Geriatric Dermatology: Experts Discuss Skin Health in Older Adults and the Role of Technology

The GeriPal Podcast, a platform dedicated to advancing care for older adults, recently hosted a comprehensive discussion on geriatric dermatology, featuring leading experts Eleni Linos, MD, DrPH, and Daniel Butler, MD. The conversation, spanning over an hour, delved into the unique dermatological challenges faced by older populations, the evolving landscape of skin cancer detection and treatment, and the burgeoning role of artificial intelligence in healthcare.

Dr. Linos, an associate dean of research at Stanford University School of Medicine and leader of its Center for Digital Health, and Dr. Butler, a dermatologist and researcher at the University of Arizona, joined hosts Eric Widera, MD, and Alex Smith, MD, to explore a range of topics. The episode underscored the growing need for specialized approaches in dermatology for older adults, highlighting that skin aging is not merely cosmetic but often indicative of underlying health and poses distinct clinical considerations.

The Genesis of Geriatric Dermatology

The discussion began with an exploration of how the distinguished guests became interested in geriatric dermatology. Dr. Butler revealed a pre-existing passion for geriatrics, stemming from his early medical school experiences and the profound influence of his grandparents. He noted that during his time in geriatrics clinics, patients with serious conditions like heart disease or cognitive impairment would often pivot to concerns about skin issues, such as itching or moles. This observation sparked his curiosity about who was addressing these prevalent, yet often overlooked, dermatological concerns in the elderly.

Dr. Linos shared a similar sentiment, influenced by her upbringing in Greece, where elders are highly respected. Her residency in dermatology revealed a significant proportion of patients were older adults, yet the field lacked a distinct focus or subspecialty for this demographic, unlike pediatric dermatology. She identified a gap in tailored approaches and the nascent recognition of "geriatric dermatology" as a field. The serendipitous connection between dermatology and geriatrics, often through spouses who are geriatricians, as highlighted by both Dr. Butler and Dr. Linos, served as a recurring theme and a catalyst for their shared interest.

Addressing Age-Related Skin Changes and Sun Protection

A significant portion of the conversation focused on practical advice for maintaining skin health as it ages. Dr. Butler emphasized the critical role of sun protection in mitigating skin aging and damage. He cautioned against the common misconception that dermatologists advise complete avoidance of the sun, stressing instead the importance of vigilance and protection.

"The sun is certainly a cause of morbidity, mortality, but really it is the cause of most of the aging of our skin that we see," Dr. Butler stated. He recommended consistent use of sunscreen, protective clothing, and seeking shade during peak sun hours. Beyond sun protection, he highlighted the importance of moisturizing. He advised choosing unscented moisturizers in tubs for easier application and emphasized that expensive products are not necessarily superior.

Dr. Linos offered a slightly different perspective, suggesting that for many individuals, a "do nothing until you need to do something" approach to moisturization can be equally effective. She advocated for simpler sun protection strategies like avoiding midday sun, wearing hats, and utilizing protective clothing, particularly for those who find daily sunscreen application burdensome. This nuanced debate underscored that individual needs and preferences play a crucial role in effective skincare.

The Nuances of Skin Cancer in Older Adults

The conversation then shifted to skin cancer, a prevalent concern in older populations. Actinic keratoses (AKs), often described as precancerous lesions, and basal cell carcinomas (BCCs), the most common cancer in the United States, were key discussion points.

Dr. Linos and Dr. Butler clarified the distinction between seborrheic keratoses (SKs), which are benign, and AKs, which have a small but significant risk of progressing to squamous cell carcinoma. Dr. Linos described SKs as brown, round, or oval, bumpy growths, common in older adults and generally harmless. AKs, conversely, are pink, scaly, and often smaller, with a potential to develop into squamous cell carcinoma, estimated at a 2% progression rate over several years.

A critical aspect of the discussion revolved around the over-treatment of low-risk skin cancers in older adults. Dr. Linos recounted a poignant experience during her residency where aggressive treatment of basal cell carcinomas on an elderly veteran’s ear, involving multiple Mohs surgeries, proved unnecessary as the patient died of unrelated causes. This realization spurred her research into the natural history of BCCs, suggesting that many slow-growing, low-risk lesions might be managed with active surveillance rather than immediate intervention, especially in patients with limited life expectancy.

This approach, while gaining acceptance, was noted to have been controversial within the dermatology community, which traditionally favors more aggressive treatment. Dr. Butler echoed this, emphasizing the need to "stop the conveyor belt" of automatic biopsy and excision for all lesions, advocating for a more personalized approach that balances the risks of cancer progression with the patient’s overall health and preferences. He highlighted that Mohs surgery, while effective, can be a significant intervention for older adults, and watchful waiting for low-risk lesions, particularly those on less critical areas like the back, could be a viable option.

The Challenge of Pruritus (Itch) in Older Adults

The discussion also addressed pruritus, or itching, a common and often debilitating symptom in older adults and palliative care patients. Dr. Butler expressed his particular interest in this topic, noting that itch is the most common reason people over 50 seek dermatological care. He explained that the pathophysiology of itch is complex, involving the skin barrier, immune system, and nerves, all of which undergo changes with aging.

He debunked the long-held belief that itch is solely due to allergies, emphasizing that it stems from dysregulation in these three systems. Treatment strategies therefore focus on addressing the specific underlying cause: moisturizing for barrier dysfunction, topical steroids for immune-mediated inflammation like eczema, and nerve-targeting therapies for neuropathic itch.

The concept of "notalgia paresthetica," a localized itch on the mid-back, and "brachioradial pruritus" on the dorsal forearm, were explained as examples of nerve-related itch syndromes. Dr. Butler also touched upon the challenge of generalized itch in older adults, where topical steroids can be used diagnostically and therapeutically, followed by more advanced treatments like biologics for immune-related causes, often with good adherence in older populations due to simpler administration schedules.

Medications and Itch: A Complex Relationship

The conversation touched upon medications that can contribute to itching. Dr. Butler noted that while there isn’t a single drug universally causing itch, calcium channel blockers and ACE inhibitors have been linked to it in older adults, though sometimes this association is due to their widespread use. A more significant current concern is immune checkpoint inhibitors, commonly used in palliative care, which frequently cause itch as a side effect, often requiring immune-modulating treatments.

Notably, traditional antihistamines were discussed with a degree of skepticism. Dr. Butler explained that for most forms of itch, antihistamines have limited efficacy and are not targeted treatments, diverging from the common practice of prescribing them. He emphasized that the geriatric community’s focus on uncoupling the concept of itch from allergy and antihistamines is crucial for more effective management.

The Future of Dermatology: AI and Telemedicine

The final segment of the discussion turned towards the integration of technology in dermatology. Dr. Linos highlighted the rapid advancements in Artificial Intelligence (AI) and its potential to revolutionize skin cancer diagnosis. Studies have shown AI models can diagnose potentially malignant lesions with accuracy comparable to dermatologists. Furthermore, AI has demonstrated the ability to augment physician performance, improving diagnostic accuracy across all levels of medical training.

The challenge, Dr. Linos explained, lies in the effective implementation of these AI tools into clinical workflows. The way AI assistance is presented to clinicians—whether visually or through textual analysis—can influence its effectiveness, depending on individual cognitive processing styles. While current general AI models like ChatGPT may not yet offer definitive dermatological diagnoses from images, specialized tools are emerging.

Telemedicine was also discussed as a growing modality. Dr. Linos affirmed its utility in dermatology, particularly for older adults. Ongoing research is focused on ensuring that older patients can provide high-quality images for remote diagnosis, with initial findings showing promising results, though body location can influence image quality and require tailored instructions. The integration of AI with telemedicine, including full-body dermoscopy analyzed by AI, is seen as an imminent development that could reshape dermatological practice.

In conclusion, the GeriPal podcast episode provided a deep dive into the specialized field of geriatric dermatology. It highlighted the evolving understanding of age-related skin changes, the importance of personalized treatment strategies for skin cancer, and the increasing role of technology in enhancing dermatological care for older adults. The experts underscored the need for a paradigm shift from aggressive intervention to a more nuanced, patient-centered approach, emphasizing the "should we" question in medical decision-making, particularly for older and vulnerable populations.