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Older adults frequently suffer from dry, rough, scaly skin. Aging skin becomes thinner and loses water. Dry skin is most common in winter because of low humidity, and it is made worse by other environmental factors, including central heating, irritation from hot water, and frequent washing with harsh soaps and cleansers. Dry skin is usually worst on the legs.

Emollients and skin moisturizers are the best treatment for dry skin. These should be applied immediately after bathing, while the skin is still moist, and used indefinitely to prevent dry skin from returning. Some moisturizers can reduce roughness and scaliness. Taking tepid showers instead of hot baths helps prevent soap and water from removing natural oils and protects skin from heat damage. Corticosteroids can be applied to the skin when irritation or inflammation is severe.

Discoloration, softening, and inflammation in skin folds are common among older adults, especially those who are obese or who have diabetes. The areas most commonly involved include the breast cleavage, belly folds, groin, and arm pits. The medical term for this chronic condition is intertrigo.

Intertrigo is characterized by skin folds that are painful and tend to become red and cracked. The skin folds often have a bad odor. Various bacteria or fungi are usually present on the skin and can lead to more serious infections. Intertrigo is made worse by decreased ability to move, moisture buildup, friction, and poor hygiene.

Diagnosis is based on the characteristic type and location of the skin folds. Treatment consists of keeping the skin open to the air by removing clothing and manually separating the skin folds. A fan, hair dryer, or other source of dry air should be used on affected areas for at least 10-15 minutes several times a day. Applying absorbent powders in the skin folds after bathing (and as needed to keep the area dry) is also helpful. An antifungal cream may be prescribed if the affected area appears to have a fungal infection. Applying steroids to the skin is not usually necessary and should be done only under the supervision of a physician or dermatologist because of the risk of added infection and skin thinning.

Many conditions cause itching. Itching can sometimes be severe, resulting in much discomfort and compromising quality of life (especially sleep).

Itching is most commonly caused by dry skin, which can be easily treated with moisturizers. However, itching can also be caused by a variety of skin conditions, including allergies and infections. In a small percentage of older adults, itching is a sign of an underlying illness. For example, diseases of the kidney, liver, gallbladder (eg, stones), and thyroid can cause itching, as can some types of cancer (eg, Hodgkin's disease). Itching is more likely to be a sign of a serious illness if it begins suddenly and is extremely severe.

Itching all over the body can also be linked to an anxiety disorder, depression, or even psychosis. In one psychosis called "delusory parasitosis," people think that they are covered with parasites, and often vividly describe the movement of insects on their skin. An older person with itching that begins suddenly should visit their healthcare provider for a physical examination and sometimes blood tests. Treatment depends on the underlying cause. Itching can often be relieved with corticosteroids, moisturizers, or menthol or calamine preparations that are applied to the skin. Oral antihistamines should be used cautiously in older adults, because they rarely help and may actually cause a state of confusion, dry mouth, urinary retention, and other side effects.

Skin infections caused by fungi are common, especially in warm climates. Athlete's foot is particularly common, causing itchiness between the toes or a scaliness over the entire sole of the foot. In a fungal infection of the toenail, the nail usually becomes thickened, crumbly, and discolored without other symptoms. Fungal infections can also commonly involve the groin or the hands.

The signs and symptoms of fungal infection are similar to those seen in intertrigo, namely itching, pain, redness, and unpleasant odor. Fungal infections can also cause skin breaks and cracks that can lead to severe bacterial infection under the skin.

Pustules may develop, sometimes on the back or other covered areas where moisture tends to build up. Fungal infection of the mouth (known as "thrush") may develop in people who are on corticosteroid inhalers, antibiotics, or drugs that suppress the immune system. Thrush is also common in some types of medical illness, such as diabetes.

The diagnosis for most common fungal infections is based on history and physical examination. Sometimes, a skin scraping or culture is needed to confirm the diagnosis. Fungal infection can usually be controlled by daily application of antifungal creams or powders. Treatment for 4-6 weeks is generally needed to cure a severe fungal infection of the foot. Chronic nail infections can rarely be totally cured. Prevention consists of keeping the areas dry and improving hygiene. However, fungal infections of the foot tend to come back, and another round of treatment is often necessary.

Any bacterial infection of the skin that is seen in younger people may also be seen in older adults (see also Infectious Illness). However, two skin infections that are especially relevant in older adults are erysipelas and cellulitis.

Erysipelas is seen in very young and very old people who are sick and debilitated. Erysipelas is characterized by red, warm, tender skin areas that are raised, swollen, and have a defined border. Small blisters may occasionally develop. In older adults, erysipelas usually involves the face, and people are very ill with fever, chills, headache, and general distress. There can also be significant eye problems, blood clots within the head, or blood poisoning (septicemia).

Cellulitis is a sudden, red rash that initially involves the layers of the skin. The rash is typically red, tender, warm, and swollen, but the skin areas are not raised and do not have distinct borders (as in erysipelas). Cellulitis can eventually spread to deeper structures below the skin. Cellulitis can develop anywhere on the body but is most frequently seen on the legs of older adults, usually as the result of trauma, poor circulation, diabetes, or swelling. The source of leg infection is most often a crack in the skin between the toes. Cellulitis is a common complication of infected pressure ulcers, bites, scrapes, scratches, puncture wounds, or surgery.

Diagnosis and treatment: These two illnesses are usually diagnosed based on the appearance of the skin. Blood cultures are done to determine if the infection has spread to the bloodstream. These infections are serious and often require hospitalization and intravenous antibiotics. Older adults with cellulitis who are otherwise healthy and do not have involvement of the face can sometimes be placed on oral antibiotics without hospitalization.

Contact dermatitis is a skin rash caused by an irritating or allergic substance. Poison ivy is a familiar example.

Contact dermatitis can result in both immediate and longer-lasting changes in the skin, including redness, liquid-filled blisters (called vesicles), and thickening and scaling. Inflammation may be subtle, especially in aging skin, which often has a slower and weaker inflammatory response.

Treatment focuses on avoiding the offending irritant or allergen. However, sometimes this is difficult to identify. Until the cause is found, prescription creams or lotions that contain a corticosteroid are often used. Creams or lotions are also useful for cuts or skin breaks that weep fluid. Ointments, which are greasier than creams or lotions, are often more soothing and effective for chronic inflammation.

In psoriasis, well-defined red patches on the skin are covered with a silvery scale. Psoriasis is most common in people in their mid-20s and those older than 50 years of age. The problem is rapid and excessive growth of skin cells.

The extent and severity of psoriasis varies widely among older people. In most people, psoriasis is fairly limited and typically consists of a well-defined scaly red plaque on the elbows or knees. Sometimes, this is accompanied by scaling of the scalp or pitting of the fingernails. These pits are small depressions that look as though the nail had been pricked with a pin. Psoriasis is also common in body folds such as the buttocks, especially in those who are overweight. Affected areas can be painful but are usually not itchy. The first patches of psoriasis may appear at any age. However, once red patches appear, psoriasis usually persists indefinitely, switching back and forth between flare-ups and quiet periods.

When psoriasis is extensive, the skin surface layers are lost and replaced rapidly. This means that scales from the surface of the skin are constantly shedding. These scales contain a lot of protein, and so much protein may be lost that dietary protein requirements may increase. In severe cases, the whole skin surface may become covered with psoriasis, causing severe chills because the body is no longer able to regulate temperature. Up to a third of older adults with psoriasis also suffer from psoriatic arthritis, which is characterized by pain, swelling, and stiffness in the small joints. Severe psoriasis can lead to heart failure in people who already have some type of heart disease.

Various factors may trigger psoriasis. Psoriasis sometimes appears on skin that was injured (eg, burned) several days earlier. Other factors that can trigger or worsen psoriasis include infection, stress, and various medications, including oral corticosteroids, lithium, beta-blockers, ACE inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Seborrhea is similar to psoriasis, although the scales are greasy rather than dry and silvery. Seborrhea develops in areas of the body that are rich in oil glands, such as the hairline and scalp, forehead, chest, and the areas behind the ears, or around the eyes. Dandruff may be an early stage of this condition, and treatment often targets the scalp with special shampoos that contain selenium sulfide. Seborrhea is more common in men than in women, and more common in people suffering from HIV (see Infectious Illness) or Parkinson's disease (see Diseases of the Nervous System). The cause is unknown but is thought to involve yeasts that live on the skin.

Treatment: Treatment for psoriasis and seborrhea must be individualized, based on the location and extent of the disease. Corticosteroid creams or ointments applied to the skin rapidly decrease the scaling and often provide good improvement for limited psoriasis with only a few plaques. However, corticosteroids cannot be used long term because they thin the skin and lose their effectiveness over time. A wide variety of other products derived from tar, sulfur, anthralin, retinoids, or other materials are also available. Some of these treatments may be irritating or messy to apply.

People with psoriasis who do not improve with treatments applied to the skin may be helped by more generalized treatment, such as "phototherapy" or immunosuppressive drugs. In phototherapy, a person is exposed to artificial light that contains ultraviolet and infrared rays, under physician supervision several times a week. Even every-day exposure to the sun is helpful. Phototherapy can be combined with agents applied to the skin. Drugs that suppress the immune system (eg, cyclosporine and methotrexate) are effective in treating psoriasis but have significant side effects that require careful monitoring. Side effects may include drug interactions, kidney damage, high blood pressure, and lung disease. It is difficult to cure psoriasis or seborrhea, although both can usually be controlled.

Rosacea (also known as adult acne) is common in fair-skinned adults of all ages. The cause is unknown. A common symptom is facial flushing from many things, including sunlight, alcohol, hot beverages, and drugs that cause blood vessels to relax or widen. Medications such as oral niacin and steroids applied to the skin can often lead to the start of rosacea or make it worse. Usually, the center areas of the face (nose, forehead, cheeks, and chin) become red and splotchy. In more advanced cases, pustules and even cysts can develop. Rosacea can also involve the eye, causing irritation, burning, and redness. Seborrhea is often present as well.

Shingles is a specific type of painful skin rash caused by reactivation of the chickenpox virus (Herpes zoster). This rash is most common in older people or in people whose immune system is not functioning well. People with shingles are contagious to those who have never had chickenpox, and chickenpox (not shingles) can develop in these individuals.

One side of the body is often painful, burns, itches, and can become tender or numb for several days before the rash appears. The first signs on the skin are little groups of blisters (called vesicles) on a patch of reddened skin. These vesicles begin to form scabs and dry out after 7-10 days. The rash usually heals in about 4 weeks, although pain may continue for days or weeks after the skin rash disappears. The rash sometimes involves the eye, leading to vision problems, or the nerves of the ear, leading to hearing problems.

Diagnosis and treatment: Diagnosis is usually based on the characteristic symptoms and rash in a person who once had chickenpox. Material from the weeping vesicles can be stained to confirm the diagnosis.

Shingles usually gets better on its own in healthy older adults, although it can be quite painful. However, drug treatment within 72 hours of the appearance of the rash can have significant benefits, including the following:

Unfortunately, there is no best treatment for the pain that can remain after a bout of shingles. Narcotics, NSAIDs, local anesthetics, acupuncture, and corticosteroids have all been tried with variable success. Tricyclic drugs used for depression or anticonvulsants help in some people. Capsaicin ointment, which contains an extract of hot chili peppers, also helps some people, but others find that it "burns" too much.

Bullous pemphigoid is characterized by large, tense blisters on normal or reddened skin. It is seen almost exclusively in people in their 60s and 70s. The blisters are usually filled with clear fluid but occasionally contain blood. Blisters can be found anywhere on the body, including on the mucous membranes. There may be itchy patches instead of blisters. The cause of bullous pemphigoid is uncertain, but certain drugs can set it off, including diuretics (ie, "water pills"), pain relievers, antibiotics, and ACE inhibitors.

Diagnosis is based on the appearance of the skin and a skin biopsy. Bullous pemphigoid often clears up on its own, although it may last for months to years. Treatment depends on severity. Groups of blisters can be treated with corticosteroids applied to the skin. More extensive disease can be treated with oral corticosteroids and tetracyclines, especially during sudden flare-ups. However, oral corticosteroids can have serious side effects, especially in older adults. Because bullous pemphigoid is mediated by the immune system, drugs that suppress the immune system are often added as steroids are gradually tapered off.

Scabies is caused by a mite, which is a microscopic parasite similar to an insect. Scabies is spread by person-to-person contact. In nursing homes, it can cause epidemics that are difficult to control. Female mites burrow into the top layer of the skin, where they lay eggs. Days to weeks later, infected people develop allergic reactions to the mites or to the mite saliva or excretions.

Most of the time, scabies causes severe itching, especially on the hands, wrists, underarms, abdomen, and groin. The head and neck are almost never involved. Itching can be so intense that people may scratch to the point of bleeding, which increases the risk of secondary skin infection. Red bumps or nodules may show up as crooked, raised lines along the path that the mite digs in the skin.

Diagnosis is confirmed by skin scrapings, in which mite droppings, eggs, or (rarely) the mite itself can be seen under the microscope. Treatment involves killing the mites, decreasing the itching, and treating any people in close contact with the infected person. A gentle insecticide (eg, permethrin) is used to rid the body of mites. Permethrin is applied from the neck to the toes and rinsed off after 8-12 hours. This treatment is repeated in 1 week to kill any mite eggs that hatch during that time. People who are in close personal contact (eg, spouse) with the affected person should also be treated. Bedding, clothes, and towels should be washed with hot water to remove the mites from the surroundings.

Although this treatment plan cures scabies in more than 90% of people, it does not immediately decrease the itching, which can last for weeks to months. Skin moisteners and steroid creams can often improve the itching within a few days. There is also an alternative oral treatment (ie, a drug called ivermectin) for scabies.

Lice are parasitic insects that can infest the body, scalp, or pubic hair. Lice are typically far less common than scabies. Body or head lice spread from person to person through physical contact or by contact with clothing or bedding. Body lice feed on the body, but live on clothing, where they lay eggs, often near the seams. Head lice lay eggs on the base of the hair shafts, which can be visible as white specks called nits. Pubic lice, which are spread by sexual contact, also deposit nits on the pubic hair.

Involved areas are always itchy. Scratching can lead to damaged skin and secondary bacterial infection.

Treatment involves killing the lice, treating people in close contact with the affected person, and treating any secondary infections. Head and pubic lice are killed with a gentle insecticide (eg, pyrethrin or permethrin) applied to the affected areas. These insecticides also kill the eggs, so only one 10-minute treatment is needed. Combs, brushes, hats, clothing, bedding, towels, and anything in close contact with the person must be thoroughly washed in hot water or dry cleaned.

A change in the skin caused by poor circulation is called stasis dermatitis. In this condition, the veins deteriorate. This causes pressure in the veins to increase, swelling, inflammation, and poor blood supply to the skin.

Stasis dermatitis affects the lower legs. Early on, the skin develops itchy, small purple dots about the size of pinheads. These areas are points where blood has leaked from the very small vessels because of the increased pressure in the veins. Over time, the skin surface of the lower legs develops a red-brown color and may become shiny and feel tight. Sometimes, the legs may swell with fluid. If pressing a finger on the skin over the ankle leaves a deep fingerprint behind when the finger is taken away, there is fluid buildup. Minor trauma to these skin areas can result in ulcers that do not heal well because of the poor circulation.

Treatment: The ideal treatment of stasis dermatitis would be to correct the underlying blood vessel problems, although this is rarely possible. The immediate goal of treatment is to help reduce the pressure in the veins by using support stockings, elastic bandages, or other forms of pressure around the legs to help push the fluid back into the vessels. Raising the legs above the level of the heart for periods of time is also helpful. Hydrocortisone ointments are sometimes prescribed to improve the itching and the irritation. However, these ointments should be used with caution because of potential side effects. Long-term use of steroids can also cause the skin to become thinner and possibly result in new skin problems.

Ulcers can be avoided by preventing injury to the lower legs. People who have stasis dermatitis should see their healthcare providers right away for a skin ulcer, even if it is very small. Development of ulcers can also be decreased by making lifestyle changes including increasing exercise, eating a diet low in cholesterol, stopping smoking, losing weight, and better managing diabetes (which is often present).

An ulcer in the lower leg that is neglected or treated with home remedies can enlarge rapidly and have significant complications. Surgical or chemical removal of dead tissue is the key to ulcer healing. Specialized bandages can be used to encourage wound healing. The type of dressing depends on the type of ulcer and the amount of drainage. Surgery of the blood vessels or angioplasty may be necessary to improve blood flow. Oral blood thinners, such as aspirin or clopidogrel, can improve leg circulation, although these drugs do not decrease the risk of new ulcers or speed the healing of existing ones.

Many benign growths develop on the skin. Skin tags, small reddish spots called cherry angiomas, and seborrheic keratoses often appear regardless of the degree of sun exposure. These growths are not a health problem, but they may cause distress from a cosmetic standpoint. Regardless, it is important to remember that any skin growth or discoloration with any of the following characteristics should be evaluated by your healthcare provider to exclude the possibility of a skin cancer:

Small skin tags commonly develop around the neck, under the arms, below the breasts, and in the groin. They are usually ¼-½ inch in diameter and are generally flesh colored. Hereditary factors (genetics) seem to have a significant role in their development.

Cherry angiomas are smooth, dome-shaped red spots about the size of a match head. They are common on the trunk of the body. They usually first appear on people in their 20s, and more develop over time. Cherry angiomas are benign but can bleed when injured.

Seborrheic keratoses are oily, scaly patches or plaques that may become several centimeters in diameter. They commonly develop on the trunk and limbs, but they can be found anywhere on the body. Seborrheic keratoses can be brown to black, waxy, and appear to be stuck to the skin in an irregular, heaped-up manner, although they have smooth borders. Occasionally, a biopsy is needed to make sure the skin patches are not a melanoma, especially if they are darkly pigmented.

Skin tags and cherry angiomas can be easily removed, if desired. Seborrheic keratoses can be left alone or treated, depending on personal preference and advice of your healthcare provider. These growths can be removed by various types of treatments, including surgery.

Actinic keratoses (also called solar keratoses) are caused by chronic sun (UV light) exposure in fair-skinned persons. These growths appear as scaly, red bumps or rashes on sun-exposed areas of the skin, such as the face, ears, and back of the hands and arms. Some feel thick and hard. These growths respond to a variety of treatments, including surgery, freezing, and application of certain medications. Freezing with liquid nitrogen for 10-15 seconds works well but can be somewhat uncomfortable and can cause color changes. Larger growths can be treated at home by applying other strong medications, but these drugs can also cause redness and discomfort.

Most skin cancers are caused by exposure to sunlight. The chance of having a skin cancer increases with age and lifetime sun exposure. The number of skin cancer cases in the United States has gone up a lot over the last several decades, most probably because of the popularity of sunbathing and winter vacations in sunny climates.

Basal cell carcinoma is the most common skin cancer in the United States. As with other skin cancers, fair-skinned persons who have had chronic sun exposure are at risk. Basal cell cancer is generally found on the body surfaces that have received the most sun. This tumor is usually a pearly, dome-shaped growth with small blood vessels that are visible. As the tumor gets larger, an ulcer may develop in the center. Some of these tumors may be pigmented and confused for melanoma, especially in darker-skinned people.

Basal cell cancer rarely spreads to other locations on the body. However, untreated tumors can destroy the tissues that surround them. Treatment depends on the location and tumor characteristics. Surgery is most common. Other treatments include freezing, radiation, and electrodessication. Most treatments provide a 95% or even better cure rate.

Squamous cell carcinoma is the second most common form of skin cancer. It affects people in mid- to late life and is most common on areas that have had chronic sun exposure. This cancer also tends to develop in longstanding, nonhealing wounds and in burn and radiation scars.

These tumors appear as chronic reddened bumps, plaques, or nodules with scales, crusts, or ulcers. They destroy nearby tissues if not treated but have a low risk of spread to other areas. However, the risks of spread and the tumor coming back after removal increase with the following:

Surgery is the most common treatment. Freezing and radiation have also been effective.

Melanoma is the most dangerous form of skin cancer, with the greatest risk of spread to other locations. Melanoma is increasing in the United States, in all adult age groups. Risk factors include the following:

• fair skin
• family history
• having a type of precancer called "dysplastic nevi"
• sunlight exposure, particularly occasional blistering sunburns in childhood

Melanomas usually cause no symptoms, so regular skin examinations and early detection are essential for successful treatment. Most appear as irregularly shaped tan or brown moles (although the color can vary from black to white) anywhere on the body. Melanoma can also appear as a rapidly growing black/grey bump or as a black/brown patch on the palm, sole, or nail bed. Any new pigmented growth or change in the color, size, surface, or borders of a mole you already have should be examined and biopsied by your healthcare provider.

The treatment for melanoma is surgical removal. Lymph node biopsies are often done for melanomas that appear deep or that may have spread. Follow-up chemotherapy is sometime needed.

Prognosis depends largely on how deep the tumor was. Most tumors that are limited to the skin can be completed cured. Tumors that extend into the body fat are more difficult to cure. Melanomas that spread to other locations can rarely be cured.

Protection from the sun (ie, sun block, clothing, hats, etc) should ideally begin in childhood. Early detection is also important, because disability and death from skin cancer are directly related to the size and depth of the tumor at diagnosis. The entire skin surface should be regularly examined for darkened lesions with certain characteristics:

• larger than ¼ inch in diameter
• variable color, such as red, white, blue, and shades of brown
• irregular or notched outline or surface
• ulcers or bleeding

Ideally, this examination should be done by a dermatologist or physician experienced in the diagnosis of skin cancer.