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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



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


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

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According to the definition by the World Health while the intrinsic type is found in 20-30% of AD
Organization (WHO), elderly are those aged over patients. In intrinsic type, there is no sensitization
60 years.8 The population of elderly increased to environmental allergen and the serum level of
almost three folds between 2012 and 2013. 9 The IgE is low.2,3,16
aging process causes various reduced skin
function, which leads to atypical clinical features Tanei reports that the frequency of senile AD with
of AD in elderly.10 pure intrinsic type is 6,25%; while the mixed type
(with a history of asthma) is 12,5%.1 Katsarou and
Epidemiology Armenaka demonstrate that the prevalence of
extrinsic AD is higher than the intrinsic type. 5
AD affects 20% children of industrial countries Results of a study conducted by Folster-Holst, et
worldwide, but lower prevalence is found in al. shows that extrinsic type of senile AD is more
agricultural countries. The International Study of common than the intrinsic type and it is usually
Asthma and Allergies in Childhood (ISAAC) found in patients with a family history of atopy.17
demonstrates that the incidence of AD is
increasing, particularly in developed and In general, the pathogenesis of AD is a complex
developing countries and women are more interaction of genetic susceptibility, the host
affected than men.2 In 2012, there were 1,1% AD environment, epithelial barrier dysfunction and
patients aged 13-14 years in Indonesia. Reports dysregulated immune response. This concept is
from five hospitals that provide pediatric also applicable to senile AD.5
dermatology care in Indonesia show that there are
261 AD cases among 2.356 new patients Genetic susceptibility
(11.8%).3 A study has reported that there are some gene
mutations in AD patients, i.e. coding genes of T
Data on the prevalence of senile AD is limited helper (Th)2 cytokines including interleukin (IL)-4
since it is an uncommon subtype.1,6,11 It has been and IL-13 genes on chromosome 5q31-33, serine
reported that the prevalence is 0,6% per year in protease inhibitor Kazal type 5 (SPINK5) gene on
Mexico and 2,6% per year in Japan.1 A study in chromosome 5q31, IL-4 receptor gene on
German has reported that the prevalence range of chromosome 16p12.1-11.2, mast cell chymase
senile AD is 1,5-10% in those aged over 50 gene on chromosome 14q11.2 and filaggrin gene
years;12 while in Iran, it is only 1,5%.13 It has also on chromosome 1q21.1,5
been reported that atopic dermatitis is found in
0,5% of elderly patients who have skin complaints The gene mutation of filaggrin is the most
in India.14 Unlike the children and adult stage AD, commonly found mutation in AD patient. The gene
senile AD affects men more than women with a mutation will reduce its role in retaining water
ratio of 3:1. The data is established based on (transepidermal water loss/TEWL) and
results of nine years studies in Japan and maintaining skin flexibility. Decreased expression
Australia.1,5,6 of filaggrin can be observed in the skin lesion and
also unaffected skin of patients with AD.3,5 A
Based on the data from the Geriatric Division of study in Europe demonstrates that a mutation on
Outpatient Clinic in Department of Dermatology chromosome 1q21 is a predisposing factor for
and Venereology, dr. Cipto Mangunkusumo persistent early onset atopic dermatitis and
National Hospital, there were 57 patients out of extrinsic type in adults; however its effect on
the total visit of AD patients between January other atopy manifestation is not known.18
2013 and August 2014. The number of new senile Unfortunately, until now, there has been no report
AD patients of the total visit was 13 patients with on a study analyzing the gene mutation,
greater prevalence in women as compared to men particularly in senile AD population.10,18
The host environment
Pathogenesis 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
AD is categorized into two types, i.e. the
homes of AD patients. Patients with senile AD,
extrinsic/allergic type and intrinsic/ non-allergic
especially those aged 75 years and over,
type. The extrinsic type is found in 70-80% of AD
experience reduced daily living activities that
patients. In this type, there is sensitization to
increases the risk of exposures to allergens
environmental allergen and increased serum IgE;
(house mite, pollen, molds, food), irritants

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(inappropriate clothing, sweat) and environmental The aging of the immune system that involves
pathogens (Staphyloccocus aureus). Longevity is thymic involution has important role in the
also associated with increased risk of pathogenesis of senile AD.22 The overall number
sensitization. 1 of T cells is significantly decreased in those aged
over 75 years. Naïve T cells are reduced,
Epithelial barrier dysfunction particularly the CD8, but memory T cells are
Defects in epithelial barrier in AD patients occur in increased.25,26 The hypothesis is supported by the
the skin and gastrointestinal tract. It explains the incidence of AD-like dermatitis found in primary T
development of IgE reactivity in atopic children cell immunodeficiency disorders.5,22 The aging
against various foods that takes place in process also relatively reduces the level of
approximately 40% of patients with childhood AD. suppressor T cells, which may induce an
The epithelial function of gastrointestinal tract activation of hypersensitivity reactions and
improves with the increasing age; therefore, most intolerance to environmental allergens in elderly
patients will be tolerant against food allergies by patients. 26,27 Table (1) shows details of altered
the age of three. Aging will cause recurrent immune response experienced by elderly
dysfunction of the gastrointestinal epithelial barrier patients.28
and subsequently increases the susceptibility of
elderly patients to food allergens. The process of Inducing factors
allergen, irritant and pathogens introductions can 1. Allergen and irritant
lead to systemic sensitization in elderly patients Sensitization occurs in senile DA, particularly in
with AD.1,5 moderate to severe condition, except for food
sensitization, which has lesser roles in senile DA.
Mutation of filaggrin gene causes reduced natural Food may have its role through the non-allergenic
moisturizing (NMF) level resulting dry skin. It is pathway such as alcohol and food preservatives
worsen by reduction of water content and lipid that induce exacerbation through the non-
level in the stratum corneum, changes in immunological mechanism. Results of prick test
ceramide structure and inefficient degradation of against food are not always positive for adult AD
corneodesmosome in the elderly skin.19-21 patients who show a response to food. 5
Combination of those various problems will cause
skin xerosis of the elderly which become the port The levels of total IgE and specific-aero allergen
d’entrée of various allergens, irritants and are increased in AD patients of all stages and they
pathogens.5,19-21 tend to be stable with increasing age. A study has
reported that 86% of senile AD patients have IgE-
Dysregulated immunologic response specific-aero-allergen, particularly to house dust
In AD patients, there is predominant systemic Th2 mite and pollens.5,17 Tanei et al have found that
cells level followed by abnormal IgE production, there is IgE-medicated inflammation in senile AD,
peripheral eosinophilia, activation of mast cell and particularly the extrinsic type. Researchers have
cytokine induction (e.g. IL-4 and IL-13). Analysis also reported that the total IgE level in patients
on extrinsic and intrinsic type shows increased with a history of adult onset is higher compared to
Th2 cells and reduced Th1 cells in AD patients. patients with childhood onset.29
The acute phase of AD will have Th2 cell
predominance, while the chronic phase of AD will The correlation between atopy and allergen
be affected by the production of Th1 cells contact is still unclear. However, atopic dermatitis
cytokines, i.e. IL-12, IL-18, IL-11 and transforming is a risk factor for sensitization of allergic contact
growth factor (TGF)-β1.1, 5, 22 Recently, IL-31 dermatitis.30 A study involving adult AD patients in
cytokines production has been reported as one of Scandinavia found that the results of patch test
the causes of itching in AD. 23 had positive relevance for at least one allergen,
particularly on nickel.5 Atopic dermatitis can be
Eosinophilia is one of the important markers for exacerbated by irritants. Excessive washing,
AD. There is an increase of CD69 and CD 38 soaps and detergents will induce flare of AD.4,31
expressions as markers of the activation, which Atopic dermatitis is also the most common cause
can be detected in peripheral blood. The of occupational dermatitis, and it increases the
possibility that these findings may affect the risk of irritant contact dermatitis by two folds,
severity of disease is still vague.24 particularly for those occupations involving wet

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

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Clinical manifestations Further discussion on the management of AD is
categorized into pharmacological
The major and typical subjective complaint of AD (medicamentosa) and non-pharmacological (non-
is itching, that can be so severe that it causes medicamentosa) treatment.
sleep disturbance. The efflorescence of AD lesion
depends on the disease onset and severity. Acute Pharmacological
lesion is characterized by circumscribed 1. Topical treatment
erythematous lesion, papule, papulovesicles, Topical treatment for senile AD consists of
erosions and exudations. The subacute lesion moisturizer, steroid, antibiotics, antiseptic and
appears as erythematous plaque, squamous antifungal. Moisturizer is used on all skin surface,
lesion, excoriation and papules; while the chronic either affected or unaffected skin. The use of
lesion consists of thick plaque, lichenification, moisturizer is continued although the lesion has
hyperpigmentation or fibrotic papules (prurigo). 3 been healed. Ideal moisturizer should be able to
provide well hydration to stratum corneum and
The onset of senile AD consists of three forms, can reduce TEWL. Skin barrier in elderly is
such as senile onset, recurrent with a history of impaired and hardly corrected; therefore, the ideal
classic AD in childhood, and recurrent and or moisturizer should be emphasized more on
continuity of AD in adulthood.1,5-7 improving appearances, keeping the skin
comfortable and preventing further impacts of skin
Skin manifestations of senile AD are identical with aging. The selection of moisturizer in senile AD
the adulthood stage when the diagnosis is patients is different for each individual. In general,
established based on Hanifin-Rajka criteria. Signs moisturizer with emollient-dominant effect will give
of chronic dermatitis can be found on the face and more advantage for senile skin. Additional of
neck including lichenification or exudative lesions active ingredients, the hypoallergenic nature, the
on the trunk, lichenification with or without convenience and practical usage as well as the
pruriginous papules and nodes on the cost are factors to be considered in choosing the
extremities.5 ideal moisturizer for patients.33-35

The senile AD manifestation that can differentiate It is recommended to use topical steroid for acute
between the senile and adulthood stages is the lesion together with topical calcineurin inhibitor in
involvement of elbows and knees. Local order to prevent long term side effects of steroid
lichenification of both areas is uncommon in the treatment. Tacrolimus is more effective than
senile stage unlike the adulthood stage AD. The pimecrolimus for adult patients with moderate to
noticeable feature of the senile stage is severe AD. The adult AD patients can tolerate the
eczematous dermatitis around free-lesion fossa use of tacrolimus for 2-4 years.36
area. The feature is typical for senile stage, but
not for other stages. Another typical feature that The use of topical antibiotics, antiseptics,
has been reported is erythroderma and non- antifungal can be considered in order to reduce
specific chronic dermatitis.1,5-7 the number of bacterial and fungal colonization;
however, care should be taken on the possibility
The atopic stigma other than the above mentioned of developing antibiotics resistance S. aureus.5,36
can still be found in senile AD such as the
Hertoghe’s sign, erythematous and pale face, the 2. Systemic treatment
dirty neck sign and papule with accentuation.1 In senile AD patients, it may be difficult for them to
avoid trigger factors and to apply topical
Management medication optimally as they have reduced daily
activity; therefore, systemic treatment can be
The management of AD in Indonesia consists of 5 considered.
pillars; these are: 3
1. Providing educational and efficient endeavors For acute lesion, short-term oral steroid treatment
for patients and their caregivers (prednisolone 20-40 mg) can be used.5 For elderly
2. Avoiding and modifying the environmental patients, the use should be monitored, particularly
trigger factors and modifying lifestyle for the possibility of increased blood glucose,
3. Strengthening and maintaining the optimal blood pressure, myopathy, osteoporosis, obesity,
function of skin barrier thrombosis, cataract and gastric ulcer. 37
4. Eliminating skin inflammation
5. Controlling and eliminating the scratch-itch A sedative antihistamine (AH) can be used to
cycle. reduce itching; however, precautions must be

J Gen Pro DVI. 2016;1(2):54-61 58

taken on effectiveness and safety for the use in Score of Atopic Dermatitis (SCORAD)
the elderly.5 The first generation of sedative significantly.40-41
antihistamine such as hydroxyzine, clemastine
and dimethindene can reduce cognitive function Non-pharmacological
and is considered as inadequate treatment. The The primary principle of AD treatment is avoiding
second generation of AH, e.g. cetirizine, trigger factors. Food plays little role as a trigger in
desloratadine, loratadine can be the appropriate senile AD patients.33,36 Non-immunological
choice to reduce itching. Administration of second process caused by alcohol and food preservative
generation AH need to consider patient safety can be managed by pseudoallergen diet. It has
principle, particularly patient’s kidney function.37 been reported that 6-week pseudoallergen diet
has provided clinical improvement for 60% of
The antibiotic administration can be considered adult AD patients.5
when there is a serious infection. The choices of
systemic antibiotics are erythromycin, A meta-analysis study has reported the use of
clarithromycin or cephalosporin for 7-10 days. probiotics as a treatment for moderate to severe
Ketoconazole, which is specific for skin yeast is AD patients, both in adults and children. The
recommended for patients with IgE administration of probiotics with Lactobacillus
hypersensitivity; however, the recommendation of species is effective in improving SCORAD of AD
ketoconazole administration still need to be patients aged over one year.42
supported by larger studies.5 The administration of
antibiotics and antifungal should consider patient’s Atopic dermatitis can increase psychological
kidney function and the possibility of interaction of stress and reduce patient’s quality of life
concomitant drug treatment.37 significantly. Psychological stress can also affect
the spouse of senile AD patients. Psychological
The first line treatment for AD patients includes intervention can help healing and can prevent
the abovementioned systemic and topical agents. recurrent AD in elderly patients.32
The second line treatment, which is considered
effective for senile AD is phototherapy, particularly Conclusion
the combination of ultraviolet (UV) UV-A and UV-
B. In addition, for severe AD, cyclosporine may Atopic dermatitis in elderly or senile AD is still
effectively reduce symptoms; however, the rarely reported. Almost all reports have showed
tolerance is lower and there is a higher possibility that the prevalence of senile AD is higher in men
of nephrotoxicity and neurotoxicity in the elderly than women. The most common clinical features
while compared to younger patients.36-37 are dermatitis around the folds of elbows and
behind knees, erythroderma and non-specific
It has been reported that the use of chronic dermatitis. Aeroallergen has a greater role
immunotherapy on Dermatophagoides provides than food or contact allergen in senile AD. The
improved AD. Subcutaneous injection using mite management of the disease is complex since
allergen extract can reduce basophil activation. there are many physiological changes due to
The use of such immunotherapy in the elderly is aging; therefore, treatment must be provided while
not completely established either for its considering effectiveness and safety. The quality
effectiveness or safety.38 of life of AD patients is a very important aspect;
thus, care on the aspect should be taken in
A study has been conducted on dupilumab, a providing AD treatment for the elderly.
monoclonal antibody used in adult AD patients.
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