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ABSTRACT
The elderly in North America represent the fastest growing segment of the population and the most common skin complaint in this age group is pruritus. The multitude of variables that come with advanced age means that the management of pruritus in the elderly poses a particular therapeutic challenge. Pruritus in advanced age may result from a variety of etiologies, although xerosis is the most common. In addition, certain cutaneous and systemic diseases that are associated with pruritus are more prevalent in the elderly. At present, there is no universally accepted therapy for pruritus. Currently, management of pruritus in the elderly must take an individualistically tailored approach with consideration of the patient's general health, the severity of symptoms, and the adverse effects of treatment. Physical and cognitive limitations, multiple comorbid conditions, and polypharmacy are some aspects that can influence the choice of treatment in this age group.
Pruritus is the most common skin complaint in patients over the age of 65 years.1,2 This often neglected symptom can have a profound impact on the quality of life in the elderly, especially through sleep deprivation. Given the multitude of variables that come with advanced age, the management of pruritus in the elderly poses a particular clinical challenge.
Pathophysiology
Pruritus in advanced age may result from a variety of etiologies. Xerosis (dry skin), which increases with age, is probably the most common cause of pruritus in the elderly.3,4 As skin ages, the integumentary and vascular systems undergo atrophy, leading to suboptimal moisture retention. However, many elderly patients have pruritic skin without xerosis. Other skin changes in advanced aged patients that may contribute to itch include decreased skin surface lipids and clearance of transepidermally absorbed materials from the dermis, reduced sweat and sebum production, as well as diminished barrier repair.4
A decline of normal immune function that occurs with aging also produces a higher incidence of autoimmune skin disorders that can induce pruritus, such as bullous pemphigoid and postherpetic neuralgia. Additional factors may also play a role, such as age-related changes in nerve fibers and polypharmacy. Certain cutaneous and systemic disorders that are associated with pruritus are also more prevalent in advanced aged patients (as discussed below). However, in many instances, no apparent cause is found.
Clinical Features
A detailed history, review of systems, and physical examination are of prime importance in guiding antipruritic treatment of senescent skin. Once cutaneous and systemic causes of itch are excluded, idiopathic itch of the elderly may be considered. However, if an underlying cause is discovered, it should be addressed, as this frequently leads to symptomatic improvement. Certain pruritic cutaneous diseases are more prevalent in the elderly population, such as xerosis, nummular dermatitis, and seborrheic dermatitis. The later is especially common in patients with dementia and Parkinson's disease. Systemic diseases that are associated with pruritus, such as chronic kidney disease, hepatic dysfunction, and endocrine disorders, are also more prevalent in the elderly. Notably, infectious etiologies of pruritus, including scabies and lice, may be more common in this age group especially within institutionalized care settings. In addition, medications frequently used in the elderly increase the possibility of drug-induced pruritus (e.g., aspirin, opioids, and angiotensin converting enzyme inhibitors). Another serious consideration in this cohort is that chronic pruritus may be a presenting sign of underlying malignancy (e.g., low grade lymphoma, multiple myeloma, and myleodysplastic syndromes), and thus, any case with a high index of suspicion necessitates a thorough work-up.5 Psychogenic and neuropathic disorders are also common causes in this age group.6
General Principles
The management of pruritus in the elderly poses a particular challenge. Physical and cognitive impairments may make application of topical treatments impossible and compliance an issue. Comorbid conditions, especially those involving the liver and kidney, as well as the frequent polypharmacy in this age group, confers a greater risk of adverse drug reactions. At present, there is no universally accepted therapy for itch. Instead, management of pruritus, especially in the elderly, requires an individualistically tailored approach with consideration of the patient's general health, the severity of symptoms, and the adverse effects of available treatments. Some of the treatments discussed are unlicensed for use in pruritus and should be administered under a specialist setting.
There are a number of general measures that may be useful in the management of pruritus in the elderly, irrespective of the underlying cause (Table 1). Patient education is central to the management of pruritus.7 Identifying and removing aggravating factors are often the initial steps in effective treatment. Breaking the "itch-scratch" cycle is critical and patients should be informed of the increased cutaneous inflammation that scratching causes. Simple measures, such as keeping finger nails short, may help to interrupt this vicious cycle. The sensation of pruritus is often heightened by warmth, thus, where appropriate, measures such as tepid showering, wearing light clothing, and the use of air conditioning should be undertaken to keep the skin cool. Wherever possible, simple topical regimens are preferable in order to maximize compliance and limit potential adverse drug reactions.
Source: The Management of Chronic Pruritus in the Elderly
The elderly in North America represent the fastest growing segment of the population and the most common skin complaint in this age group is pruritus. The multitude of variables that come with advanced age means that the management of pruritus in the elderly poses a particular therapeutic challenge. Pruritus in advanced age may result from a variety of etiologies, although xerosis is the most common. In addition, certain cutaneous and systemic diseases that are associated with pruritus are more prevalent in the elderly. At present, there is no universally accepted therapy for pruritus. Currently, management of pruritus in the elderly must take an individualistically tailored approach with consideration of the patient's general health, the severity of symptoms, and the adverse effects of treatment. Physical and cognitive limitations, multiple comorbid conditions, and polypharmacy are some aspects that can influence the choice of treatment in this age group.
Pruritus is the most common skin complaint in patients over the age of 65 years.1,2 This often neglected symptom can have a profound impact on the quality of life in the elderly, especially through sleep deprivation. Given the multitude of variables that come with advanced age, the management of pruritus in the elderly poses a particular clinical challenge.
Pathophysiology
Pruritus in advanced age may result from a variety of etiologies. Xerosis (dry skin), which increases with age, is probably the most common cause of pruritus in the elderly.3,4 As skin ages, the integumentary and vascular systems undergo atrophy, leading to suboptimal moisture retention. However, many elderly patients have pruritic skin without xerosis. Other skin changes in advanced aged patients that may contribute to itch include decreased skin surface lipids and clearance of transepidermally absorbed materials from the dermis, reduced sweat and sebum production, as well as diminished barrier repair.4
A decline of normal immune function that occurs with aging also produces a higher incidence of autoimmune skin disorders that can induce pruritus, such as bullous pemphigoid and postherpetic neuralgia. Additional factors may also play a role, such as age-related changes in nerve fibers and polypharmacy. Certain cutaneous and systemic disorders that are associated with pruritus are also more prevalent in advanced aged patients (as discussed below). However, in many instances, no apparent cause is found.
Clinical Features
A detailed history, review of systems, and physical examination are of prime importance in guiding antipruritic treatment of senescent skin. Once cutaneous and systemic causes of itch are excluded, idiopathic itch of the elderly may be considered. However, if an underlying cause is discovered, it should be addressed, as this frequently leads to symptomatic improvement. Certain pruritic cutaneous diseases are more prevalent in the elderly population, such as xerosis, nummular dermatitis, and seborrheic dermatitis. The later is especially common in patients with dementia and Parkinson's disease. Systemic diseases that are associated with pruritus, such as chronic kidney disease, hepatic dysfunction, and endocrine disorders, are also more prevalent in the elderly. Notably, infectious etiologies of pruritus, including scabies and lice, may be more common in this age group especially within institutionalized care settings. In addition, medications frequently used in the elderly increase the possibility of drug-induced pruritus (e.g., aspirin, opioids, and angiotensin converting enzyme inhibitors). Another serious consideration in this cohort is that chronic pruritus may be a presenting sign of underlying malignancy (e.g., low grade lymphoma, multiple myeloma, and myleodysplastic syndromes), and thus, any case with a high index of suspicion necessitates a thorough work-up.5 Psychogenic and neuropathic disorders are also common causes in this age group.6
General Principles
The management of pruritus in the elderly poses a particular challenge. Physical and cognitive impairments may make application of topical treatments impossible and compliance an issue. Comorbid conditions, especially those involving the liver and kidney, as well as the frequent polypharmacy in this age group, confers a greater risk of adverse drug reactions. At present, there is no universally accepted therapy for itch. Instead, management of pruritus, especially in the elderly, requires an individualistically tailored approach with consideration of the patient's general health, the severity of symptoms, and the adverse effects of available treatments. Some of the treatments discussed are unlicensed for use in pruritus and should be administered under a specialist setting.
There are a number of general measures that may be useful in the management of pruritus in the elderly, irrespective of the underlying cause (Table 1). Patient education is central to the management of pruritus.7 Identifying and removing aggravating factors are often the initial steps in effective treatment. Breaking the "itch-scratch" cycle is critical and patients should be informed of the increased cutaneous inflammation that scratching causes. Simple measures, such as keeping finger nails short, may help to interrupt this vicious cycle. The sensation of pruritus is often heightened by warmth, thus, where appropriate, measures such as tepid showering, wearing light clothing, and the use of air conditioning should be undertaken to keep the skin cool. Wherever possible, simple topical regimens are preferable in order to maximize compliance and limit potential adverse drug reactions.
Source: The Management of Chronic Pruritus in the Elderly
