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Abstract

Purpose: The clinical features of eczema and dermatitis in the elderly have not been fully studied. To investigate the proportion and clinical features of geriatric eczema patients in mainland China.

Patients and methods: A multicenter cross-sectional study conducted in outpatients with eczema from 39 tertiary hospitals in 15 provinces.

Results: 1128 elderly patients (12.88%) had eczema and dermatitis. The mean age of those was 68.2 ± 6.8 years (range, 60–90 years) with a median course of 5.5 ± 8.9 years, which is much longer than that of non-geriatric patients (2.6 ± 4.1 years, p < 0.001). Compared to non-geriatric patients, more patients involved in extremities (76.2% vs 61.5%, p < 0.001) and trunk (37.2% vs 26.4%, p < 0.001), but less in head and neck (18.3% vs 30.4%, p < 0.001; 25.3% vs 20.6%, p < 0.001). 13.4% of eczema and dermatitis in the elderly was widespread, which is much higher than that of 8% in non-geriatric group (13.4% vs 8%, p < 0.001). 22.9% of geriatric eczema patients reported severe itching, which is much higher than that of 14% in counterparts (22.9% vs 14%, p < 0.001). A positive correlation was observed between age and severe itching (Spearman’s rank correlation test, p < 0.001). More geriatric patients had xerosis (39.6% vs 30.4%, p < 0.001) and more lichenification was found (25.6% vs 13.3%, p < 0.001).

Conclusion: More than 10% of eczema occurs in the elderly patients. Longer disease duration, more severe itching, more extremities and trunk involvement, and prone to widespread, xerosis, and lichenification make it a special entity which should be studied further.

Keywords

dermato-epidemiology epidemiological characteristics itch multicenter xerosis

Introduction

Along with the increased longevity, geriatric related disease is a challenge worldwide. China is the most populous country in the world, the National Bureau of Statistics released data showing that at the end of 2019, the total population of the mainland of China was 1400.05 million, an increase of 4.67 million over the end of the previous year. A country is considered to have an aging population when the proportion of the population age 60 over exceeds 10% of the total population or age 65 over exceeds 7%.¹ By the end of 2014, China had an elderly population age 60 or over numbering 212 million; this population accounted for 15.5% of the country’s total population of 1.37 billion, which means that China has passed the threshold for an aging population.² According to the World Health Organization, China’s elderly population (65+) will likely increase to 330 million by 2050, around a quarter of its total population.³ These demographic changes reflect the dramatic social and economic development that has taken place in China since the reform and open-up, along with enhanced medical services and improved nutrition.⁴

In the meanwhile, dermatological diseases in elderly are increasing and thus put a great burden on health-care system. It is important to identify the patterns of geriatric skin disorders for effective delivery of health-care services. A US study found a 10.2% 1-year prevalence of eczema and 3.2% prevalence of atopic dermatitis (AD) in adults by using a population-based approach.⁵ And a study of 34,613 adults (2012 National Health Interview Survey) found the prevalence of “eczema or skin allergy” in the past year to be 7.2%.⁶ The prevalence of adult AD ranged from 2% to 17% in previous international studies.⁷ A recent international, Web-based survey found the prevalence of previously diagnosed and active adult AD ranged from 2.1% to 4.9%.⁸ Research from China has shown that the prevalence of adult AD in outpatients with dermatitis and eczema was 4.6%.⁹ However, clinical features of eczema and dermatitis in the elderly in China have not been regarded as important and studied fully. The goal of this study is to determine the prevalence and clinical characteristics of eczema and dermatitis in the elderly by using data obtained from a hospital-based multicenter cross-sectional epidemiologic survey in Chinese outpatients with dermatitis and eczema.

Material and methods

Data source

This prospective cross-sectional study was performed between July 2014 and September 2014. We approached 9688 outpatients diagnosed with eczema and dermatitis, among whom 9393 (97%) agreed to participate in the study. After eliminating cases with missing information, the final sample sizes used in the analyses are 8758 with complete answers. The subjects were collected from 39 tertiary hospitals in 15 provinces and municipalities in mainland China, those located in latitude 20°01^′–25°N was Guangdong Province; latitude 25°01^′–30°N included Chongqing, Hunan, and Jiangxi Provinces; latitude 30°01^′–35°N included Henan, Zhejiang, Shanghai, Hubei, Jiangsu, Anhui, and Shanxi Provinces; latitude 35°01^′–40°N included Beijing, Tianjin, and Shandong province; and latitude 40°01′–45°N included Liaoning Province, which covered most areas of China.¹⁰ The inclusion criteria were as follows: diagnosed with eczema and dermatitis and informed agreement to participate in the study. Among of them, patients aged 60 years or more were defined as geriatric patients in our study. Exclusion criteria were as follows: patients who were unable to understand the study procedures (e.g., due to mental state).

Study design

This was a cross-sectional study involving a 2-stage process. Stage 1: Each outpatient was inspected by a dermatologist independently. The doctor diagnosed the disease strictly according to the definition of the disease from Andrews’ Diseases of the Skin: Clinical Dermatology 10th edition, simplified Chinese edition, and multiple diagnoses were allowed. Specific types of dermatitis, including atopic dermatitis (based on “UK Working Party criteria), irritant contact dermatitis (ICD), widespread eczema, hand eczema (HE), allergic contact dermatitis (ACD), neurodermatitis, seborrheic dermatitis, nummular eczema, asteatotic eczema, photosensitive dermatitis, autosensitization eczema, dyshidrotic eczema, and stasis dermatitis, were classified based on the International Classification of Diseases (ICD)−10 (eczema ICD-10 codes: L30.902).¹¹ Widespread eczema refers to the involvement of more than three body parts, without clinical features of other specific types of eczema. Stage 2: A questionnaire survey was conducted by dermatologists after a 10–15 min dermatological physical examination. The questionnaire used in this study was pilot-tested and validated.¹⁰ In addition to basic demographic data such as age, sex, and disease duration, a detailed medical history was gathered, with a particular focus on severity of itching, distribution of lesions, and type of skin lesions. History of allergic disease included asthma, allergic rhinitis, allergic conjunctivitis, and AD. Based on the degree of impact on daily activities nor sleep, itching was assessed and divided into four levels: (i) no itching; (ii) mild itching (neither the participant’s daily activities nor sleep was interrupted); (iii) moderate itching (daily activities were interrupted, but sleep was not affected); and (iv) severe itching (both the daily activities and sleep of participants were affected). Secondary bacterial infection was clinically suspected if superficial pustules, prudent exudation, or yellow crust was detected. The questionnaire is available in the supplementary file. Permission to use the questionnaire was obtained from the copyright holder.

Data processing and statistical methods

All data processing and statistical analyses were performed with IBM SPSS version 20 software (IBM, Armonk, NY, USA). As the continuous variables having different distributions, the Kolmogorov–Smirnov test was used to check the normality of data. Mean ± standard deviation was used to describe the data distributions continuous variables. The ages of the patients obeyed normal distributions. But the disease durations of the patients obeyed a skewed distribution. The T-test was used to check the differences in age and disease duration between the elderly group and the control group. The differences in clinic diagnoses, suspected bacterial infections, skin lesion types, type of dermatitis, medical histories, and genders between the elderly group and the control group were checked by the chi-square tests. Differences in itching degrees between two groups were analyzed by the linear-by-linear association test. The relationships between age and itching degrees were analyzed by the Spearman Correlation Analysis. Missing data were excluded from the final analyses. All the analyses were two-tailed tests with the significance level of 0.05.

Results

Respondent characteristics

A total of 1128 elderly patients suffered from eczema and dermatitis, resulting in a prevalence of 12.88% (1128/8758). Clinical characteristics of the examined individuals displayed in different age groups ( ≥ 60 years vs < 60 years) are shown in Table 1. Subjects with geriatric eczema patients were 56% males with a mean age of 68.2 ± 6.8 years (range, 60–90 years). Significantly, longer disease duration was seen in ≥60 years age groups (5.5 ± 8.9 for patients aged ≥ 60 years, 2.6 ± 4.1 for those aged < 60 years, p < 0.001). Unsurprisingly, moderate itching predominance was seen in both groups, and a positive correlation was observed between age and severe itching (Spearman’s rank correlation test, p < 0.001, Figure 1). Severe itching in ≥ 60 years age groups tended to be higher than those of < 60 years age groups (22.9% vs 14%, p < 0.001). In regard to eczema distribution, head and face was observed in ≥ 60 years age groups comprising 18.3%, which is significantly lower than those in counterparts (18.3% vs 30.4%, p <0.001). On aggregate, eczematous dermatitis presented in 25.3% involving the neck, 37.2% involving the trunk, and 76.2% involving the extremities in elderly eczema patients. Furthermore, history of allergic disease was less common in ≥ 60 years age groups (10.3% vs 15.3%, p < 0.001). The proportion of suspected bacterial infection was not high with no statistically significant difference between two groups (16.3% vs 16.6%, p = 0.812).

Table 1.

Baseline demographics of geriatric eczema patients (N = 1128).

Variables	≥60 years (n = 1128)	<60 years (n = 7630)	p-value
Age (y), mean ± SD^a	68.2 ± 6.8	31.4 ± 14.8	<0.001
Disease duration (y), mean ± SD^a	5.5 ± 8.9	2.6 ± 4.1	<0.001
Sex, n (%)^b			<0.001
Male	632 (56)	3803 (49.8)
Female male	496 (44)	3827 (50.2)
Eczema distribution, n (%)^b			<0.001
Head and face	206 (18.3)	2318 (30.4)
Neck	285 (25.3)	1570 (20.6)
Trunk	420 (37.2)	2018 (26.4)
Extremities	860 (76.2)	4690 (61.5)
Itching, n (%)^c			<0.001
No	25 (2.2)	234 (3.1)
Mild	286 (25.4)	2343 (30.7)
Moderate	559 (49.6)	3986 (52.2)
Severe	258 (22.9)	1067 (14)
History of allergic disease n (%)^b	116 (10.3)	1169 (15.3)	<0.001
Suspected bacterial infection, n (%)^b	184 (16.3)	1266 (16.6)	0.812

^aT-test of two independent samples.

^bChi-square test.

^cLinear-by-linear association test. Questions included the following: How old are you? How long have you suffered from this disease? What is your sex? What body locations were involved in? (diagnosed by a doctor). Is there itching? (No: no itching; Mild: neither the participant’s daily activities nor sleep was interrupted; Moderate: daily activities were interrupted, but sleep was not affected; Severe: both daily activities and sleep of participants were affected). Is there history of atopic diseases (asthma; allergic rhinitis; allergic conjunctivitis; atopic dermatitis)? Is there a suspected bacterial infection? (diagnosed by a doctor).

Figure 1.

Relationship between age and itching severity. Notes: * A negative correlation was observed between age and mild itching. # A positive correlation was observed between age and severe itching. Spearman’s rank correlation test, mild itching, p = 0.021; moderate itching, p = 0.135; severe itching, p < 0.001.

Proportion of each type of dermatitis

The proportion of geriatric patients in each type of dermatitis are summarized in Table 2. The leading subtypes of specified eczema and dermatitis in the elderly were widespread eczema, which was up to 151 cases (13.4%), followed by asteatotic eczema and hand eczema (91 cases [8.1%] and 87 cases [7.7%], respectively). Although the proportion of atopic dermatitis in <60 years age groups was quite prominent, there had also maintained a considerable proportion in ≥60 years age groups (8.1% vs 5.4%, p <0.001). In addition, irritant contact dermatitis and allergic contact dermatitis were less common in ≥ 60 years age groups (5.3% vs 9.8%; 3.5% vs 6.2%, respectively). And the proportion of hand eczema, neurodermatitis, and seborrheic dermatitis was relatively high in two groups, and no significant difference was identified (7.7%, 5.7%, 5.4% for patients aged ≥ 60 years vs 6.6%, 5.5%, 5.1% for those aged <60 years, p = 0.166, 0.816, 0.619, respectively).

Table 2.

The proportion of geriatric patients in each type of dermatitis (N = 1128).

Classification^a	≥ 60 years (n = 1128)	< 60 years (n = 7630)	p-value^b
Widespread eczema (765/8758)	151 (13.4)	614 (8)	<0.001
Asteatotic eczema (301/8758)	91 (8.1)	210 (2.8)	<0.001
Hand eczema (590/8758)	87 (7.7)	503 (6.6)	0.166
Neurodermatitis (483/8758)	63 (5.7)	420 (5.5)	0.816
Atopic dermatitis (682/8758)	61 (5.4)	621 (8.1)	0.001
Seborrheic dermatitis (447/8758)	61 (5.4)	386 (5.1)	0.619
Irritant contact dermatitis (810/8758)	60 (5.3)	750(9.8)	<0.001
Stasis dermatitis (123/8758)	55 (4.9)	68 (0.9)	<0.001
Nummular eczema (400/8758)	42 (3.7)	358 (4.7)	0.146
Allergic contact dermatitis (513/8758)	39 (3.5)	474 (6.2)	<0.001
Photosensitive dermatitis (244/8758)	32 (2.8)	212 (2.8)	0.911
Dyshidrotic eczema (220/8758)	23 (2)	197 (2.6)	0.277
Autosensitization dermatitis (221/8758)	13 (1.2)	208 (2.7)	0.002

^aDermatitis and eczema were classified based on the International Classification of Diseases (ICD)−10 (eczema ICD-10 codes: L30.902) [11]. The doctor diagnosed the disease strictly according to the definition of the disease from Andrews’ Diseases of the Skin: Clinical Dermatology 10th edition, simplified Chinese edition, and multiple diagnoses were allowed. In the cases with overlaps, the diagnosis was made based on medical history and clinical features with high accuracy. These results faithfully reflect the actual circumstances in tertiary hospitals of China, which is convenient for appraisal and comparison.

^bChi-square test.

Skin lesion types

Interestingly, the top five common types of skin lesions in the two groups are exactly the same order as follows: erythema, papule, scratches, xerosis, and scales ( ≥ 60 years age groups vs <60 years age groups, 64.1% vs 60.5%, p = 0.022; 48% vs 49%, p = 0.76; 40.3% vs 32.4%, p < 0.001; 39.6% vs 30.4%, p < 0.001; 34.8% vs 26.6%, p < 0.001, respectively, Figure 2). For the latter three, there was significant difference between the two groups. Besides, the proportion of lichenification, nodule, and plaque in ≥60 years age groups were higher than those in <60 years age groups (25.6 vs 13.3%, p < 0.001; 14.6% vs 8.9%, p < 0.001; 20% vs 11.4%, p < 0.001; respectively, Figure 2).

Figure 2.

Skin lesions of eczema outpatients. Notes: * There was significant difference between the two groups, chi-square test, p < 0.05.

Discussion

The World Health Organization defines geriatric population to be above 60 years of age. In China, the legal retirement age is 60 for men and 55 for most women. Thus, 60 years old is generally considered to be the age of the elderly and be labeled an old man. Our study shows that the proportion of geriatric eczema patients is 12.88% (1128/8758), much higher than another study, which out of the total 29,422 patients seen in dermatology department from August 2012 to 2014, 4.7% (1,380) were aged 60 years and above, and erythemato-squamous disorders taken collectively constituted the major skin disorder seen in 38.9% patients.¹² Among the subtypes in our study, widespread eczema (13.4, 151/1128) and asteatotic eczema (8.1%, 91/1128) have higher percentage, which are characterized by large areas of lesions or xerosis. This is determined by the skin characteristics of the elderly. The aged epidermis is frequently associated with multiple important structural and functional impairments. These include, for example, epidermal atrophy due to decreased cellular turnover, slow reepithelization, weaker barrier function, lower mechanical resistance, decreased DNA repair capacity, and lower sweat and sebum production.¹³ Besides decreased elastin and collagen content as well as their structural rearrangement, intrinsic aging also has other consequences such as increase in trans-epidermal water loss, reduction in skin moisture content, diminished sebum production, arteriosclerosis of small and large vessels, thinning of vessel walls,¹⁴ reduction in mast cells,¹⁵ melanocytes, Langerhans’s cells, Meissner cells, Merkel cells and Pacinian corpuscules,^15,16 and increase in skin surface pH¹⁷ after 70 years of age.¹⁸ Furthermore, typical alterations in aging skin involve a reduction of the dermis thickness, a significant expansion of the dermal white adipose tissue as well as modifications of the content and distribution of hyaluronan, impairment of autophagic flux, a reduction of collagen expression, and an increase in tissue inflammation. All of these phenomena can be connected with changes in Cav-1 expression in the aging skin.¹⁹ Another study showed that the NF-κB pathway is of vital importance in skin aging. Excessive free radicals activate the NF-κB signaling pathway and MAPK signaling pathway, contributing to the activation of AP-1 and NF-κB. Then, it increased the level of TNF-α and the expression of MMPs, which induce the degradation of ECM and accelerated skin aging.²⁰ Eczema and dermatitis in the elderly have a wide range of the skin lesions that deserves our attention and studying.

Unexpectedly, atopic dermatitis in ≥60 years age groups maintained a considerable proportion (5.4%, 61/1128). At present, there are some researches about adult-onset atopic dermatitis, but few researches are focused on geriatric atopic dermatitis. Adult-onset AD was found to be present with distinct clinical phenotypes, including less involvement for the flexural areas and a greater predilection for the head/neck, and/or hands/feet.²¹ Whether geriatric atopic dermatitis is present with different lesional morphology and distribution, there are many issues that require further study and discussion.

Moreover, we found an interesting phenomenon that more body locations involved expect head and face in elderly eczema patients, and that explains ICD and ACD had lower proportion in ≥60 years age groups, which head and face were the common site. More than half of the reported cases of ACD related to cosmetics involve the face and the periocular area.²² We suspect that this should be owed to the lack of cosmetics contact history in elderly. Furthermore, it is a consideration that skin reactivity to irritants tends to decrease along with the increase of age.²³

Although intrinsic aging is inevitable, the skin barrier may be specifically adjusted to allow penetration. For this reason, daily skin care may increase skin regeneration, elasticity, and smoothness and thus temporarily change the skin’s condition.²⁴ Age influences the skin reaction pattern to mechanical stress and its repair level through skin care products. Surprisingly, the aged skin has shown better barrier repair capacity compared with the young skin, and also better hydration levels. The basal “inflammatory tone”—represented by erythema—could be the fuel for this repairing property.²⁵ At present, emollient is a routine drug for the treatment of AD, in which important role was not fully realized for eczema and dermatitis in the elderly. The lipid film, which constitutes the main part of residual skin surface components, is essential for skin barrier functions, contributing to water retention, oxidation resistance, and antioxidant transportation, and all these functions decline with age.^26,27 In this quest, scratches, xerosis, and scales are clinical symptoms for eczema and dermatitis in the elderly. Abnormal elongation of the sensory nerve into the epidermis due to drying and inflammation, as well as sensitizing of the peripheral/central nerve, are possible causes of hypersensitivity, leading to itch. ²⁸ In this article, about one in five geriatric eczema patients have severe pruritus, much higher than in the young (22.9% vs 14%, p<0.001). Therefore, it is particularly important to use moisturizer in sufficient quantity and regularly for geriatric eczema patients in addition to drug treatment.

Treatment of moderate-to-severe atopic dermatitis (AD) in the elderly may be challenging, due to side-effects of traditional anti-inflammatory drugs and to comorbidities often found in this age group. Biologics are the latest treatment options available today, but unfortunately, innovative drugs for atopic dermatitis were not yet licensed in China at the time of this survey. An Italian clinical study showed that therapy with dupilumab led to a significant improvement of AD over a 16-week treatment period, with a good safety profile.²⁹ Therefore, dupilumab could be considered as an efficacious and safe treatment for AD also in the elderly. This is a hot topic, and we will study the efficacy and safety of innovative drugs such as dupilumab in more detail in the future.

There are several strengths in our study. First, this is a real-world study, reflecting the clinical actual circumstances of eczema and dermatitis in the elderly in China. Second, as a multicenter research, this is very thorough survey with broader range of coverage. The territory of China is approximately 9.6 million square kilometers, this is the first large-scale investigation of eczema and dermatitis in the elderly. However, our study also has some limitations. First, due to limited conditions, some routine laboratory tests such as whole-blood count and allergens were not performed. Second, no adequate treatment or follow-up were documented in our study. Another limitation is sample size selected for this study was not been calculated, which was relatively small considering the total 1.4 billion Chinese population, and a selective bias was inevitable due to a nonhomogeneous population and differential spatial distribution. All these factors might have led to an unavoidable bias.

Conclusion

In summary, this study provides an informative profile of eczema and dermatitis in the elderly in Chinese outpatients. Some characteristics of geriatric eczema outpatients include longer disease duration, more severe itching, more extremities and trunk involvement, and prone to widespread, xerosis, and lichenification. Future studies are guaranteed to confirm its unique clinical characteristics.

Supplemental Material

sj-pdf-1-eji-10.1177_20587392211069758 – Supplemental Material for Clinical features of eczema and dermatitis in the elderly: A cross-sectional study in mainland China

Supplemental Material, sj-pdf-1-eji-10.1177_20587392211069758 for Clinical features of eczema and dermatitis in the elderly: A cross-sectional study in mainland China by Xin Wang and Lin-Feng Li in European Journal of Inflammation

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is supported by Dermatology Committee, Chinese Association of Integrative Medicine.

Ethics approval

Ethical approval no.2014117 for this study was obtained from Institutional Review Board (IRB) committee of Beijing Friendship Hospital, Capital Medical University.

Informed consent

Verbal informed consent was obtained from all subjects before the study, and written informed consent was waived by the Institutional Review Board/Ethics Committee.

ORCID iDs

Xin Wang

Lin-Feng Li

Supplemental material

Supplemental material for this article is available online.

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