. This leaves us with only a genuine and earnest commitment to try. It is with that same genuine and earnest commitment that the field of geriatric dermatology aims to remedy these shortcomings. The work is just getting started.
Dr Butler is an assistant professor at University of California, San Francisco, department of dermatology, and codirector of the Geriatric Dermatology Clinic and cofounder of the Geriatric Dermatology Expert Resource Group.
Disclosure: The author reports no relevant financial relationships.
References
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2. GSI: about us. American Geriatrics Society. Accessed November 30, 2020. https://www.americangeriatrics.org/programs/geriatrics-specialists-initiative/gsi-about-us
3. Geriatric emergency department accreditation program. American College of Emergency Physicians. Accessed November 30, 2020. https://www.acep.org/geda/
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6. Bailey A, Vasicek B, Tao J, Janeczek M, Mitri A, Tung A. Management of keratinocyte carcinoma – special considerations in the elderly. Int J Women Dermatol. 2019;5(4):235-245. doi:10.1016/j.ijwd.2019.05.005
7. Mutasim DF. Autoimmune bullous dermatoses in the elderly: diagnosis and management. Drugs Aging. 2003;20(9):663-681. doi:10.2165/00002512-200320090-00004
8. Lam M, Zhu JW, Maqbool T, et al. Inclusion of older adults in randomized clinical trials for systemic medications for atopic dermatitis. JAMA Dermatol. 2020;156(11):1240-1245. doi:10.1001/jamadermatol.2020.2940
9. Schaap MJ, van Winden MEC, Seyger MMB, de Jong EMGJ, Lubeek SFK. Representation of older adults in randomized controlled trials on systemic treatment in plaque psoriasis: a systematic review. J Am Acad Dermatol. 2020;83(2):412-424. doi:10.1016/j.jaad.2019.07.079
