3.11: Abnormal Changes

The ability of the integumentary system to serve the body is reduced by factors other than aging. While all these factors can affect the integument in the young as well as the elderly, they are more relevant for the elderly. One reason is that older individuals have had more opportunities to be exposed to harmful environmental factors. Sometimes a cumulative effect develops; an excellent example is the effect of sunlight.

Another reason is that the elderly more often have a decline in the functioning of body systems on which the integumentary system depends. For example, the ability of the nervous system to control the size of dermal blood vessels diminishes with age, further reducing the ability of the skin to regulate body temperature. A third reason is the increasing incidence of diseases in body systems on which the skin relies. A common example is circulatory system diseases such as atherosclerosis, which reduces blood supply to the skin. The skin then becomes thinner, weaker, and more susceptible to injury and infection.

Another effect of such factors is that the elderly have a higher incidence of abnormal changes in the integumentary system. Studies have shown that up to 40 percent of otherwise healthy individuals between ages 65 and 74 have at least one skin disorder serious enough to require treatment. Many of these individuals have more than one skin disorder at the same time. It is noteworthy that all these disorders can also be found at least occasionally in the young.

Though almost none of these abnormalities are fatal and almost all are preventable or treatable, they are important in several ways. First, some integumentary system problems alter the structure and functioning of the integument so that it is less able to perform its usual functions. For example, bedsores increase the risk of infection. Second, some problems produce a considerable degree of discomfort. For example, excessively dry skin causes intense itching, which can be so distracting that it disrupts normal daily activities. Finally, some problems, such as excessive wrinkling from prolonged exposure to sunlight, adversely affect the appearance of the skin. (Suggestion 63.0104)

Effects of Sunlight

Sunlight can cause many skin abnormalities. For example, exposure to very strong sunlight for even a few hours can cause sunburn. However, of more concern here are problems that take years to develop because each exposure advances the problem only slightly. The results are apparent only after they have accrued for decades. They are so subtle and widespread that until recently they were widely thought to be age changes. Many researchers believe that the ultraviolet light in sunlight causes these long‑term effects, but other components of sunlight may be more to blame. Energy from UV light damages DNA directly, and UV light promotes free radical (*FR) production in the skin while reducing its *FR defenses. Even short doses (e.g., minutes) of low intensity UV light, which is not enough to cause skin reddening, causes damage to fibroblasts and increases elastin synthesis. Smoking increases the adverse effects from sunlight, probably by reducing blood flow to the skin and by increasing *FR production. Certain cosmetics, medications, and chemical air pollutants also increase *FR formation by UV light.

Chronic exposure to sunlight affects the epidermis in several ways. The keratinocytes reproduce irregularly, and the new cells produced are uneven in shape. This makes the epidermis appear to be uneven in thickness and rough in texture. The irregularity of the cells also seems to contribute to the higher incidence of epidermal skin cancer in the elderly. In addition, the melanocytes become more unevenly distributed, increasing the number of age spots and intensifying the blotchy appearance of the skin. Langerhans cells decrease in number, leading to a reduction in their defense capability. Finally, sweat gland function declines.

The dermis is also changed by years of exposure to sunlight. There is a net loss in collagen, and the remaining collagen becomes weaker. Elastin fibers become more numerous but also become very irregular in shape and arrangement from excess cross-links, and many develop unusual thickenings. Production of abnormal molecular complexes in the gel reduce its ability to hold water. These changes may be a main reason for the excessive wrinkling of sun‑exposed skin.

Unlike elastin fibers, dermal blood vessels in sun‑exposed skin decrease in number, leading to a reduced blood supply to the skin. The capillaries that remain have thicker walls, and this may further reduce the vital movement of material between the blood and skin cells. In addition, certain materials, such as topically applied chemicals and antibodies produced by the immune cells, tend to accumulate within the skin. These materials can injure and irritate the skin, leading to discomfort and blistering.

Sunlight also affects the sebaceous glands, causing them to enlarge considerably. Some become so large that they become visible as unattractive comedones (blackheads).

Obviously, all the effects of long‑term exposure to sunlight are detrimental. All can be prevented by shading the skin from repeated and prolonged exposure to sunlight. This can be done easily by wearing appropriate clothing, hats, and sun screen lotions that block most of the harmful rays. Protection while in water is also important because water blocks only some UV light. Sun screen lotion with an SPF15 is adequate to absorb almost all harmful UV light. Lotions with higher SPF provide very little additional protection. The benefits from protecting skin from excess sunlight include more attractive and healthier skin and a reduced risk of cancer.

It may be possible to prevent UV and other types of oxidative damage to the skin by using topical or oral supplements to increase the skin's *FR defenses. Research suggests that the best method may be a combination of oral supplements of selenium, vitamin C, vitamin E, and β-carotene. Supplements must be used carefully to avoid some toxic effects and to prevent additional *FR formation by unbalancing *FR defenses.

Treatments for cosmetic effects from photoaging of skin include alpha-hydroxy acid peels (e.g., glycolic acid), carbon dioxide laser treatment, and cryotherapy for epidermal color problems. Glycolic acid treatment requires months of regular applications and visits to a dermatologist's office. Beneficial may include smoothing and thickening of the epidermis; reduction in comedones, small wrinkles, and age spots; and thickening of the dermis. Undesirable side effects can include redness, itching, burning, scabbing, pain, and tightness, which may take from a few days to a week to subside after each treatment. Other possible problems include scarring and reactivation or spreading of Herpes I sores and warts.

Topical application of a vitamin A derivative called tretinoin (i.e., all-trans tretinoic acid) can help reverse the effects of photoaging, and it also reverses normal age changes. Benefits in the epidermis include thicker, smoother, and more dense epidermis; reduction in abnormal keratinocytes and uneven skin color (e.g., age spots); and faster healing when used for weeks or months before surgery or injury. Thickening of the epidermis is temporary. Benefits in the dermis include increases in normal collagen; in capillaries; in dermal vessels dilation; in number and length of dermal papillae; and in attachment of the dermis to the epidermis. Tretinoin treatment also reverses normal age changes and adverse effects from reduced blood flow.

Tretinoin seems to act by stimulating DNA synthesis and tissue growth factors. There seems to be no risk of abnormal cells, precancerous cells, or cancer. The new cells seem to be even more "normal" than the normal but somewhat altered keratinocytes and melanocytes in photoaged skin.

Tretinoin may be applied topically or by injections. A combination of injections plus topical treatment may be best in some situations. Treatment can cause some temporary redness and discomfort, and treatments may require months to complete.

Effects from heat

Chronic exposure to heat produces the same effects as photoaging except that chronic heat does not cause formation of excess and abnormal elastic fibers. Chronic exposure to heat can occur in work places, in unevenly heated living spaces, and when using localized heaters (e.g., heating pads).

Bedsores

Another largely preventable skin problem is bedsores (decubitus ulcers), patches of skin that have died because they received insufficient blood flow. The main cause is pressure, which compresses the blood vessels in the skin so that little or no blood flows through them. If blood flow is reduced for more than 2 hours at a time, the skin cells die and peel away, leaving an open wound (Figure 3.4 ).

Figure 3.4 Bedsores (a) Common locations (b) Stages (Copyright 2020: Augustine G. DiGiovanna, Ph.D., Salisbury University, Maryland. Used with permission.)

Many factors contribute to the formation of bedsores. Because the elderly are more likely than the young to encounter many of these factors at more intense levels, there is an increased incidence of bedsores among the elderly. The most important of these factors is immobility, because the weight of the body puts enough pressure on the skin to cut off blood flow through skin vessels. The most susceptible parts of the body are the buttocks and the heels because sitting or lying puts pressure on these areas. The elderly are more likely to find themselves in these positions for long periods because of disabling diseases such as strokes.

Other factors that increase the possibilities of developing bedsores include normal weakening of the skin; thinning of the subcutaneous fat; diseases of the circulatory system that reduce blood flow; poor nutrition; and poor skin hygiene. All these factors are more prevalent among the elderly. Physical forces on the skin, such as friction and uneven distribution of weight, also contribute to the formation of bedsores.

Once a bedsore has formed, it may become deeper and penetrate through the dermis and the subcutaneous layer. Bedsores heal very slowly if at all. Those that heal are likely to recur.

Bedsores often become infected because the barrier against microbes has been broken. The reduced blood flow also leaves the skin with weak defense mechanisms. Finally, bedsores can be quite painful and can be repugnant for care givers and others.

With proper preventive measures, bedsores can be largely avoided. Frequent changes in position, the use of soft supporting materials that distribute body weight evenly, and good hygiene can greatly reduce the occurrence of these undesirable skin afflictions.

Neoplasms

Sometimes the production of new cells in the skin gets out of control. Instead of producing the number of cells needed and then stopping, cell production continues unabated. This condition is called a neoplasm. If the extra cells stay tightly together in one place, the mass is called a benign neoplasm (Figure 3.5 ). This type of neoplasm is usually not very harmful. However, if the cells begin to spread out or move to other parts of the body, they constitute a malignant neoplasm or cancer (Figure 3.5 ). Cancer is much more likely to cause serious problems because it disrupts the structure and functioning of any body part it invades.

Figure 3.5 Skin neoplasms (a) Benign neoplasm (b) Malignant neoplasm (Copyright 2020: Augustine G. DiGiovanna, Ph.D., Salisbury University, Maryland. Used with permission.)

In the skin, both types of neoplasm occur considerably more frequently as people get older. Furthermore, the elderly have more cases of cancer of the skin than cases of all other forms of cancer combined.

There are many reasons for the high incidence of skin neoplasms among the elderly, and they correlate with other age‑related changes in the skin. These changes include age changes such as (1) increased irregularity in the cells produced, (2) reduced number of Langerhans cells, (3) decreased amounts of melanin, (4) a decreased inflammatory response, which can warn of the presence of noxious carcinogens, and (5) slower removal of materials such as carcinogens. Note that all these changes are amplified by exposure to sunlight and that sunlight itself causes neoplasms. Therefore, protecting the skin from long‑term exposure to sunlight can significantly reduce the risk of developing skin neoplasms.

Benign Skin Neoplasms

Common benign neoplasms of the elderly include basal cell papilloma, also called actinic keratosis, keratoses, senile warts, and seborrheic warts, appearing as round somewhat elevated flattened darker spots; squamous papilloma and clear cell acanthoma, appearing as small round elevations. Other benign neoplasms of the skin usually appear as small protrusions of the epidermis. These neoplasms are usually only of cosmetic importance and can be easily removed with simple surgical procedures. Removal may be desirable for cosmetic reasons and to avoid possible injury to the protruding skin, which could lead to discomfort and infection. Finally, removal of benign neoplasms is often recommended because they may become malignant.

Malignant Skin Neoplasms

Common malignant skin neoplasms include basal cell carcinoma and squamous cell carcinoma. The first type is the most common. It appears as a slow growing light-colored spot, which develops into a sore that will not heal. Squamous cell carcinoma appears as thickened areas with irregular surfaces. Both types develop from keratinocytes. Because their cells are not well attached to each other, these malignant neoplasms can weaken the skin, greatly increasing the risk of injury and infection. As they spread, they affect larger areas of the skin. Fortunately, they are easily detected while still in the early stages of growth and can then be removed by means of simple surgery.

Malignant melanoma is a third type of skin cancer. It is usually caused by exposure to sunlight. Malignant melanoma derives from the melanocytes, and often appears as dark irregular mottled spots that enlarge. Though less common than the other two skin cancers, it is a very serious and often life‑threatening cancer. It grows very rapidly and spreads quickly to many other organs. Wherever it is found, it displaces the normal cells in the area, causing that part of the body to stop functioning normally. It also weakens body parts so that there is an increased risk of infection. Malignant melanoma can be cured if it is removed before it enlarges and spreads.

Melanoma causes more deaths from skin cancer than all other types of skin cancer combined. The number and rates of death from melanoma have increased several fold over the passed 50 years, including among the elderly. Still, the elderly have a greater age-related increase in deaths from non-melanoma skin cancers and a greater total mortality from non-melanoma skin cancers than from malignant melanoma. This trend may result from earlier deaths of those most susceptible to melanoma.

Since skin cancers can become dangerous quickly, early detection and treatment are essential. Knowing the warning signs of skin cancer and noticing them when they appear can help. The signs include any unusual lump or thickening, any sore or wound that does not heal quickly, the appearance of dark spots, and any change in the shape or size of a wart, mole, or other dark spot. Any dark spot that develops a rough texture or an irregular outline is especially noteworthy. All suspicious areas should be reported immediately to a physician for further diagnosis and appropriate treatment.