Review Article

Atopic dermatitis in the elderly

Yudo Irawan, Rahadi Rihatmadja, Lili Legiawati,

Shannaz Nadia Yusharyahya, Sri Adi Sularsito

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia,

dr. Cipto Mangunkusumo National Hospital, Jakarta

Email: callmeu_do@yahoo.com

Abstract

Atopic dermatitis (AD) is a recurrent skin inflammation accompanied by itching. The incidence of AD is
increasing worldwide. AD, which persists until elderly or with an onset during elderly, is known as senile AD.
It has different prevalence and clinical features from other AD stages. Senile atopic dermatitis affects males
more than females, which is different from other stages of AD. Skin manifestation of senile AD is similar with
the adult stage of Hanifin-Rajka criteria, but can be atypical. The typical feature of senile AD is eczematous
dermatitis around a free-lesion fossa. Other common clinical manifestations are erythroderma and non-
specific chronic dermatitis. In the management of senile AD, changes related to aging process should be
considered. Management of senile AD is complex, involves combined pharmacological treatment consists of
topical and systemic agents, and non pharmacological aspects. Appropriate treatment considering
effectiveness and safety will improve the quality of life of patients with senile AD.

Keywords: atopic dermatitis, elderly, clinical feature, senilis, atypical

Abstrak

Dermatitis atopik (DA) adalah inflamasi kulit yang berulang disertai gatal. Insidens DA mengalami
peningkatan di seluruh dunia. Dermatitis atopik yang menetap sampai usia lanjut atau dengan awitan usia
lanjut disebut sebagai DA senilis. Prevalensi dan gambaran klinis DA senilis berbeda dengan DA fase
lainnya. Dermatitis atopik senilis lebih banyak mengenai pria dibandingkan wanita, berbeda dengan DA fase
lainnya. Manifestasi kulit pada DA senilis pada dasarnya sama dengan fase dewasa bila diagnosis
ditegakkan berdasarkan kriteria Hanifin-Rajka, namun dapat menjadi tidak khas. Gambaran yang tampak
khas pada DA senilis adalah dermatitis eksematosa mengelilingi daerah fosa yang bebas lesi. Manifestasi
klinis lainnya yang sering pada DA senilis adalah eritroderma dan dermatitis kronik non spesifik. Tatalaksana
penyakit ini cukup rumit dan harus memperhatikan perubahan yang terjadi akibat penuaan. Kombinasi
medikamentosa dengan terapi topikal dan sistemik serta tetap memperhatikan aspek non-medikamentosa
merupakan pilihan terapi yang terbaik untuk pasien DA senilis. Tatalaksana yang tepat sambil tetap
memperhatikan efektifivitas dan keamanan obat akan kembali meningkatkan kualitas hidup pasien DA
senilis yang menurun akibat penyakit tersebut.

Kata kunci: dermatitis atopik, usia lanjut, gambaran klinis, senilis, atipik

Introduction disease is commonly found in infants, children

and adults.1,4 The incidence of persistent AD or
Atopic dermatitis (AD) is a chronic recurrent skin those with adult onset is increasing in many
inflammation, which is accompanied by itching developing countries.5 Atopic dermatitis affects 1-
and occurs in certain predilection site. 1-3 The 3% adult and elderly patients.1,5-7

J Gen Pro DVI. 2016;1(2):54-61 54

According to the definition by the World Health
Organization (WHO), elderly are those aged over
60 years.8 The population of elderly increased
almost three folds between 2012 and 2013. 9 The
aging process causes various reduced skin
function, which leads to atypical clinical features
of AD in elderly.10
Epidemiology
AD affects 20% children of industrial countries
worldwide, but lower prevalence is found in
agricultural countries. The International Study of
Asthma and Allergies in Childhood (ISAAC)
demonstrates that the incidence of AD is
increasing, particularly in developed and
developing countries and women are more
affected than men.2 In 2012, there were 1,1% AD
patients aged 13-14 years in Indonesia. Reports
from five hospitals that provide pediatric
dermatology care in Indonesia show that there are
261 AD cases among 2.356 new patients
(11.8%).3
Data on the prevalence of senile AD is limited
since it is an uncommon subtype.1,6,11 It has been
reported that the prevalence is 0,6% per year in
Mexico and 2,6% per year in Japan.1 A study in
German has reported that the prevalence range of
senile AD is 1,5-10% in those aged over 50
years;12 while in Iran, it is only 1,5%.13 It has also
been reported that atopic dermatitis is found in
0,5% of elderly patients who have skin complaints
in India.14 Unlike the children and adult stage AD,
senile AD affects men more than women with a
ratio of 3:1. The data is established based on
results of nine years studies in Japan and
Australia.1,5,6
Based on the data from the Geriatric Division of
Outpatient Clinic in Department of Dermatology
and Venereology, dr. Cipto Mangunkusumo
National Hospital, there were 57 patients out of
the total visit of AD patients between January
2013 and August 2014. The number of new senile
AD patients of the total visit was 13 patients with
greater prevalence in women as compared to men
(8:5).15
Pathogenesis
Etiology
AD is categorized into two types, i.e. the
extrinsic/allergic type and intrinsic/ non-allergic
type. The extrinsic type is found in 70-80% of AD
patients. In this type, there is sensitization to
environmental allergen and increased serum IgE;
J Gen Pro DVI. 2016;1(2):54-61
while the intrinsic type is found in 20-30% of AD
patients. In intrinsic type, there is no sensitization
to environmental allergen and the serum level of
IgE is low.2,3,16
Tanei reports that the frequency of senile AD with
pure intrinsic type is 6,25%; while the mixed type
(with a history of asthma) is 12,5%.1 Katsarou and
Armenaka demonstrate that the prevalence of
extrinsic AD is higher than the intrinsic type. 5
Results of a study conducted by Folster-Holst, et
al. shows that extrinsic type of senile AD is more
common than the intrinsic type and it is usually
found in patients with a family history of atopy.17
In general, the pathogenesis of AD is a complex
interaction of genetic susceptibility, the host
environment, epithelial barrier dysfunction and
dysregulated immune response. This concept is
also applicable to senile AD.5
Genetic susceptibility
A study has reported that there are some gene
mutations in AD patients, i.e. coding genes of T
helper (Th)2 cytokines including interleukin (IL)-4
and IL-13 genes on chromosome 5q31-33, serine
protease inhibitor Kazal type 5 (SPINK5) gene on
chromosome 5q31, IL-4 receptor gene on
chromosome 16p12.1-11.2, mast cell chymase
gene on chromosome 14q11.2 and filaggrin gene
on chromosome 1q21.1,5
The gene mutation of filaggrin is the most
commonly found mutation in AD patient. The gene
mutation will reduce its role in retaining water
(transepidermal water loss/TEWL) and
maintaining skin flexibility. Decreased expression
of filaggrin can be observed in the skin lesion and
also unaffected skin of patients with AD.3,5 A
study in Europe demonstrates that a mutation on
chromosome 1q21 is a predisposing factor for
persistent early onset atopic dermatitis and
extrinsic type in adults; however its effect on
other atopy manifestation is not known.18
Unfortunately, until now, there has been no report
on a study analyzing the gene mutation,
particularly in senile AD population.10,18
The host environment
Exposures to allergens, irritants and
environmental pathogens are associated with AD
incidence. House dust mite of Dermatophagoides
genus is found at ten folds concentration in the
homes of AD patients. Patients with senile AD,
especially those aged 75 years and over,
experience reduced daily living activities that
increases the risk of exposures to allergens
(house mite, pollen, molds, food), irritants
55
(inappropriate clothing, sweat) and environmental
pathogens (Staphyloccocus aureus). Longevity is
also associated with increased risk of
sensitization. 1
Epithelial barrier dysfunction
Defects in epithelial barrier in AD patients occur in
the skin and gastrointestinal tract. It explains the
development of IgE reactivity in atopic children
against various foods that takes place in
approximately 40% of patients with childhood AD.
The epithelial function of gastrointestinal tract
improves with the increasing age; therefore, most
patients will be tolerant against food allergies by
the age of three. Aging will cause recurrent
dysfunction of the gastrointestinal epithelial barrier
and subsequently increases the susceptibility of
elderly patients to food allergens. The process of
allergen, irritant and pathogens introductions can
lead to systemic sensitization in elderly patients
with AD.1,5
Mutation of filaggrin gene causes reduced natural
moisturizing (NMF) level resulting dry skin. It is
worsen by reduction of water content and lipid
level in the stratum corneum, changes in
ceramide structure and inefficient degradation of
corneodesmosome in the elderly skin.19-21
Combination of those various problems will cause
skin xerosis of the elderly which become the port
d’entrée of various allergens, irritants and
pathogens.5,19-21
Dysregulated immunologic response
In AD patients, there is predominant systemic Th2
cells level followed by abnormal IgE production,
peripheral eosinophilia, activation of mast cell and
cytokine induction (e.g. IL-4 and IL-13). Analysis
on extrinsic and intrinsic type shows increased
Th2 cells and reduced Th1 cells in AD patients.
The acute phase of AD will have Th2 cell
predominance, while the chronic phase of AD will
be affected by the production of Th1 cells
cytokines, i.e. IL-12, IL-18, IL-11 and transforming
growth factor (TGF)-β1.1, 5, 22 Recently, IL-31
cytokines production has been reported as one of
the causes of itching in AD. 23
Eosinophilia is one of the important markers for
AD. There is an increase of CD69 and CD 38
expressions as markers of the activation, which
can be detected in peripheral blood. The
possibility that these findings may affect the
severity of disease is still vague.24
J Gen Pro DVI. 2016;1(2):54-61
The aging of the immune system that involves
thymic involution has important role in the
pathogenesis of senile AD.22 The overall number
of T cells is significantly decreased in those aged
over 75 years. Naïve T cells are reduced,
particularly the CD8, but memory T cells are
increased.25,26 The hypothesis is supported by the
incidence of AD-like dermatitis found in primary T
cell immunodeficiency disorders.5,22 The aging
process also relatively reduces the level of
suppressor T cells, which may induce an
activation of hypersensitivity reactions and
intolerance to environmental allergens in elderly
patients. 26,27 Table (1) shows details of altered
immune response experienced by elderly
patients.28
Inducing factors
1. Allergen and irritant
Sensitization occurs in senile DA, particularly in
moderate to severe condition, except for food
sensitization, which has lesser roles in senile DA.
Food may have its role through the non-allergenic
pathway such as alcohol and food preservatives
that induce exacerbation through the non-
immunological mechanism. Results of prick test
against food are not always positive for adult AD
patients who show a response to food. 5
The levels of total IgE and specific-aero allergen
are increased in AD patients of all stages and they
tend to be stable with increasing age. A study has
reported that 86% of senile AD patients have IgE-
specific-aero-allergen, particularly to house dust
mite and pollens.5,17 Tanei et al have found that
there is IgE-medicated inflammation in senile AD,
particularly the extrinsic type. Researchers have
also reported that the total IgE level in patients
with a history of adult onset is higher compared to
patients with childhood onset.29
The correlation between atopy and allergen
contact is still unclear. However, atopic dermatitis
is a risk factor for sensitization of allergic contact
dermatitis.30 A study involving adult AD patients in
Scandinavia found that the results of patch test
had positive relevance for at least one allergen,
particularly on nickel.5 Atopic dermatitis can be
exacerbated by irritants. Excessive washing,
soaps and detergents will induce flare of AD.4,31
Atopic dermatitis is also the most common cause
of occupational dermatitis, and it increases the
risk of irritant contact dermatitis by two folds,
particularly for those occupations involving wet
work.5,31
56
 Tabel 1. Summary of Immunosenescence features*

Cell type Changes with aging

Reduced phagocytosis
Neutrophils Reduced reactive oxygen species production
Defect in apoptotic cell death
Reduced degranulation
Eosinophils Reduced superoxide production
Reduced phagocytosis
Reduced cytokine and chemokine secretion
Monocytes/macrophages
Reduced generation of nitric oxide and superoxide
Reduced degranulation
Mast cells Dysregulation in function
Reduced phagocytosis and pinocytosis
Increased IL-6 and TNF- alfa production
Dendritic cells Diminished TLR expression and function
Dysregulation in function
Reduced response and proliferation
Reduced CD 28 expression
Reduced TCR diversity
T cells
Reduced signal transduction
Dysregulation in function
Production of low-affinity antibodies
Increased oligoclonal expansion
Decline in serum total IgE values
B cells
Reduced surface MHC class II molecule expression
Dysregulation in function
Impaired production of cytokines
Epithelial cells Decreased clearance of particles
Reduced numbers or increased in several tissues
NK cells and NKT cells Reduced cytotoxicity and proliferation
*
data obtained from reference no. 28

2. Microorganism increased total IgE level. Specific sensitization to

Skin infection, colonization of skin microorganisms
and sensitization to skin microorganisms are
predisposing factors of AD. Microorganism can be
an inducing factor for eczematous reaction in
sensitized AD patients. Colonization
Staphylococcus aureus has been reported to be
relatively high in adult AD patients (86%) and the
IgE level, which is specific to toxins, is associated
with the severity of dermatitis. The highest
prevalence of IgE (92%) against enterotoxin has
been seen in adult patients with total IgE level of
>2000 IU/mL. S. aureus toxins increase immune
response and causes chronic dermatitis in 34% of
adult patients.2,4,5
Colonization of Malassezia is more commonly
found in AD patients with adulthood stage than
those with childhood stage, which is supported by
findings of specific IgE level against Malassezia
species in most of adult AD patients with
Malassezia sympodialis has been found in many
AD patients with extrinsic type (50-64%) and
intrinsic type (36-50%). Patients with chronic
dermatitis are susceptible to sensitization. 5
of
3. Psychological stress
There is a complex psycho-neuro-immunological
involvement in AD patients. Stress changes the
function of skin barrier, T cells and antimicrobial
immune response. Stress also induces itching,
which will be followed by further skin damage due
to scratching. AD is known to have a stress-
related exacerbation. Stress is one of the
important factors that can induce AD. Intervention
to reduce psychological stress can improve skin
condition and patients’ quality of life.1,5,32

J Gen Pro DVI. 2016;1(2):54-61 57

Clinical manifestations
The major and typical subjective complaint of AD
is itching, that can be so severe that it causes
sleep disturbance. The efflorescence of AD lesion
depends on the disease onset and severity. Acute
lesion is characterized by circumscribed
erythematous lesion, papule, papulovesicles,
erosions and exudations. The subacute lesion
appears as erythematous plaque, squamous
lesion, excoriation and papules; while the chronic
lesion consists of thick plaque, lichenification,
hyperpigmentation or fibrotic papules (prurigo). 3
The onset of senile AD consists of three forms,
such as senile onset, recurrent with a history of
classic AD in childhood, and recurrent and or
continuity of AD in adulthood.1,5-7
Skin manifestations of senile AD are identical with
the adulthood stage when the diagnosis is
established based on Hanifin-Rajka criteria. Signs
of chronic dermatitis can be found on the face and
neck including lichenification or exudative lesions
on the trunk, lichenification with or without
pruriginous papules and nodes on the
extremities.5
The senile AD manifestation that can differentiate
between the senile and adulthood stages is the
involvement of elbows and knees. Local
lichenification of both areas is uncommon in the
senile stage unlike the adulthood stage AD. The
noticeable feature of the senile stage is
eczematous dermatitis around free-lesion fossa
area. The feature is typical for senile stage, but
not for other stages. Another typical feature that
has been reported is erythroderma and non-
specific chronic dermatitis.1,5-7
The atopic stigma other than the above mentioned
can still be found in senile AD such as the
Hertoghe’s sign, erythematous and pale face, the
dirty neck sign and papule with accentuation.1
Management
The management of AD in Indonesia consists of 5
pillars; these are: 3
1. Providing educational and efficient endeavors
for patients and their caregivers
2. Avoiding and modifying the environmental
trigger factors and modifying lifestyle
3. Strengthening and maintaining the optimal
function of skin barrier
4. Eliminating skin inflammation
5. Controlling and eliminating the scratch-itch
cycle.
J Gen Pro DVI. 2016;1(2):54-61
Further discussion on the management of AD is
categorized into pharmacological
(medicamentosa) and non-pharmacological (non-
medicamentosa) treatment.
Pharmacological
1. Topical treatment
Topical treatment for senile AD consists of
moisturizer, steroid, antibiotics, antiseptic and
antifungal. Moisturizer is used on all skin surface,
either affected or unaffected skin. The use of
moisturizer is continued although the lesion has
been healed. Ideal moisturizer should be able to
provide well hydration to stratum corneum and
can reduce TEWL. Skin barrier in elderly is
impaired and hardly corrected; therefore, the ideal
moisturizer should be emphasized more on
improving appearances, keeping the skin
comfortable and preventing further impacts of skin
aging. The selection of moisturizer in senile AD
patients is different for each individual. In general,
moisturizer with emollient-dominant effect will give
more advantage for senile skin. Additional of
active ingredients, the hypoallergenic nature, the
convenience and practical usage as well as the
cost are factors to be considered in choosing the
ideal moisturizer for patients.33-35
It is recommended to use topical steroid for acute
lesion together with topical calcineurin inhibitor in
order to prevent long term side effects of steroid
treatment. Tacrolimus is more effective than
pimecrolimus for adult patients with moderate to
severe AD. The adult AD patients can tolerate the
use of tacrolimus for 2-4 years.36
The use of topical antibiotics, antiseptics,
antifungal can be considered in order to reduce
the number of bacterial and fungal colonization;
however, care should be taken on the possibility
of developing antibiotics resistance S. aureus.5,36
2. Systemic treatment
In senile AD patients, it may be difficult for them to
avoid trigger factors and to apply topical
medication optimally as they have reduced daily
activity; therefore, systemic treatment can be
considered.
For acute lesion, short-term oral steroid treatment
(prednisolone 20-40 mg) can be used.5 For elderly
patients, the use should be monitored, particularly
for the possibility of increased blood glucose,
blood pressure, myopathy, osteoporosis, obesity,
thrombosis, cataract and gastric ulcer. 37
A sedative antihistamine (AH) can be used to
reduce itching; however, precautions must be
58
taken on effectiveness and safety for the use in
the elderly.5 The first generation of sedative
antihistamine such as hydroxyzine, clemastine
and dimethindene can reduce cognitive function
and is considered as inadequate treatment. The
second generation of AH, e.g. cetirizine,
desloratadine, loratadine can be the appropriate
choice to reduce itching. Administration of second
generation AH need to consider patient safety
principle, particularly patient’s kidney function.37
The antibiotic administration can be considered
when there is a serious infection. The choices of
systemic antibiotics are erythromycin,
clarithromycin or cephalosporin for 7-10 days.
Ketoconazole, which is specific for skin yeast is
recommended for patients with IgE
hypersensitivity; however, the recommendation of
ketoconazole administration still need to be
supported by larger studies.5 The administration of
antibiotics and antifungal should consider patient’s
kidney function and the possibility of interaction of
concomitant drug treatment.37
The first line treatment for AD patients includes
the abovementioned systemic and topical agents.
The second line treatment, which is considered
effective for senile AD is phototherapy, particularly
the combination of ultraviolet (UV) UV-A and UV-
B. In addition, for severe AD, cyclosporine may
effectively reduce symptoms; however, the
tolerance is lower and there is a higher possibility
of nephrotoxicity and neurotoxicity in the elderly
while compared to younger patients.36-37
It has been reported that the use of
immunotherapy on Dermatophagoides provides
improved AD. Subcutaneous injection using mite
allergen extract can reduce basophil activation.
The use of such immunotherapy in the elderly is
not completely established either for its
effectiveness or safety.38
A study has been conducted on dupilumab, a
monoclonal antibody used in adult AD patients.
The study reported that the administration of
dupilumab reduces inflammation, itching, the
incidence of infection and it is well tolerated by the
patients.39
Many studies have been started on the role of
vitamin D in AD patients. Vitamin D deficiency in
senile AD patients occurs due to the AD disease
and aging process itself. Elderly patients have
reduced vitamin D synthesis three folds compared
to adult patients. It is a common finding in some
studies that supplementation of 4000 IU vitamin D
daily for 21 days in AD patients can improve the
J Gen Pro DVI. 2016;1(2):54-61
Score of Atopic Dermatitis (SCORAD)
significantly.40-41
Non-pharmacological
The primary principle of AD treatment is avoiding
trigger factors. Food plays little role as a trigger in
senile AD patients.33,36 Non-immunological
process caused by alcohol and food preservative
can be managed by pseudoallergen diet. It has
been reported that 6-week pseudoallergen diet
has provided clinical improvement for 60% of
adult AD patients.5
A meta-analysis study has reported the use of
probiotics as a treatment for moderate to severe
AD patients, both in adults and children. The
administration of probiotics with Lactobacillus
species is effective in improving SCORAD of AD
patients aged over one year.42
Atopic dermatitis can increase psychological
stress and reduce patient’s quality of life
significantly. Psychological stress can also affect
the spouse of senile AD patients. Psychological
intervention can help healing and can prevent
recurrent AD in elderly patients.32
Conclusion
Atopic dermatitis in elderly or senile AD is still
rarely reported. Almost all reports have showed
that the prevalence of senile AD is higher in men
than women. The most common clinical features
are dermatitis around the folds of elbows and
behind knees, erythroderma and non-specific
chronic dermatitis. Aeroallergen has a greater role
than food or contact allergen in senile AD. The
management of the disease is complex since
there are many physiological changes due to
aging; therefore, treatment must be provided while
considering effectiveness and safety. The quality
of life of AD patients is a very important aspect;
thus, care on the aspect should be taken in
providing AD treatment for the elderly.
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