CLINICAL STUDY OF GERIATRIC DERMATOSES

Dissertation submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY, CHENNAI

With Partial fulfillment of the regulations

For the award of the Degree of
MD BRANCH XX
Dermatology, Venereology and Leprosy
MADRAS MEDICAL COLLEGE, CHENNAI

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY, CHENNAI,

TAMILNADU

APRIL 2017
 CERTIFICATE

Certified that this dissertation entitled “CLINICAL STUDY OF GERIATRIC

DERMATOSES” is a bonafide work done by Dr.M.VAIRAPRABHA DEVI,

Postgraduate student of Dermatology Venereology and Leprosy, Madras Medical

College, Chennai, during the academic year 2015-2017.

Prof. Dr. U.R.DHANALAKSHMI, Prof. Dr. M.K.MURALIDHARAN,

M.D.,D.D.,DNB, M.S.,M.Ch. (Neurosurgery),
Professor and Head, Dean,
Department of Dermatology, Madras Medical College,
Madras Medical College, Chennai - 03.
Chennai – 03.
 DECLARATION

The dissertation entitled “CLINICAL STUDY OF GERIATRIC

DERMATOSES” is a bonafide work done by Dr.M.VAIRAPRABHA DEVI at

Department of Dermatology, Venereology and Leprosy, Madras Medical College,

Chennai – 3, during the academic year 2015 – 2017 under the guidance of

Prof.Dr.V.SAMPATH M.D., Professor, Department of Dermatology, Madras Medical

College, Chennai -3.

This dissertation is submitted to The Tamil Nadu Dr. M.G.R. Medical University,

Chennai towards partial fulfillment of the rules and regulations for the award of M.D

Degree in Dermatology Venereology and Leprosy (BRANCH – XX)

Prof. Dr. V. SAMPATH, M.D.,

Professor,

Department of Dermatology,

Madras Medical College,

Chennai-03.
 DECLARATION

I declare that this dissertation entitled “CLINICAL STUDY OF GERIATRIC

DERMATOSES” has been conducted by me at Government Madras Medical College. It

is submitted in part of fulfillment of the award of the degree of M.D ( D.V.L.) for the

April 2017 examination to be held under The Tamilnadu Dr.M.G.R Medical

University, Chennai. This has not been submitted previously by me for the award of any

degree or diploma from any other University.

Place :

Date : (Dr.M.VAIRAPRABHA DEVI)

 ACKNOWLEDGEMENT

I express my sincere thanks to Prof. Dr.M.K.MURALIDHARAN, M.S., M.Ch.

(Neurosurgery), Dean, Madras Medical College, Chennai - 03 for allowing me to

conduct this study using the available facilities.

I am greatly indebted to Prof. Dr. U.R.DHANALAKSHMI, M.D., D.D., DNB,

Professor and Head, Department of Dermatology, Madras Medical College, Chennai for

her able guidance and encouragement throughout the study.

I am grateful to Prof. Dr. S.KALAIVANI, M.D., D.V., Professor and Director In-

charge, Institute of Venereology for her valuable support and motivation.

I am greatly indebted to my Guide Prof. Dr. V.SAMPATH, M.D., Professor,

Department of Dermatology, Madras Medical College, for his invaluable guidance and

suggestions throughout the study period.

I express my sincere gratitude to Prof. Dr. S.KUMARAVEL, M.D., D.D.,

Professor, Department of Dermatology, Madras Medical College, for his encouragement

and suggestions.

I express my sincere thanks to Prof. Dr. S.NIRMALA, M.D., Professor,

Department of Occupational Dermatology, Madras Medical College, for her kindness and

support.
 I humbly thank Prof. Dr.R.PRIYAVATHANI, M.D., D.D., DNB., Professor,

Department of Occupational Dermatology, Madras Medical College, for her advice and

encouragement.

I sincerely thank Prof. Dr. A.RAMESH, M.D., D.D., DNB (DVL)., Professor,

Department of Dermatology, Madras Medical College, for his help and support.

I am grateful to Prof. Dr.J.MANJULA, M.D., DNB., Professor,

Department of Dermatology, Madras Medical College, for her kind suggestions and

support.

I am thankful to Prof.Dr.S.SIVAKUMAR, M.D.(Geriatric Medicine), Professor

and Head, Department of Geriatrics, Madras Medical College, for his valuable guidance

and support.

I also thank Prof. Dr.K.MANOHARAN, M.D., D.D., former Professor and

Head, Department of Dermatology, Madras Medical College, for his advice and

encouragement.

I also thank Prof.Dr.THILAGAVATHI, M.D.,D.V., former Director(I/c),

Institute of Venereology, Madras Medical College for her suggestions and support.

I would like to thank Prof.Dr.C.JANAKI, M.D.,D.D., former Professor,

Department of Dermatology, Madras Medical College for her advice and help.

I express my sincere gratitude to my Co-Guide Dr.C.L.CHITHRA, M.D.(DVL),

Assistant Professor, Department of Dermatology, Madras Medical College, for her

valuable guidance and support throughout the study.

 I would also like to thank the Assistant Professors of Department of Dermatology,

Madras Medical College, Dr. R.MADHU, M.D.(Derm), D.C.H., Dr.V.N.S.AHAMED

SHARIFF, M.D.(DVL), Dr.SAMUEL JEYARAJ DANIEL, M.D.(DVL),

Dr.B.VIJAYALAKSHMI, M.D.(DVL), Dr.K.UMA MAHESWARI, M.D.(DVL),

Dr.R.MANIPRIYA, M.D.(DVL), D.C.H., and Dr.K.DEEPA, M.D.(DVL) for their

invaluable suggestions and guidance throughout the study.

I would like to thank the Assistant Professors of the Institute of Venereology,

Madras Medical College, Dr.P.PRABHAKAR, M.D.(DVL), Dr.C.VIDHYA,

M.D.(DVL), Dr.R.HEMAMALINI, M.D.(DVL), Dr.H.DHANASELVI, M.D.(DVL),

Dr.K.GAYATHRI, M.D.(DVL), Dr.E.BALASUBRAMANIAN, M.D.(DVL) and

Dr.R.SNEGAVALLI, M.D.(DVL) for their support and guidance.

I express my sincere thanks to my former Assistant Professors

Dr.N.SARAVANAN, M.D.(DVL), Dr.NITHYA GAYATHRI DEVI, M.D.(DVL),

Dr.S.VENKATESAN, D.V., DNB(DVL) and Dr.V.GOMATHY, M.D.(DVL) for their

guidance and support.

I also thank my colleagues, friends and staff of our hospital for their help and

support.

Finally, I would like to thank all the patients who whole-heartedly gave their

consent and cooperation for this study.

 CONTENTS

S.No CHAPTER PAGE NO

1. INTRODUCTION 1-2
2. REVIEW OF LITERATURE 3 - 37
3. AIMS AND OBJECTIVES 38
4. MATERIALS AND METHODS 39 - 43
5. RESULTS AND ANALYSIS 44 - 77
6. DISCUSSION 78 - 91
7. CONCLUSION 92 - 93
8. ANNEXURES
 BIBLIOGRAPHY
 PROFORMA
 INFORMED CONSENT
 ETHICAL COMMITTEE CERTIFICATE
 PLAGIARISM
 ABBREVIATION
 MASTER CHART
INTRODUCTION
 INTRODUCTION

Thanks to the staggering advancement in healthcare in recent times the

average life span of human beings is getting expanded further and further. Hence

the number and proportion of persons living well beyond their prime is

continuously on the rise (1).

Based on the projections from the current rate of population growth it has

been proposed that by the year 2050 the geriatric population of India will be more

than the entire population of the United States (2).

This recent onset demographic shift is posing a new diagnostic and

therapeutic challenge to the health care providers since the physiological and

pathological implications of ageing has hitherto been understudied.

Akin to machines human body is also subject to the usual wear and tear of

ageing. This leads to progressive decline in the function and reserve capacity of

all the organs in the body.

Skin, the largest and most visible organ of the body bears the brunt of

being the beacon of ageing. This alteration in skin appearance may be because of

intrinsic or extrinsic ageing.

Intrinsic ageing or the so called “True Ageing” is an inevitable process that

occurs with the passage of time. This is due to the predetermined genetic program

in the mammalian cells which reach a state of ‘Replicative Senescence’ after a

fixed number of mitotic divisions.

1
 On the other hand, extrinsic ageing or “Photoageing” is attributable to

chronic environmental insults which are amenable to modification and prevention.

Moreover the immune response in older individuals is poor which

predisposes them to have a greater susceptibility to skin infections. Also, the

incidence of cutaneous neoplasms increases manifold due to this slack immune

response.

Wound healing process is impaired because of reduced inflammatory and

immune response, delayed replenishment of blood vessels and diminished

collagen degradation.

So far only a very few studies have been done in India regarding the

physiological and pathological changes occurring in geriatric skin. Of particular

note is the relative paucity of studies done in South India.

A study regarding the physiological and pathological cutaneous

manifestations of ageing is the need of the hour which will provide more insight

into this relatively uncharted area of dermatology.

Hence this study “Clinical Study of Geriatric Dermatoses” has been

undertaken to fulfill the aforementioned intents.

2
REVIEW OF
LITERATURE
 REVIEW OF LITERATURE

Ageing is a process of progressive reduction in the maximal functioning

and reserve capacity of all organs in the body, including the skin(1). This

functional decline is further compounded by environmental insults such as

ultraviolet and infrared irradiation. These irradiations along with the pollutants in

urban air together act as environmental carcinogens.

Cellular ageing occurs both due to pre programmed genetic signaling as

well as cumulative environmentally imposed damage. Ageing induced arrest in

cell division has been identified as the most important mode of cancer prevention

in multi-cellular animals, particularly mammals by which there is restriction of

unregulated and unlimited growth of DNA damaged senescent cells (3).

Thus it becomes implied that the more proficient the DNA repair capacity

of the cell, the more prolonged would be its life span. Also, there is a negative

correlation between the basal metabolic rate and life span of an organism.

Furthermore, the cumulative oxidative DNA damage due to aerobic metabolism

augments the ageing process.

Mechanisms of ageing:

Telomeres are the terminal portions of all eukaryotic chromosomes and

mammalian cells consist hundreds of tandem TTAGG short sequence repeats.

3
 During mitotic cycle in a somatic cell, the DNA polymerase will not be in

a position to replicate all the final base pairs of each chromosome. This results in

progressive shortening of base pairs with each mitotic cycle. This can be

prevented by Telomerase, a special reverse transcriptase present in stem cells and

germline cells which can replicate these chromosomal ends. But this enzyme is

present in very low levels in somatic cells. The rate of cell division also affects the

size of telomeres. The relatively quiescent cutaneous fibroblasts and melanocytes

usually have longer telomeres than the more active keratinocytes.

If the telomere level in the cell falls below a certain critical threshold, the

signal for apoptosis is triggered resulting in death of the cell. Thus telomeres serve

as a biologic clock that determines the life span and functional level of all cells.

DNA damage and Ageing:

Even in organisms with very astute DNA repair mechanisms, not all

damages are plausible for repair and damaged DNA accumulates in the cells

leading to defective cellular function.

It has been postulated that by shifting the energy utilization of a DNA

damaged cell from growth and proliferation has a distinct survival advantage in

preventing the occurrence of cancer. Epigenetic events like DNA methylation are

affected in ageing and this leads to impaired function of tumour suppressor genes

which results in increased incidence of cancer(3).

4
Immune system and ageing:

The major functions of the immune system are:

1. Defending against external insults

2. Immunological surveillance

The problems facing the immune system in ageing include:

1. Decreased T cell memory

2. Defective cellular and humoral immunity

3. Loss of naïve T cell population

There is an increased susceptibility to environmental insults owing to the

increased auto-reactivity, chronic inflammatory state and decreased immunity to

exogenous antigens.

The increased levels of proinflammatory reactive oxygen species within

cells leads to oxidative stress which leads to low grade inflammation. The

compromise in mitochondrial electron transfer in oxidative phosphorylation leads

to leakage of the reactive oxygen species into the cytoplasm.

This increase in reactive oxygen species is the major contributing factor of

decline in innate immunity and sluggish adaptive immune response. All these

changes in toto ultimately result in the increased susceptibility to infections and

malignancies in geriatric individuals.

5
Skin ageing:

Ageing of skin occurs due to two different mechanisms namely intrinsic

and extrinsic.

Intrinsic ageing is a universal process occurring as a consequence of

passage of time alone and is supposedly inevitable. It is manifested by physiologic

alterations in both healthy and diseased skin.

Extrinsic ageing on the other hand is largely a result of chronic sun

exposure and environmental insults. Hence it has been rightly labelled as

photoageing (Dermatoheliosis). It has both physiological and morphological

manifestations and is amenable to prevention or modification.

Intrinsic skin ageing:

Intrinsic ageing is manifested in its purest form in upper inner aspect of

arms, hips and buttocks - the sites which are usually protected from sun exposure.

The salient features of intrinsic ageing are:

1) Dryness

2) Laxity

3) Wrinkling

3) Atrophy

4) Sagging

5) Sparse grey hair

6) Dyspigmentation

6
 A lot of histological changes occur in the skin with intrinsic ageing. In the

epidermis, there is flattening of dermal-epidermal junction, decrease in thickness,

size and shape with occasional nuclear atypia and decrease in the number of

melanocytes and Langerhan’s cells.

There is atrophy and shortened capillary loops of dermis with fewer

fibroblasts, mast cells and blood vessels. Hair loss and depigmentation are

common along with conversion of terminal hair to vellus hair. The nail plates will

be abnormal and the glands in the appendages will be fewer.

The most accepted theory of intrinsic ageing is that there is a continuous

generation of free radicals because of aerobic metabolism which leads to

repetitive DNA damage. When the DNA repair mechanisms are exhausted or

overwhelmed the cell becomes senescent and turns apoptotic(3).

Oxidative stress leads to alteration in terminal portion of the telomeres and

increase in stress regulatory protein levels. These led to accumulation of degraded

proteins and they interfere with normal cellular function ultimately culminating in

cell death.

Cellular senescence, thought to be an evolutionary check mechanism to

prevent unlimited division of cells, restricts the number of times a cell can

replicate. Older cells have shorter telomeres, impaired resistance to apoptosis,

over expression of genes which block cell cycle progression and decreased levels

of tissue inhibitors of MMPs.

7
The functions of skin that decrease with ageing are:

1) Barrier function

2) Epidermal hydration

3) Mechanical protection

4) Thermoregulation

5) Sebum production

6) Sensory perception

7) Sweat production

8) Vitamin D synthesis

9) Immune responsiveness

10) DNA repair

11) Cell replacement

12) Wound healing

13) Chemical clearance

Extrinsic Ageing:

Extrinsic ageing is commonly labelled as photoageing and usually results

from the damaging effects of UV light exposure. It is characterized by the

following:

1) Thick, dry and rough skin

2) Deep wrinkles with actinic keratoses

3) Irregular freckling

4) Lentigines

8
5) Citrine skin (Milian)

6) Sebaceous hyperplasia

7) Nodular elastoidosis with cyst and comedones (Favre Racouchot syndrome)

8) Senile Purpura

9) Cutis rhomboidalis nuchae (Jadassohn)

10) Diffuse elastoma (Dubreuilh)

11) Elastotic nodule of ear

12) Acrokeratoelastoidosis marginalis

13) Stellate Pseudoscars

14) Dyspigmentation

15) Fine elasticity

16) Fine nodularity

17) Venous lakes

18) Telangiectasia

19) Actinic granuloma

20) Actinic comedonal plaque

21) Striated beaded lines

Dyspigmentation in photoageing is manifested either as hypopigmentation

or hyperpigmentation. Photoageing is commonly seen in the most sun exposed

areas namely - face, upper chest, extensor aspect of forearms, dorsal aspect of

hands and neck(4).

Elastosis is the most important feature of photoageing characterized by

yellow discolouration of skin. Histologically it shows tangled masses of degraded

9
elastic fibres and amorphous mass composed of damaged tropoelastin and

fibrillin(5).

Wrinkling is manifested as fine surface lines, deep furrows, stellate

pseudoscars, elastosis, inelasticity, telangiectasia, venous lakes, purpura,

comedones and sebaceous hyperplasia.

Skin Types: (4)

Skin colour on Sunburn Tanning Skin cancer

Skin Type
sun-protected site risk ability risk

I White ++++ +/- High

II White +++ + High

III White ++ ++ Moderate

IV Olive + +++ Moderate

V Brown +/- ++++ Low

VI Black/Dark brown +/- ++++ Low

As it turns out, photoageing doesn’t occur in a similar manner among

individuals with same age reflecting the predetermined genetic differences in the

vulnerability and repair ability of skin following sun exposure. Similarly,

photoageing occurs not only in fair skinned individuals belonging to skin

phototypes I and II but also in persons with darker cutaneous phototypes III and

IV. Asymmetrical photoageing in face has also been demonstrated with the side

exposed to sun ageing prematurely than the less exposed side. For instance, the

10
side of face exposed to sun during driving ages more than the other less exposed

half(4).

Although the site of photo-damaged skin is similar (face, neck and extensor

aspect of upper extremity) in both fair and dark skinned individuals the gross

appearance differs. While atrophic and dysplastic changes like actinic keratoses

and epidermal malignancies are common in fair skinned individuals, hypertrophic

changes like furrowing, coarseness and lentigenes are common in dark skinned

individuals.

Traditionally UV-B has been considered to be more damageing then UV-A

in a dose to dose comparison. But the sheer abundance of UV-A content in

sunlight leads to greater penetration of the dermis. Even then, UV-B photons are

1000 times more energetic than UV-A photons and they cause more DNA damage

resulting in photocarcinogenesis, sun tanning and sun burn.

Most of the age related decrements in the functions of skin like delayed

wound healing and reduced immunoresponsiveness are also augmented by sun

exposure.

Other contributors to extrinsic ageing :

Cigarette smoking is an important contributor to extrinsic ageing. Smokers

tend to have more wrinkles, gray hairs and delayed wound healing. Compounded

with Vitamin A deficiency, cigarette smoke leads to increased dryness, atrophy

and risk of malignancy(5).

11
Epidermis:

The most characteristic feature of cellular ageing in epidermis is the

flattening of dermo-epidermal junction and effacement of epidermal rete pegs and

dermal papillae. The net effect is reduced surface area of communication between

dermis and epidermis resulting in less efficient nutrient transfer. Hence even

minor trauma can lead to dermal-epidermal separation explaining the injury prone

nature of older skin.

Epidermis starts to thin from as early as third decade which progresses

relentlessly further and further. There is an overall thinning of epidermis to the

tune of 50%. There is an increase in senescent epidermal keratinocytes with

advancement in age which are resistant to apoptosis. These keratinocytes

accumulate mutations and are prone for malignant transformation (3).

Defects in the synthesis of cholesterol results in decreased hydration and

diminished lipid content in stratum corneum. Thus, ageing leads to reduction in

percutaneous absorption of lipid soluble drugs. Of greater significance is the

insufficient repair of the barrier function due to reduction in lipid content.

Epidermal filaggrin is markedly reduced in the elderly throughout the body

and it is more pronounced in the lower limbs. Filaggrin is vital for macrofibril

formation of keratin filaments. This leads to the dry and scaly looking skin in the

elderly. The barrier function of epidermis might also be affected by this change in

filaggrin content.

12
 Thymidine labelling index and epidermal turnover rate decreases gradually

as age advances. Hair and nail growth rate also falls and the replacement interval

of stratum corneum increases. So after injury there is a significant delay in wound

healing.

Ageing also leads to a reduction in the number of enzymatically active

melanocytes. This leads to reduced protection against sun exposure and increased

risk of injury from UV rays. This coupled with the reduced ability of damaged

DNA repair leads to the manifold increase in cutaneous cancer risk.

The epidermal Langerhan cell count is reduced drastically with

advancement in age. Since these cells are a very important line of defence against

foreign pathogens their reduction in number means increased propensity to

infection. These coupled with the reduction in cytokine production by

lymphocytes leads to diminished immune responsiveness in geriatric patients.

Another important function of human skin is the production of Vitamin D

from sunlight. The level of epidermal 7-dehydro-cholesterol, an essential

component in the manufacturing process of vitamin D is reduced in elderly.

Consequently, they tend to have lower levels of Vitamin D in the serum.

Vitamin D is well known for its role in calcium homeostasis but it plays an

important role in encoding the proteins of the Wnt signaling pathway. This

pathway is vital for the formation of cornified epithelium and growth of hair.

Hence the reduced vitamin D level leads to acceleration of the ageing process(3).

13
Dermis:

As the skin gets old, there is an age related decrease in elastic fiber and

collagen content in the dermis. Sun-protected areas manifest thinning only by the

eighth decade while the non-protected areas lose upto 20% of dermis even earlier.

The reduction in inflammatory response resulting from decreased

synthesis of keratinocyte-derived cytokines coupled with rigid blood vessels

contribute to increased vascular fragility and compromised thermoregulation in

older skin.

Impaired wound healing is caused by the biochemical changes in elastin,

collagen and dermal ground substance of elderly skin leading to increased skin

rigidity. Then density and luminal size of the lymphatic vessels are reduced .

Also, there is a decrease of 1% collagen content in skin with each passing year in

adult life. These changes along with increased collagenase levels account for the

impaired wound healing.

Wrinkles (Rhytides): (4)

Wrinkles are a characteristic feature of ageing skin. They are seen as

creases or furrows on the skin surface. They are more pronounced in hypertrophic

skin photodamage and in smokers.

They are classified into 3 morphological types - Crinkles, Glyphic wrinkles and

Linear furrows.

14
1) Crinkles:

These are very fine wrinkles which occur even in sun protected areas. Their

characteristic feature is that they disappear when skin is slightly stretched. They

are caused by the deterioration of the vertical subdepidermal fine elastic fibres

which anchor the epidermis with the dermis in tight apposition. Even in normal

people, this sign of ageing starts from 30 years onwards regardless of sun

exposure although it is augmented by sun exposure.

2) Glyphic wrinkles:

These are accentuation of normal skin markings and they tend to occur on skin

which has been prematurely aged by elastotic degeneration caused by sunlight.

3) Linear furrows:

These creases seen in the face of elderly people are usually long and may be

straight or curved grooves. The common incidence is along the horizontal frown

lines along the forehead, creases from the nose to the corners of the mouth and

“Crow’s Feet” - radiating from the lateral canthus of the eye.

Favre Racouchot syndrome:

Favre Racouchot syndrome is synonymous with senile comedones and

solar comedones. Chronic sun exposure in elderly people leads to occurrence of

multiple open and closed comedones on periorbital and malar areas. Ultraviolet

radiation leads to solar damage in supporting dermis causing injury to

pilosebaceous duct which becomes distended with impacted corneocytes(4).

15
Cutis Rhomboidalis nuchae (Jadassohn):

Cutis rhomboidalis nuchae is a clinical manifestation of severe photo

damage to the normally redundant skin lying over the neck. This is a form of solar

elastosis that results in deep furrows that form a rhomboidal pattern. The skin

becomes roughened, leathery and the skin markings are exaggerated(4).

Idiopathic Guttate Hypomelanosis:

Idiopathic Guttate Hypomelanosis is due to irreversible damage to the

melanocytes caused by UV radiation injury. It is more pronounced over the

extensor aspects of upper and lower limbs. It becomes more exaggerated during

summer when the surrounding normal skin darkens due to sun tanning(5).

Senile Pruritus (Willans itch):

Ageing leads to dryness of the skin which becomes more worse in the

winter than in summer. Although the water loss from ageing skin is not increased,

the water content in the epidermis is reduced. Also, decreased lipid content,

ceramides reduce the barrier function of the skin resulting in pruritus. However,

other causes of pruritus like infection, malignancy, renal disease, thyroid disease

and diabetes should be ruled out(5).

Senile Xerosis:

The aforementioned reasons mentioned in senile pruritus will also lead to

xerosis of elderly skin and it is one of the most common cutaneous ageing

changes.

16
Subcutaneous tissue, Muscles and Bone:

Wrinkle formation in face is augmented by the accumulation of

lipofuschin, diminished neuromuscular control and depletion of subcutaneous fat

in the temporal, buccal, forehead, perioral and preorbital areas. Conversely, there

is an age related increase of fat in the submental region, nasolabial folds, lateral

malar areas and the jowls. Together, they lead to sagging and drooping of facial

skin(3).

Similar to other parts of the body, there is a reduction in bone mass which

is more pronounced over the mandible, maxilla and frontal areas. This bone loss

accentuates the sagging of skin and is responsible for the obliteration of the

visible demarcation between the neck and jaw seen in younger individuals.

Infectious Processes:

Folliculitis and furunculosis are the bacterial infections caused by

Staphylococcus aureus and it is predisposed by the existing malnourishment in the

developing countries. Diabetes is believed to predispose to furunculosis.

Fungal infections are widely prevalent in south India because of the

tropical environment with high temperature and humidity. Dermatophytosis is a

superficial mycosis caused by a group of fungi called dermatophytes belonging to

the genera of Trichophyton, Microsporum and Epidermophyton. These are

keratinophilic fungi and are confined to keratin of stratum corneum, hair and nail.

Onychomycosis are fungal infections of the nail caused by a variety of fungi like

17
dermatophytes, yeast and moulds. The infection is usually persistent and chronic.

Adult males are most commonly affected than females(3).

Scabies presents with atypical cutaneous lesions and reduced inflammation

and pruritus in the elderly. Onychomycosis, Candida infections and Tinea pedis

also occur in increased frequency. Post-herpetic neuralgia occurs more frequently

following Varicella Zoster infection.

Chronic ulcers of all aetiologies and Bullous pemphigoid are far more

common in elderly than in younger individuals. Also, adverse drug reactions of all

kinds show an increased frequency with increasing age. This can be attributed to

the fact that elderly consume more medications compared to younger age groups

due to the presence of co-morbid conditions(4).

Dermatosis papulosa nigra:

DPN is a pigmented papular eruption of the face and neck caused by a

naevoid developmental defect of the pilosebaceous follicles, with histology

resembling Seborrheic keratoses. The condition is most common among

individuals with a darker skin complexion. These are more common among

individuals with a darker skin

complexion. It is more common in females. FGFR3 mutations have recently been

implicated.

Lesions may be black or dark brown, flat or cupuliform papules. They

measure 1–5 mm in diameter. The cheeks and forehead are most commonly

affected. Although rare, lower parts of the face and chin, neck, chest, abdomen

and back may all be affected.

18
Seborrheic keratosis:

It is a benign tumour commonly present in the elderly and is composed of

epidermal keratinocytes with various morphological features. It is also called as

“seborrheic wart / senile wart / basal cell papilloma”. It is usually asymptomatic,

rarely pruritic. Sunlight has been proposed as the causative factor. It can occur on

any body site but it most commonly affects the face and upper trunk. It can be

pedunculated, acanthotic, domed, heavily pigmented and smooth surfaced(4).

Stasis eczema:

Eczema secondary to venous hypertension is stasis eczema and it is also

called as “gravitational eczema”. The eczema is usually associated with the

varicosity of superficial veins, purpura, edema, ulceration, atrophic telangiectatic

scarring (Atrophie Blanche) (4).

Asteatotic eczema:

Asteatotic eczema also called as “winter eczema or eczema craquele” is

characterized by dry, cracked, and fissured lesions. It is common in winter. It is

commonly seen secondary to xerosis. The finger pulps are dry, cracked producing

distorted prints but they retain a prolonged depression after application of pressure

(Parchment Pulps). On legs, the pattern is called as “crazy-paving pattern or

eczema craquele”

Nummular eczema:

It is also called as “Discoid eczema”. The cause is usually unknown. Local

physical or chemical trauma plays a part in some cases. In the elderly, dry skin

due to low humidity in the environment leads to nummular eczema.

19
Hair:

Graying of hair is an important aspect of old age and 50% of the scalp hair

is gray by the end of fifth decade. This is because of the loss of melanocytes from

the hair bulb. The theory behind this accelerated melanocyte loss is that these cells

have a higher division and metabolic rate during the anagen phase compared to

skin cells. Scalp hair turns gray earlier than other hair in the body due to its higher

anagen to telagen ratio(3).

Balding, another old age phenomenon occurs because of the androgen

induced conversion of thick terminal hairs into fine vellus hairs. Although women

don’t suffer from balding as severely as men because of the protection offered by

oestrogen, post-menopausal loss of oestrogen leads to facial hirsutism and mild

scalp hair loss.

Nails:

Normally the finger nails grow at the rate of 1 cm / 3 months and toe nails

grow at the rate of 3 mm / 3 months. With increase in age, there is a reduction in

the rate of growth by approximately 0.5% per year starting from the age of 25

years. Men usually have thicker nails than females and toe nails tend to be thicker

than finger nails in both sexes(4).

With advancement in age there is a gradual thinning of nails associated

with reduction in the longitudinal curvature and increase in the transverse

convexity. Also, the nails become more friable leading to increased fissuring,

20
splitting and striations. There is a colour change from pink to yellow-gray

discolouration(5).

The skin changes in elderly presents a myriad of challenges to the treating

physician owing to the superimposition of age defined cutaneous changes on pre

existing co-morbid conditions.

C. Guy Lane and Ethel M. Rockwood et al have done one of the

pioneering studies in Geriatric Dermatoses and their research was published in

New England Journal of Medicine with much fanfare. In this observational study

they have stressed on the importance of creating a new sub specialty on Geriatric

Dermatoses based on the observation of changing dynamics of the population

pyramid.

Of the 1145 patients included in the study, 57 percent were in the sixties,

34 percent were in the seventies, 9 percent were in the eighties and only 0.4

percent were above the age 90. In these set of patients, Senile Keratoma was

found out to be the commonest presenting lesion in a geriatric patient followed by

epithelioma, seborrheic keratosis, eczema and contact dermatitis.

This study also emphasized on the fact that the skin changes in the elderly

must be studied not only based on the age and general medical condition of the

patient but also on various other factors like life style and habits(6).

Mateusz Cybulski and Elzbieta Krajewska-Kulak et al had conducted a

recent study Geriatric Dermatoses in Poland during 2015 and published their

results in May 2016. The participants were the elderly residents in public nursing

homes in Bialystok, Poland.

21
 As per their study, Birth marks, fungal infections and bedsores were the

common complaints of elderly individuals. There was a questionnaire regarding

the awareness among elderly persons about skin ageing and the protective

preparations utility.

Almost 40% of the study population scored average and 25% scored poor

in their knowledge about skin ageing. Only one third of them had good knowledge

regarding skin care and the need for using protective measures to reduce skin

ageing. This finding emphasized the need for educating elderly about skin ageing

and the means to protect it from extrinsic ageing.

Further, stasis dermatitis was the commonest cutaneous disease as per this

study and it is usually a marker of underlying increased venous pressure in the

lower extremities. Pallor, frail nails, excessive keratosis, irregular pigmentation,

age spots, diffuse thinning of hair, tendency to develop blisters, delayed wound

healing, hair roughness and graying, telangiectasia, drying, wrinkling and sagging

were the other common complaints.

Warts, fungal infections, eczema, actinic keratoses, cutaneous horn,

erysipelas, benign and malignant neoplasms, xanthelasma, shingles, leg ulcers and

drug reactions were the other diseases observed in geriatric population included in

this study(7).

In Indian context, Joan Felicita Samson, Mariam Philip, Susamma

Ebenezer, V Vivek Prabhakar, Libu G K et al had conducted a study during

2014 in Dr SMCSI Medical College, Trivandrum, Kerala. A total of 397 patients

were included in the study of which males accounted for 46.6% and females 53.4

22
%. The mean age of the participants was 65.21 years and the oldest person was

aged 85 years.

Non-infective dermatoses were the predominant manifestation as per this

study with 172 individuals having this complaint. Eczema was the commonest and

124 out of the 172 persons had it. 15 % had psoriasis and 12 % had vitiligo.

Infective dermatoses accounted for 99 cases and among them 18% had

bacterial infections like cellulitis, furuncles, folliculitis and one person had

erythrasma. Viral infections like verrucae, herpes zoster occurred in 24.24 %

participants while the majority (55.55 %) suffered from fungal infections like

candidiasis, Tinea versicolor and dermatophytic infections. Only 2 persons had

manifestations of Scabies.

3.3 % (13 individuals) had multiple skin conditions like eczema with

bacterial infection, eczema with secondary cellulitis, eczema with fungal

infections. Fungal infection along with vitiligo, eczema with psoriasis and fungal

infection with bacterial infection were the other mixed skin conditions seen.

In toto, 54 different dermatoses were seen among the participants in this

study and only 3.3 % had more than one dermaotses(8).

Abbas Darjani, Zahra Mohtasham- Amiri, Kiarash Mohammad

Amini, Javad Golchai, Shahryar Sadre-Eshkevari and Narges Alizade et al

had their study published in the Dermatol Res Pract Journal in 2013. This cross-

sectional study was conducted in Northern Iran and the study group comprised of

440 patients. Of these, 232 (52.7 %) were male and the rest were female.

23
 Seven categories were assigned including erythemato squamous diseases

(psoriasis, lichen planus, contact dermatitis, paederus dermatitis, lichen simplex

chronicus, stasis dermatitis, pilaris rubra pityriasis and seborrheic dermatitis),

infectious diseases (bacterial, fungal and viral), benign neoplasm (Pilar cyst,

keloids, seborrheic keratosis, lipoma, pyogenic granuloma, epidermal cyst, skin

tag and keratoacanthoma), precancerous lesions (Leukoplakia, bowen and actinic

keratosis), cutaneous malignancy (basal cell carcinoma, Squamous cell

carcinoma, kaposi’s sarcoma and mycosis fungoides), age-related skin conditions

(Senile lentigo, xerosis, senile comedone, angioma and nail ridging) and

miscellaneous (insect bite, sarcoidosis, leg ulcer, ingrowing toe nail, corn, vitiligo

and vasculitis).

In the study population benign neoplasm was the commonest skin

condition with 65 % of the study population having this condition. 35.3 % had

erythemato-squamous lesions and 26.1 % had precancerous lesions.

Among the erythemato-squamous lesions dermatitis was the commonest

presenting in 16.6 % followed by psoriasis (12.3%). Lichen planus was present in

5.45 % and pilaris rubra pityriasis was seen in 1.1%. Most common infectious

diseases were caused by the fungi (8.2 %) followed by viral infection (4.5 %) and

infestations (4.3 %).

Among the precancerous lesions, actinic keratoses was the leading

cutaneous condition presenting among 24.3 %. Basal cell carcinoma was most

prevalent skin carcinoma and was seen in 8.8 % individuals emphasizing the role

of sun exposure in this region which is mostly arid and hot owing to the desert

24
like nature of the country. Pruritus was the commonest presenting problem among

those attending the outpatient clinics.

Another interesting finding in this study is that skin tags were commonly

found in females (69%) compared to males with (10).

Anne Lynn S, Chang MD, Jillian W Wong MS, Justin O Endo MD,

Robert A Norman DO et al presented a study in the American journal of

Dermatology in the year 2013. In this study, they have emphasized the use of less

stigmatic and more accurate terms like Solar and Bateman’s in the place of

derogatory terminologies like senile purpura and xerosis respectively.

They also pointed out the lack of proper training modules in geriatric

dermatology for students. This is attributed to the lack of awareness among the

academic coordinators about the substantial growth of the geriatric population in

recent years. So new academic curriculums must be designed which should make

Geriatricians and Dermatologists adept in meeting the needs of this ever growing

geriatric population.

This study makes an elaborate notification about pressure sores - aetiology,

grading, investigations and management of all grades of pressure ulcers along

with the usual geriatric manifestations mentioned in other studies. They have

outlined a management chart which helps to tackle even the most refractory

pressure sores.

‘Dermatogeriatrics’ - a new branch of dermatology is the brain child of this

study which if properly planned implemented will be of great help to elderly

individuals (9).

25
 Hrvoje Cvitanovl, Eva Kneevl, Ilko Kuljanaci, Ervin Jan-I et al, 2010,

had done an elaborate study in Croatia comprising of 822 patients with the age

cut-off limit set at 65 years instead of 60. Ratio of male to female in this study

was 0.76 : 1.

Males had a higher incidence of verrucae vulgares (7.3%) and dermatitis

nummularis (13.2 %). In contrast, females had a higher incidence of actinic

keratoses (26.6%) and fibroma (2.64%).

As per this study, the commonest cutaneous diagnosis in the elderly were

actinic keratoses 23.3 %, verrucae seborrhoicae 18.98 %, dermatitis nummularis

9.37 %, dermatitis allergica 7.30 %, fungal infections 6.81 %, psoriasis 6.20 %,

verrucae vulgares 4.74 %, fibroma 3.28 %, naevi 1.09 % and acne in 0.12 %.

This study also highlights the impact of standard of living, racial and

cultural differences on the prevalence of skin tumours and infectious diseases.

Excessive bathing and soap application in the native people might play a role in

increased xerosis and pruritus. They also emphasized the fact that multi

medications resulted in unwanted iatrogenic cutaneous effects and hence this

practice must be curtailed.

The distinguishing feature of this study compared to Indian studies is that

pruritus not even comes in the top ten cutaneous conditions whereas it is usually

the most common complaint as per Indian studies(11).

Sirisha N L, Pavan Kumar M, Sowjanya M have published a

study in 2015 about the dermatological problems in Geriatric patients. This study

26
was done in Rajiv Gandhi Institute of Medical Sciences, Kadappa during the

period March 2014 to March 2015. This is retrospective study analyzing the

medical records of 937 patients.

Of this, 349 patients were female and 588 were male with a female to male

ratio of 0.59. As per this study, the most commonly seen diseases among the

elderly were eczema, fungal infection, pruritus and viral infections essentially in

the same order. Interestingly, pruritus was recorded only in 7.3 % of the study

population which is in contrast to other Indian studies (12).

Choi HC and Oh CH et al had done a study to collect clinically relevant

data regarding dermatological diseases and skin care in geriatric population and

their study was published in the Korean Journal of Dermatology. They had

examined a total of 172 volunteers aged between 51 and 90 years.

It was a questionnaire based study comprising of 32 questions followed by

clinical examination of the cutaneous lesion. The male to female sex ratio is 1.14

and the mean age of the study population was 74.4 years.

They found that the most common complaint in the elderly was pruritus.

Seborrheic Keratosis was the commonest disease followed by senile lentigenes,

xerosis and cherry angioma. They found that there is a statistically significant

association between the incidence of xerosis and the presence of pruritus(13).

Liao et al found out that dermatitis, fungal infections and pruritic

dermartoses were the usual presenting complaints among the geriatric patients in

27
Taiwan. This study was published in Taiwan Journal of Dermatology in the year

2001(14).

Yap, Siew and Gow et al reported that eczema, dermatitis and epidermic

keratoses were the most common skin diseases in elderly aged over 75 years in

Singapore(15).

Schaefer et al published a study in 2008 about the geriatric dermatoses in

Germany. As per this study, contact eczema, acne and seborrheic dermatitis were

the frequent cutaneous manifestation in the study population(16).

DK Thapa, AK Jha, C Kharel and S Shreshta et al have done a study in

Nepal Medical College, Kathmandu during the year 2012. 330 geriatric patients

who visited the hospital during the study period were included in the study. The

male to female ratio is 1:1.

The most common cutaneous dermatoses was eczema which accounted for

35% of the cases followed by fungal infection 13.6 %, viral infection 7.6%,

pruritus, scabies and photo dermatitis 4.5% each. Inflammatory papulosquamous

disorders, bacterial infection, icthyosis, prurigo nodularis, keratoderma, diabetic

ulcer, callus, burger’s disease, burning feet syndrome, drug rash and senile acne

constitute the miscellaneous conditions(17).

Weismann K, Krakauer R, Wanscher B et al had analysed about

geriatric dermatoses and their study was publishes in Acta Derm Venereology

journal. The mean age of the elderly population included in this study was 80

years ( Range 55 to 106 years ). As per his study, Pityriasis of scalp was the

commonest skin condition accounting for 44.3 % followed by asteatosis which is

28
seen in 28.9 % individuals. 2.9 % had psoriasis, 1.2 % had vitiligo and 3.8 % had

contact dermatitis (18).

Mohammad Jafferany, Trung V Huynh, Melissa A Silverman, Zohra

Zaidi et al, 2012 have done a study in United States of America regarding

Geriatric dermatoses. Instead of doing a routine analytical study about various

geriatric dermatoses they have focused on the novel concept of the role of psycho-

dermatological aspects of the lesions in the elderly. Although they also have done

a short study about the various intrinsic and extrinsic skin manifestations, what

puts this study as unique is the introduction of the psychological impact of the

cutaneous changes. More number of studies is the need of the hour to completely

understand the significance of this new dimension(19).

Mihail Alexandru Badea MA, Silviu Horia Morariu et al have done a

study regarding geriatric dermatoses in the Department of Dermatology,

University hospital of Tirgu Mures, Romania. This study emphasized on a new

geriatric dermaotoses named dermatoporosis. It was originally described by Kaya

and Saurat in 2007.

Dermatoporosis or chronic cutaneous insufficiency syndrome is due to

chronic cutaneous actinic aggression. It has four stages of evolution from skin

atrophy to dissecting cutaneous hematomas. They have further studied the

molecular mechanism of this disorder and found that it is due to the decrease in

CD44 receptor for hyaluronic acid.

In dermatoporosis even minor trauma leads to the development of

pigmentations, purpura, stellate pseudoscars, ulcerations and skin dissecting

29
hematomas. The common location is in the forearms but they can also occur in the

lower limbs where the manifestations will match the features of chronic venous

insufficiency (20).

Haruko Hino has published a study in 2001 in the Asian Medical journal

regarding the topical use of steroids in the aged and their indication and side

effects. He observed that steroids applied with occlusive dressing produced more

side effects than steroids applied topically. He issues a word of caution on

development of contact dermatitis on prolonged steroid use in elderly individuals.

Steroids can exhibit systemic toxicity also after topical application in the

elderly. When a strong steroid is applied with occlusive dressing, eosinopenia,

hypoadrenalism, accumulation of sodium and water and cushingoid features tend

to appear. Although these changes revert after discontinuation of therapy, if the

daily cumulative dose is kept less than 10 g% these side effects can be minimized.

As per this study, the common inidication for steroids in the elderly is

pruritus followed by nummular eczema, asteatotic eczema, seborrheic eczema and

psoriasis vulgaris. This study stresses the need for selection of steroids with

appropriate potency for the presenting condition to minimize the side effects

attributed to it (21).

Gunduz T, Gunduz K, Degerli K, Limoncu M E et al in their study on

the epidemiological profile of onychomycosis in the elderly living in the nursing

homes had done a detailed work up on the condition of nails in the elderly. They

studied a total of 214 elderly patients of which 59 were female and 155 were

male.

30
 Among the 214, onychomycosis was clinically suspected in 102 patients

and scrapings were obtained from 122 nails. The onychomycosis were classified

into proximal subungual, distal subungual and superficial. Of these, 87 were

distal, 21 were proximal and 14 were superficial. Fungal spores were seen in

37.8% of the cases ( 3 were hand nails and 78 were toe nails ). The most common

fungal species isolated was Trichophyton rubrum (75.9%) followed by Candida

(22)
glabrata (12.9%) .

Maria Leilani L. Ramirez, Maria Assumpta Ceci R. Serrano et al had

published a study in the Journal of Phillipine Society of Cutaneous Medicine in

the year 2013. This was an extensive retrospective study involving one thousand

two hundred and sixty nine elderly patients in the age group of 65 to 99 years. 710

males and 559 females were studied. Lichen Simplex Chronicus was the most

common cutaneous manifestation in the study population as per this study. This is

an unusual finding compared to other studies which implies that the cutaneous

manifestation might vary bases on the geography and topography of the study

population (23).

Elisa Cinotti, Jean Luc Perrot, Bruno Labeille, Anne Catherine Biron,

Andrea Vierkotter, Catherine Heusele, Carine Nizard, Sylvianne Schnebert,

Jean Claude Barthelemy, Frederic Cambazard et al had done a study in

France and it was published in the European Journal of Dermatology in 2016. In

this study they had studied about the skin ageing and incidence of skin tumours

among the 209 study subjects. The peculiarity of this study is that it analysed the

different skin ageing parameters along with the incidence of skin tumours in the

31
elderly. As the study population consisted mainly of French Caucasians

unsurprisingly melanoma was found out to be the commonest cutaneous tumour

in the elderly (24).

(25)
Niranthari Chinniah, Monisha Gupta et al had published a study in

the Australian Journal of General Physicians regarding the assessment and

management of pruritus in the elderly. As per their study, pruritus was the

commonest skin complaint in the elderly over 65 years of age.

Pruritus is mediated by epidermal / dermal receptors connected to non-

myelinated C fibers which transmit the impulse from the periphery to the

thalamus and the primary somato-sensory cortex. The primary neuro transmitter

involved is histamine.

Among the causes of pruritus, xerosis is considered to be commonest cause

followed by atopic dermatitis, contact dermatitis, dermatophytes, lice, psoriasis,

scabies and utricaria essentially in the same order. Various systemic conditions

may also lead to pruritus notable being malignancies like Hodgkin’s lymphoma,

leukemia and multiple myeloma. Chronic renal failure and cholestasis can cause

intractable pruritus. Drugs like diuretics, ACE inhibitors, lipid lowering agents,

anticonvulsants and allopurinol may also cause pruritus.

Hematological conditions like Polycythemia rubra vera,

Macroglobulinemia and Iron deficiency anaemia can lead to pruritus. Among the

endocrine causes both hypo and hyperthyroidism along with hyperparathyroidism

can cause pruritus. Psychiatric disorders like depression, anxiety, obsessive

compulsive disorder and hypochondriasis can present with pruritus. Neurological

32
disorders like cerebral infarct, multiple sclerosis, brain abscess and tumours can

cause pruritus. Immunodeficiency states like HIV can also present with pruritus.

Hence, while examining a patient with pruritus a detailed history regarding

the onset, duration, associated conditions, drug intake, atopy, asthma, hay fever

and a focused dietary history are vital. The examination must include the

neglected areas like intertriginous regions, finger webs and genital areas.

Investigations to look for associated systemic causes of pruritus must be ordered

tailored to each individual based on the history and examination findings. Given

the association with malignancies, meticulous up to date age appropriate

neoplasm screening must be done. If the lesion warrants, biopsy must be done to

confirm the diagnosis.

Management of pruritus starts with the treatment of underlying condition

along with life style modification and specific medications. General measures that

can be done include quick cool showers, soap free substitutes, patting dry skin,

use of emollients on moist skin after shower, using a humidifier, avoiding usage

of synthetic and woolen garments and keeping finger nails trimmed short. Drug

therapy for pruritus includes antihistamines, 1 % aqueous Menthol, topical

corticosteroids and phototherapy based on the underlying condition.

Lusiyanti Zhuang Xue Lu et al in a dissertation paper published in the

Chongqing Medical University has done a retrospective study of geriatric

dermatoses in 506 hospitalized elderly patients with skin disease. All the patients

included in the study were aged 60 or older. The unique nature of this study was

33
that it has done a comparative analysis of the study population with mid adulthood

patients aged 45 to 59 years with skin disease.

The male to female ratio was 1.56 : 1. The commonest cutaneous disorder

in the elderly is herpes zoster as per this study followed by eczema, non specific

dermatitis, drug eruption and psoriasis. When these findings were compared with

the mid adult population it found out a statistically significant increased risk for

herpes zoster (1.9 fold), bullous pemphigoid (5 fold) and pruritus (3.4 fold).

While eczema and psoriasis were the commonest conditions seen in males,

herpes zoster, utricaria and dermatomyositis were commonly found in higher

proportion in females. Also, one third of the study population had one underlying

systemic disorder and another one third had two underlying systemic disorders.

The most frequent underlying disorder was hypertension followed by diabetes

mellitus, lung parenchymal disorder and cerebro-vascular disease. Among the

drug therapy induced cutaneous lesions, steroids were the most common drugs

associated with cutaneous side effects.

The most important distinguishing feature of this study is the comparative

analysis of the cutaneous conditions between the elderly and mid adulthood

individuals and the prediction of statistically significant increased risk for certain

cutaneous disorders. This study also highlighted the variations in the frequency of

skin diseases based on age and gender. This study also emphasized the need for

dose adjustment and monitoring for side effects of drugs used in elderly

individuals for treatment of coexisting systemic illnesses (26).

34
 Seong Jin Jo, Seung Hwan Paik, Jae Woo Choi, Jong Hee Lee, Soyum

Cho, Kyu Han Kim, Hee Chul Eun, Oh Sang Kwon et al have done a study

regarding graying of hair and their study was published in the Korean Journal of

Dermatology in April 2011. This was a questionnaire based study comprising of

1002 study subjects. Of these 522 were men and 480 were women. The graying of

hair was graded into 5 grades. If a person had < 20% gray hair, he or she was said

to having grade I graying whereas a person having > 80% gray hair was supposed

to have grade V graying.

This study found out that temporal area graying was found significantly in

men whereas women had frontal and parietal graying predominantly. They also

found out that smokers had a 1.99 times increased risk of hair graying compared

to non-smokers. Drug intake, hair loss, gender, preexisting skin disease of the

scalp and alcohol consumption do not have significant association with graying.

Another point to be noted was that early onset graying was not associated with

faster progress of graying. Rather, the extent of graying increased sharply after the

fifth decade regardless of the age of onset (27).

Archana Singal, Deepashree Daulatabad, Chander Grover et al had

done a study on premature graying of hair and it was published in Indian Journal

of Dermatology in June 2016. They analysed 52 subjects with premature graying

of hair before the age of 20 years and devised a new scoring system called

Graying Severity Score. This scoring system took in account of five representative

sites from the scalp. The grades ranged from a score of 0 to 15. It was further

subdivided as mild, moderate and severe.

35
 This grading system was unique in the sense that it was indigenously

developed and was comparable with the Hair Whitening Score by Edrogan and

Kocaman. The HWS grades from grade I to V with I being < 25 % and V being

100%.

The advantage of GSS is that it is a numeric, objective and reproducible

score which takes all the areas of scalp into consideration. The major limitation of

this scoring system is requires a lot of time to complete the score (28).

Lina Abdullah, Ossama Abbas et al had done a study in 2011 regarding

the nail changes in elderly people and it was published in the Canadian Journal of

Family Medicine. As per this study, brittle nails (Fragilitas unguium) was the

commonest nail disorder in the elderly which affects 20 % of the elderly

population and it was found to be more common in women than in men.

Clinically it was manifested as Onychoschizia and Onychorrhexis. They also

described about Onychauxis or localized hypertrophy of the nail plate which

manifests clinically as loss of translucency, discolouration and subungual

hyperkeratosis. Advancing age and faulty biomechanics were deemed to be the

commonest cause for these malformations.

Onychoclavus or subungual corn was another common hyperkeratotic

process observed in the elderly which usually affects the big toe nail. It is dark

and tender mimicking benign or malignant subungual melanocytic lesions. The

underlying causes include persistent localized pressure such as ill fitting shoes,

digiti flexi, hallux valgus, rotated fifth toes and chronic minor trauma.

36
 Onychomycosis was the commonest nail infection as per this study and the

causative organisms include dermatophytes, non-dermatophytic molds and yeasts.

Male gender, old age, underling peripheral arterial disease, diabetes,

immunodeficiency and smoking increase the risk for onychomycosis.

Trichophyton rubrum and Trichphyton mentagrophytes were the causative

organisms in 90% of the cases. Candida and Scopulariopsis brevicaulis were the

other causative organism.

Onychomycosis was classified into many subtypes among which distal and

lateral subungual were the most common types and they were usually caused by

Trichophyton rubrum. Paronychia or nail bed infection was subdivided into acute

and chronic based on the duration of infection. While acute paronychia was

caused by bacterial infection chronic paronychia was caused by Candida or Gram-

negative bacteria. Onychocryptosis or ingrown toe nail was infrequently seen in

elderly as per this study (29).

Based on these reviews, this study has been designed to find out the

clinical pattern and profile of dermatological manifestations in elderly individuals.

37
AIMS AND OBJECTIVES
 AIMS AND OBJECTIVES

1) To determine the clinical profile and pattern of dermatological manifestations

in elderly people aged 60 and above.

2) To analyze the correlation of various Geriatric dermatoses with systemic

diseases.

38
MATERIALS AND
METHODS
 MATERIALS AND METHODS

Study Design:

A hospital based prospective cross-sectional study

Study Period:

From October 2015 to September 2016

Study Population:

The study population consists of all elderly individuals aged 60 years and above

attending the outpatient clinic of Department of Dermatology, RGGGH and the

outpatient clinic of Department of Geriatrics, RGGGH during the study period.

The participants should fulfill the inclusion criteria and elderly patients belonging

to both sexes were admitted in this study. The outpatients who didn’t give consent

were excluded from the study.

Inclusion Criteria:

1) Patients older than 60 years belonging to either sex attending the outpatient

clinic of Department of Dermatology, RGGGH.

2) Patients older than 60 years belonging to either sex attending the outpatient

clinic of Department of Geriatric Medicine, RGGGH for any ailment with a

cutaneous complaint or any dermatological finding / lesion / manifestation

brought to the notice of the investigator by the treating Physician or the patient

himself.

39
Exclusion criteria:

Patients aged less than 60 years of age.

Methodology:

Approval from the Institutional Scientific and Ethical Committee of

Government Madras Medical College, Chennai was obtained. Elderly individuals

who satisfy the inclusion criteria were included in the study.

The patients were properly counseled and informed consent was obtained

from them for enrollment into the study. Detailed counseling was given regarding

physical examination, blood investigations, urine analysis, skin scraping and

biopsy. Using pretested proforma, the details of the patient, history, clinical

findings and investigations taken were recorded.

If at any point of time, if a patient was found to have parameters in the

exclusion criteria he / she was excluded from the study.

Procedure:

The patients aged more than or equal to 60 years attending the outpatient

clinics of dermatology and geriatrics at RGGGH were chosen. Their age

mentioned in the outpatient slip was confirmed by cross checking with any one of

the following ID proofs - Aadhar card, Voter ID, Ration card, Birth certificate, ID

card issued by work place/state government/central government.

After confirmation of age, the chief presenting complaint of the patient was

recorded. A detailed history of the presenting complaint was documented along

40
with the name, age, sex, OP number, occupation, marital status and treatment

history of the patient.

If a patient attending the geriatric outpatient clinic for another systemic

complaint and the cutaneous lesion was brought to the notice of the investigator

by the attending physician during examination that was also documented.

Associated systemic conditions like diabetes, hypertension, tuberculosis,

thyroid dysfunction, renal disease, liver disease, immunosuppressive states (HIV,

steroid therapy, transplant recipients, chemotherapy, radiotherapy) were recorded.

Any other significant past history was noted followed by a general and systemic

examination.

Local examination of the lesion was done under bright light with a

magnifying glass lens. Detailed description of the lesion - site of involvement,

size of the lesion, number of lesions and morphology of the lesion were noted.

The hair of the patient was examined and the abnormalities like graying

balding are noted as per the following scoring systems.

Examination of hair:

Graying of hair is analysed clinically and the predominant areas of graying

are noted. The scalp is divided into 5 anatomical areas for documentation namely

frontal, occipital, right temporal, left temporal and vertex. The total percentage of

gray hairs to black hairs is noted.

41
 Division of Scalp hair into segments

Grading of graying is done using the following score:

Grade I - < 20% gray hairs

Grade II - 20 to 40 % gray hairs

Grade III - 40 to 60 % gray hairs

Grade IV - 60 to 80 % gray hairs

Grade V - More than 80% gray hairs

The finger and toe nails of the study subjects were examined and abnormal

findings were documented.

If a lesion needs a scraping or biopsy or touch smear or aspiration or

dermoscopy or trichoscopy for confirmation of diagnosis, the same was

communicated to the patient and after getting a proper informed consent the

procedure was done. The sample taken was subjected to KOH mount, gram stain,

Tzanck smear and histo-pathological examination as the lesion warrants and the

results were documented.

42
 In patients with pre-existing systemic diseases or those with lesions

signaling underlying systemic illness, requisite blood investigations like complete

blood count, renal function test, blood sugar level, liver function test, thyroid

function test, serum electrolytes and ELISA test for HIV infection were taken and

the results were noted.

Statistical analysis:

The data collected were fed into the SPSS software version 17.1 for

Windows (SPSS Inc., New york) and analysis was done.

43
RESULTS AND ANALYSIS
 RESULTS AND ANALYSIS

This study was conducted in the outpatient departments of Dermatology

and Geriatric Medicine in Rajiv Gandhi Government General Hospital, Chennai

during the period from October 2015 to September 2016. Elderly individuals aged

60 years and above who fulfilled the inclusion criteria were included in the study.

The results were tabulated and analysed with the SPSS software version 17.1 and

Openepi software.

GENDER DISTRIBUTION

A total of 200 individuals were enrolled in this study out of which there

were 129 males and 71 females. Males contributed to 64.5 % of the study

population and females contributed to 35.5 %. The male : female ratio is 1.8 : 1.

Female 71

Male 129

Male
Female

Figure 1: Gender distribution

44
 AGE GROUP DISTRIBUTION

166

31 60 to 69 Years
70 to 79 Years
> 80 Years

Figure 2: Age Group distribution

On categorizing the elderly based on age, the maximum number of study

population were in the age between 60 to 69 years totaling 166 out of the 200

patients. 31 were in between 70 and 79 years and only 3 were aged more than 80

years.

45
 Chart 1: PHYSIOLOGICAL GERIATRIC DERMATOSES

Dermatoses Number of individuals affected

Crinkles 146

Cutis Rhomboidalis Nuchae 2

Idiopathic Guttate Hypomelanosis 43

Favre Racouchot Syndrome 3

Glyphic Wrinkles 39

Linear furrows 15

Senile Lentigenes 4

Senile Pruritus 28

Senile Purpura 1

Xerosis 49

46
 Physiological Geriatric Dermatoses
160
140
120
100
80 146
60
40
43 39 49
20 15 28
0 2 3 4 1

Figure 3: Physiological dermatoses in study population

Crinkles was present in 146 individuals (73%), Glyphic wrinkles in 39

(19.5%), Linear furrows in 15 (7.5%), Senile pruritus was present in 28 (14%) of

the study population, Xerosis in 49 (24.5%), Idiopathic Guttate Hypomelanosis in

43 (21.5%), Favre Racouchot syndrome in 3 (1.5%), Cutis rhomboidalis nuchae in

1%, senile lentigenes in 2 % and senile purpura in 1 individual. Hence wrinkling

of the skin is the commonest physiological geriatric dermatoses as per this study.

47
 Chart 2: PATHOLOGICAL GERIATRIC DERMATOSES

Dermatoses Number of Individuals

affected

I) Infections and Infestation 55

Fungal 20

Dermatophytosis 13

Onychomycosis 3

Candida 4

Viral 12

Herpes Zoster 8

Herpes Simplex 1

Wart 3

Bacterial 18

Pyoderma 3

Furunculosis 3

Folliculitis 1

Erythrasma 1

Pitted Keratolysis 4

Lupus Vulgaris 1

Leprosy 5

Parasitic 4

Scabies 4

48
Mixed 1

Intertrigo 1

II) Papulosquamous Disorder 9

Psoriasis 5

Pustular Psoriasis 1

Lichen Planus 2

Corn Foot 1

III) Bullous Disorder 7

Bullous Pemphigoid 5

Pemphigus Vulgaris 2

IV) Eczema 41

Airborne Contact Dermatitis 2

Contact Dermatitis to cement 2

Contact Dermatitis to paint 1

Contact Dermatitis to Turmeric 1

Stasis eczema 5

Asteatotic eczema 5

Stasis ulcer 2

Atopic dermatitis 1

Phytophotodermatitis 1

Lichen Simplex Chronicus 9

Nummular eczema 1

49
 Chronic eczema 3

Hand eczema 6

Prurigo Nodularis 1

Photodermatitis 1

V) Pigmentary Disorders 14

Vitiligo 8

Melasma 6

VI) Benign Tumours 96

Seborrheic Keratosis 23

Dermatosis Papulosa Nigra 33

Cherry Angioma 19

Acrochordon 21

VII) Nutritional Deficiency Disorder 3

Pellagra 3

Infections and infestations were observed in 27.5 % of the study

population. Fungal infection was the commonest infection observed and was

present in 10% of the individuals. Among the fungal infections, dermatophytosis

was present in 13 persons, onychomycosis in 3 and candidal infection was seen in

4 individuals. Viral infection was seen in 11 persons. Herpes zoster was noted in

8, herpes simplex in 1 and wart in 3 individuals.

Bacterial infections accounted for 9 % of the total cases. Leprosy was seen

in 5 persons, pitted keratolysis was seen in 4 cases, Pyoderma and furunculosis

50
were observed in 3 each and follicultis, erythrasma and lupus vulgaris were seen

in 1 individual each. 4 cases of scabies and one intertrigo were noted.

Pathological Geriatric Dermatoses

Infections and
infestations

3 Papulosquamous
disorders
96 55 Bullous disorder

Eczema
9
7 Pigmentary disorders
14
41
Benign tumours

Pellagra

Figure 4: Pathological dermatoses in study population

Among the papulosquamous disorders, psoriasis was diagnosed in 6 cases,

lichen planus in 2 and corn foot in 1 case. Bullous pemphigoid was seen in 5

patients and Pemphigus vulgaris was seen in 2 individuals. Eczema accounted for

41 cases, pigmentary disorders were seen in 14 cases, benign tumours in 96 cases

and nutritional deficiency disorder in 3 cases. No malignant tumours were seen.

51
 Chart 3: CO-MORBID CONDITIONS

Disease Number of persons affected

Diabetes Mellitus 63

Hypertension 10

Varicose vein 3

Ischaemic Heart Disease 3

Chronic Obstructive Pulmonary Disease 2

Chronic Renal Failure 1

Carcinoma cervix 1

Schizophrenia 1

Hypothyroidism 3

52
 Comorbid conditions in study
population
Diabetes Mellitus

Hypertension
111 3
32
3 Varicose vein
10
Ischaemic Heart Disease

63 Chronic Obstructive
Pulmonary Disease
Chronic Renal Failure

Carcinoma cervix

Figure 5: Comorbid conditions in study population

The commonest comorbid condition noted in the study population was

diabetes mellitus and it was seen in 31.5 % of the study group. Hypertension was

seen in 10 individuals. Varicose vein, ishcaemic heart disease and hypothyroidism

were in 3 individuals each. COPD was present in 2 individuals, CRF, carcinoma

cervix and Schizophrenia were seen in 1 person each.

53
Chart 4: PHYSIOLOGICAL GERIATRIC DERMATOSES IN MALES

Geriatric Dermatoses Number of individuals affected

Crinkles 89

Cutis Rhomboidalis Nuchae 2

Idiopathic Guttate Hypomelanosis 25

Favre Racouchot Syndrome 2

Glyphic wrinkles 27

Linear furrows 13

Senile Lentigenes 4

Senile Pruritus 19

Senile Purpura 1

Xerosis 35

54
 Physiological Dermatoses in Males
90
80
70
60
50 89
40
30
20 25 27 35
10 13 19
0 2 2 4 1
Crink Cutis IGH Favr Glyp Line Senil Senil Senil Xero
les Rho e hic ar e e e sis
mboi Raco Wrin furro Lenti Pruri Purp
dalis ucho kles ws gene tus ura
Nuc t s
hae Synd
rom
Series1 89 2 25 2
e 27 13 4 19 1 35

Figure 6: Physiological geriatric dermatoses in males

The commonest physiological geriatric dermatoses in males were crinkles

and it was seen in 68.9 % of the study population. Glyphic wrinkles were seen in

27 persons, linear furrows were seen in 13 and senile pruritus was noted in 19

individuals.

Xerosis was seen in 35 individuals, idiopathic guttate hypomelanosis was

seen in 25, cutis rhomboidalis nuchae and Favre Racouchot syndrome in 2

persons. Senile lentigenes was seen in 4 and senile purpura was seen in 1 person.

55
Chart 5: PATHOLOGICAL GERIATRIC DERMATOSES IN MALES

Dermatoses Number of individuals affected

I) Infections and Infestation 33

Fungal 10

Dermatophytosis 8

Onychomycosis 2

Viral 8

Herpes Zoster 5

Herpes Simplex 1

Wart 2

Bacterial 13

Pyoderma 3

Furunculosis 2

Folliculitis 1

Erythrasma 1

Pitted Keratolysis 1

Lupus Vulgaris 1

Leprosy 4

Parasitic 1

Scabies 1

Mixed 1

Intertrigo 1

56
II) Papulosquamous Disorder 6

Psoriasis 3

Pustular Psoriasis 1

Lichen Planus 1

Corn Foot 1

III) Bullous Disorder 4

Bullous Pemphigoid 4

IV) Eczema 28

Airborne Contact Dermatitis 2

Contact Dermatitis to cement 2

Contact Dermatitis to paint 1

Stasis eczema 5

Asteatotic eczema 5

Stasis ulcer 2

Atopic dermatitis 1

Phytophotodermatitis 1

Lichen Simplex Chronicus 3

Nummular eczema 1

Chronic eczema 2

Hand eczema 2

Prurigo Nodularis 1

57
 V) Pigmentary Disorders 6

Vitiligo 6

VI) Benign Tumours 66

Seborrheic Keratosis 16

Dermatosis Papulosa Nigra 19

Cherry Angioma 15

Acrochordon 16

VII) Nutritional Deficiency 3

Disorder

Pellagra 3

Infections and infestations were the second commonest pathological

dermatoses in males. Fungal infection was present in 10 individuals. 8 had

dermatophytosis and 2 had onychomycosis. Viral infections were seen in 8

individuals. Herpes zoster was found in 5 individuals, herpes simplex in1 and

viral wart in 2 individuals. Bacterial infection was present in 11 persons. Among

them, leprosy was seen in 4, pyoderma in 3, furunculosis in 2, folliculits,

erythrasma, pitted keratolysis and lupus vulgaris in 1 each. Scabies and intertrigo

were also seen in 1 individual each.

58
 Psoriasis was the commonest papulosquamous disorder seen in 4

individuals. Lichen planus and corn foot were seen in 1 person each. Bullous

pemphigoid was present in 4 persons. Eczema was noted in 28 individuals. Stasis

eczema and asteatotic eczema were seen in 5 persons each. Contact dermatitis was

seen in 5 individuals. Lichen simplex chronicus was seen in 3 persons and chronic

eczema, stasis ulcer and hand eczema was present in 2 persons. Nummular

eczema, atopic dermatitis, prurigo nodularis and phytophotodermatitis was seen in

1 person each.

Vitiligo was seen in 6 individuals. Benign tumours were seen in 66

individuals. Seborrheic keratoses was present in 16 persons, acrochordons in 16,

dermatosis papulosa nigra in 19 and cherry angioma in 15 individuals. Pellagra

was noted in 3 persons.

Pathological Dermatoses in Males

70
60
50
40
66
30
20 33 28
10
6 4 6 3
0
Infectio Papulo Bullous Eczema Pigmen Benign Pellagr
n and squam disorde tary tumour a
Infestat ous r disorde s
ions disorde rs
Series1 33 6
rs 4 28 6 66 3

Figure 7: Pathological dermatoses in males

59
 Chart 6: CO-MORBID CONDITIONS IN MALES

Disease Number of persons affected

Diabetes Mellitus 38

Hypertension 7

Varicose vein 3

Ischaemic Heart Disease 3

Chronic Obstructive Pulmonary Disease 1

Chronic Renal Failure 1

Schizophrenia 1

60
 Comorbid conditions in Males

40
35
30
25
20 38
15
10
5 7 3 3 1 1 1
0
Diabet Hypert Varico Ischae Chroni Chroni Schizo
es ension se vein mic c c phreni
Mellit Heart Obstru Renal a
us Diseas ctive Failure
e Pulmo
nary
Series1 38 7 3 3 Dise…
1 1 1

Figure 8: Comorbid conditions in males

Diabetes mellitus was the commonest comorbid condition seen in males

with 38 persons having this disease. 7 individuals had hypertension. Varicose vein

and ischaemic heart disease was seen in 3 individuals each. COPD, CRF and

schizophrenia were the other comorbid conditions seen.

61
 Chart 7: PHYSIOLOGICAL DERMATOSES IN FEMALES

Geriatric Dermatoses Number of individuals affected

Senile Comedones 1

Senile Pruritus 9

Idiopathic Guttate Hypomelanosis 18

Crinkles 57

Glyphic wrinkles 12

Linear furrows 2

Xerosis 14

62
 Physiological Dermatoses in Females
60
50
40
30 57
20
10 18 14
9 12
0 1 2

Figure 9: Physiological dermatoses in females

Crinkles were seen in 57 females, glyphic wrinkles in 12 and linear

furrows in 2 making wrinkling the commonest physiological geriatric dermatoses

in females. Xerosis was seen in 14 individuals, senile pruritus in 9 and senile

comedones in 1 person.

63
 Chart 8: PATHOLOGICAL GERIATRIC DERMATOSES IN FEMALES

Dermatoses Number of individuals affected

I) Infections and Infestation 22

Fungal 10

Dermatophytosis 5

Candidiasis 4

Onychomycosis 1

Viral 4

Herpes Zoster 3

Wart 1

Bacterial 5

Pitted Keratoses 3

Furunculosis 1

Leprosy 1

Parasitic 3

Scabies 3

II) Papulosquamous disorders 3

Psoriasis 2

Lichen Planus 1

III) Bullous disorders 3

Bullous Pemphigoid 1

Pemphigus Vulgaris 2

64
IV) Eczema 13

Chronic eczema 1

Contact Dermatitis to turmeric 1

Hand eczema 4

Lichen Simplex Chronicus 6

Photodermatitis 1

V) Pigmentary disorders 8

Melasma 6

Vitiligo 2

VI) Benign Tumours 30

Seborrheic Keratosis 7

Dermatosis Papulosa Nigra 14

Cherry Angioma 4

Acrochordon 5

Fungal infections were seen in 10 individuals with 5 persons having

dermatophytosis. Candidiasis seen in 4 and onychomycosis in 1 person. Viral

infections were seen in 4 individuals with 3 individuals having herpes zoster and 1

person having wart. Bacterial infection was seen in 5 individuals. Pitted

keratolysis was seen in 3 individuals and furunculosis and leprosy was seen in 1

individual each. Scabies was found in 3 individuals.

3 papulosquamous disorders were noted with 2 individuals having psoriasis

and 1 having lichen planus. Bullous disorders were seen in 3 individuals with

65
pemphigus vulgaris in 2individuals and bullous pemphigoid in 1 person. Eczema

was seen in 13 persons. Lichen simplex chronicus was seen in 6 and hand eczema

was seen in 4 persons. Chronic eczema, contact dermatitis to turmeric and

photodermatitis was seen in 1 individual each.

8 persons had pigmentary disorders with 6 persons having melasma and 2

had vitiligo. 30 persons had benign tumours, 7 had seborrheic keratosis, 14 had

dermatitis papulosa nigra, 5 had acrochordon and 4 had cherry angioma.

Pathological Dermatoses in Females

30

25

20

15 30
22
10
13
5 8
3 3
0
Infection Papulosq Bullous Eczema Pigmenta Benign
s and uamous disorder ry tumours
Infestati Disorder Disorder
Series1 22
on 3 3 13 8s 30

Figure 10: Pathological dermatoses in females

66
 Chart 9: COMORBID CONDITIONS IN FEMALES

Disease Number of Persons affected

Diabetes Mellitus 25

Hypertension 3

Chronic Obstructive Pulmonary Disease 1

Hypothyroidism 3

Carcinoma cervix 1

35 % of the females included in the study had diabetes mellitus and it was

the commonest comorbid condition in females. 3 individuals had hypertension

and another 3 had hypothyroidism. One individual was suffering from COPD.

Comorbid conditions in female

3
1 Diabetes Mellitus

3
Hypertension

Chronic Obstructive
Pulmonary Disease
Hypothyroidism
25

Figure 11: Comorbid conditions in females

67
 Chart 10: GRAYING OF HAIR IN STUDY POPULATION

Grade of Graying Number of Individuals

Grade I 5

Grade II 20

Grade III 97

Grade IV 43

Grade V 35

49 % of the study population had Grade III graying of hair, 21.5 % had

grade IV graying, 17.5 % had grade V graying, 10 % had grade II graying and

only 2.5 % had grade I graying.

Graying of Hair in Study Population

100
90
80
70
60
50 97
40
30
43
20 35
10 20
5
0
Series1 5I II
20 III
97 IV
43 V
35

Figure 12: Graying of hair in study population

68
 Chart 11: GRAYING OF HAIR IN MALES

Grade of Graying Number of Individuals

Grade I 3

Grade II 4

Grade III 71

Grade IV 24

Grade V 27

55 % of the male population had grade 3 graying of hair, 21 % had grade 5

graying and 19 % had grade 4 graying. Grade 1 graying and grade 2 graying was

seen in 3 and 4 individuals respectively.

Graying of Hair in Males

80

70

60

50

40
71
30

20
24 27
10
3 4
0
Series1 3I II
4 III
71 IV
24 V
27

Figure 13: Graying of hair in males

69
 Chart 12: GRAYING OF HAIR IN FEMALES

Grade of Graying Number of individuals

Grade I 2

Grade II 16

Grade III 26

Grade IV 19

Grade V 8

37 % of females in the study population had grade III graying of hair, 27 %

had grade IV graying, 23 % had grade V graying and 11 % had grade II graying.

Only 2 individuals had grade I graying.

Graying of hair in Females

30

25

20

15
26

10 19
16

5 8
2
0
Series1 Grade
2 I Grade
16 II Grade
26 III Grade
19 IV Grade
8 V

Figure 14: Graying of hair in females

70
Chart 13: NAIL CHANGES IN STUDY POPULATION

Condition Number of Individuals

Beau’s Lines 10

Dystrophy 2

Ridging 5

Loss of Lustre 40

Onycholysis 3

Onychomycosis 3

Paronychia 8

Pitting 6

Subungual Hyperkeratosis 12

Splinter Haemorrhage 2

71
 Nail changes in study group
40
35
30
25
20 40

15
10
10 12
5 8
5 6
2 3 3 2
0
Beau’ Dystr Ridgi Loss Onyc Onyc Paron Pittin Subu Splint
s ophy ng of holysi homy ychia g ngual er
Lines Lustr s cosis Hyper Haem
e kerat orrha
Series1 10 2 5 40 3 3 8 6 osis
12 ge
2

Figure 15: Nail changes in study population

20 % of the study population had loss of lustre in nails, 6 % had subungual

hyperkeratosis and 5 % had Beau’s lines. Paronychia was seen in 8 individuals,

pitting in 6, ridging in 5, Onychomycosis in 3 and and dystrophy in 2 persons.

72
 Chart 14: NAIL CHANGES IN MALES

Condition Number of Individuals

Beau’s Lines 8

Dystrophy 2

Ridging 4

Loss of Lustre 30

Onycholysis 1

Onychomycosis 2

Paronychia 1

Pitting 4

Subungual Hyperkeratosis 7

Splinter Haemorrhage 1

73
 Nail changes in Males

30
25
20
15 30
10
5 8 7
2 4 1 2 1 4 1
0 Onycholysis
Dystrophy

Onychomycosis

Subungual Hyperkeratosis
Paronychia
Ridging

Splinter Haemorrhage
Beau’s Lines

Pitting
Loss of Lustre

Figure 16: Nail changes in males

23 % of the males in study population had loss of lustre, 6.2 % had Beau’s

lines and 5 % had subungual hyperkeratosis. Onychomycosis was seen in 2

persons. Ridging and pitting were seen in 4 individuals, dystrophy in 2

individuals, splinter haemorrhage, onycholysis and paronychia were seen in 1

individual each.

74
 Chart 15: NAIL CHANGES IN FEMALES

Nail changes Number of individuals affected

Beau’s lines 2

Koilonycha 1

Ridging 1

Loss of Lustre 10

Onycholysis 2

Onychomycosis 1

Paronychia 7

Pitting 2

Splinter Haemorrhage 1

Subungual Hyperkeratosis 5

75
 Nail changes in Females

Beau’s lines
Koilonychia
16% 6% 3%
3% Ridging
3%
6% Loss of Lustre
31% Onycholysis
22% Onychomycosis
3% 6% Paronychia
Pitting
Splinter Haemorrhage
Subungual Hyperkeratosis

Figure 17: Nail changes in females

Loss of lustre was the commonest nail change observed in females

included in the study population and it was present in 14.1 %. Paronychia was

seen in 7 individuals and subungual hyperkeratosis in 5. Beau’s lines, pitting and

onycholysis were seen in 2 individuals each. Onychomycosis, splinter

haemorrhage, ridging and koilonychias were seen in 1 individual each.

76
 Chart 16: DURATION OF GERIATRIC DERMATOSES

Days 35

Months 77

Years 88

As much of 44 % of the study population had the dermatoses for more than

one year, 38.5 % had it for months ranging from 1 month and 12 months. Only

17.5 % of the study population had it for less than one month.

Chart 17: MODE OF DIAGNOSIS

Mode of diagnosis Number of cases

Clinical 177

Dermoscopy 12

Biopsy 5

KOH mount 3

Scraping 3

Majority of the diagnosis (88.5 %) was made by clinical examination

alone, 6% by dermoscopy, 5 cases were confirmed by biopsy and 3 cases were

diagnosed by KOH mount and scrapping.

77
DISCUSSION
 DISCUSSION

This study was conducted in the outpatient clinics of Department of

Dermatology and Department of Geriatrics at Rajiv Gandhi Government General

Hospital, Chennai. This is a world renowned tertiary care teaching institute

catering to the needs of not only Chennai city and its adjoining districts but also

for entire Tamilnadu and adjacent states.

GENDER DISTRIBUTION

Our study population comprises of 200 geriatric individuals who fulfilled

the inclusion criteria. Out of the 200 elderly under evaluation, 129 were male and

the rest 71 were female. Males contributed to 64.5 % of the study population and

females accounted for 35.5 %. The male : female ratio of the study population is

1.8 : 1. This percentage of study population is in accordance with the study done
(57)
by Pavithra S, Shukla P et al whose study had 64.7 % males and 35.3 %

females.

AGE OF THE STUDY GROUP

Based on age, the study group is categorized into 3 groups. 166 were

between the ages 60 to 69 years which is 83 % of the study group. 31 individuals

were between the ages 70 to 79 which contribute to 15.5 % of the study

population. Only 3 individuals were aged more than 80 years and they comprise

1.5 % of the population under study. This pattern of age distribution is similar to

the study done by Leena Raveendra et al(58) who had maximum number of patients

(62 %) between the ages 65 to 70.

78
 The mean age of the study population was 66.8 years. The youngest

participant was aged 60 years and the oldest participant was 86 years old. While

the studies in western countries had individuals aged more than 100 years

included in the study, this was not the case in our study. This might be due to the

fact that the life expectancy in India is low compared to western countries.

Another point could be that the elderly need assistance from family members for

visiting hospitals which might not be freely available.

PHYSIOLOGICAL GERIATRIC DERMATOSES

Among the physiological dermatoses in the study population, wrinkling of

skin was the commonest geriatric dermatoses encountered. Almost all the

participants had wrinkling in one form or another. This is in accordance with the

study by Pavithra S, Shukla P et al(57) who reported 99.3 % of wrinkling of skin.

The study done by Leena Raveendra et al(58) showed a lesser incidence of

wrinkling (88%) compared to our study.

WRINKLES

On further classification of wrinkling, crinkles were the most common

physiological geriatric dermatoses as per our study accounting for 146 out of the

200 study population (73 %). Glyphic wrinkles were noted in 39 patients which

is 19.5 % of the study population. Linear furrows were seen in 15 patients which

is 7.5 % of the study population.

As per our study, crinkles outnumber glyphic wrinkles and linear furrows

were seen in only 7.5 % of the study population. Linear furrows were

predominantly seen in the age group beyond 74 years.

79
 On analysis based on sex, in males crinkles were the commonest

physiological dermatoses seen in 69 % of the study population. Glyphic wrinkles

were seen in 21 % and linear furrows were seen in 8.5 % only.

In females, again crinkles were the commonest physiological geriatric

dermatoses accounting for 80.3 % of the study population. Glyphic wrinkles were

seen in16.9 % of the population and linear furrows were noted in 2 individuals.

This sort of variant analysis of cutaneous wrinkling into crinkles, glyphic wrinkles

and linear furrows was not done in other studies but wrinkling as a whole was

taken as a single diagnosis and analysis was done in them. In concurrence with

other studies, wrinkling was the commonest physiological geriatric dermatoses

present in our study population.

XEROSIS

Xerosis was present in 24.5 % of the study population, 27.1 % of the males

and 19.7 % of the females included in the study. The incidence of xerosis quoted

in other studies was widely variable ranging from 6 % to as high as 93 %.

Pavithra S, Shukla P et al (57) who had documented 6.6 % as the overall incidence

of xerosis. Various demographic and personal factors contribute to the incidence

of xerosis in a particular population. The incidence of xerosis in our study was

(33)
comparable to Sahoo A, Singh PC et al (12%) . The high incidence of xerosis

might be because of the use of harshser soaps, lack of emollient application and

use of drugs for comorbid conditions.

80
 IDIOPATHIC GUTTATE HYPOMELANOSIS

Idiopathic Guttate Hypomelanosis was present in 21.5% of the study

population. In males it was present in 19.4 % of the study population and in

females in 25.3 %. Patange VS, Fernandez RJ et al(30) and Beauregard S,

Gilchrest BA et al(60) had also reported a similar incidence of around 25% whereas

Grover, Narasimhalu et al had reported a very high incidence of 76.5%.

SENILE PRURITUS

Senile pruritus was seen in 14 % of our study population. This might be

due to the effect of multiple drugs taken for the comorbid conditions and the

manifestations of comorbid conditions per se. The incidence of pruritus in various

studies ranged from 7 % to 49.6%. DP Thapa, AK Jha et al(17) had showed an

incidence of 7.2 % of senile pruritus. The study done by Pavithra S, Shukla P et

al(57) also showed a similar incidence of senile pruritus (9.2 %).

FAVRE RACOUCHOT SYNDROME

Favre Racouchot syndrome was found in 1.5% of the study population.

1.55% of the males and 1.4% of the females included in this study had this

syndrome. This is in accordance with the results obtained by Leena Raveendra et

al(58) (2%) and Patange VS, Fernandez RJ et al(30) (3%).

81
 CUTIS RHOMBOIDALIS NUCHAE

Cutis rhomboidalis nuchae was found in 1% of the study population and

1.5 % of the males. It was present in daily wage labourers and their prolonged sun

exposure due to the nature of their work might point out towards its aetiology.

SENILE LENTIGENES

Senile lentigenes was another physiological dermatoses seen in 2 % of the

study population and its presence was also attributed to the prolonged sun

exposure. The decreased incidence of senile lentigenes when compared to other

studies such as Beauregard S, Gilchrest BA et al (36%) might be because of the

fact that senile lentigenes occur in a lesser frequency in dark skinned individuals

compared to light skinned individuals.

PATHOLOGICAL GERIATRIC DERMATOSES

Among the pathological geriatric dermatoses, benign cutaneous tumours

were the commonest ones noted in this study. 96 individuals (48%) had this

condition and the commonest benign tumour was Dermatosis Papulosa Nigra

which was found in 16.5% of the study group followed by Seborrheic kerstoses

which was present in 11.5% of the study population. Acrochordon was noted in

10.5% individuals and cherry angioma was found in 9.5% of the patients.

The incidence of benign neoplasms in various studies ranges from 37% to

(10)
88%. The study done by Abbas Darjani, Zahra Mohtasham Amiri et al in

Northern Iran had documented benign neoplasms to be the commonest

dermatological disease among elderly patients. They had noted a very high

82
incidence of 65% which might be attributable to the study location being a desert

with a very hot climate and abundant sun exposure.

In Indian context, the study done by Pavithra S, Shukla P et al(57) had also

notified benign neoplasms as the commonest pathological geriatric dermatoses

and their incidence was 80.5% which was surprisingly higher even than the

Iranian study.

No malignant cutaneous tumours were reported in our study. This

(18), (30), (58)
correlates with majority of the other studies . This might be because of

the low incidence of cutaneous malignancies in pigmented skin.

DERMATOSIS PAPULOSA NIGRA

DPN was present in 16.5% persons and it was the commonest benign

tumour present in our study group. Most of our subjects belong to the skin types

IV and V which has a strong predilection for development of DPN(4). The

incidence of DPN in males was 14.7% and females was 19.7%. Females

outnumber males since it occurs mostly in females with a darker skin

complexion(4).

SEBORRHEIC KERATOSES

Seborrheic keratoses occurred in 11.5% of the study group. In males it was

seen in 12.4% and in females 9.9%. Pavithra et al (27) reported 27.5% incidence of

the same. The incidence in both sexes was almost equal as per our study(4).

83
 ACROCHORDON

Acrochordon was found in 10.5% of our study population which was

similar to the incidence noted by Leena Raveendra et al(58) (19.5%). In males it

was 12.4% and in females it was 7%.

CHERRY ANGIOMA

Cherry angioma was seen in 9.5% of our study population which was much

less compared to the incidence quoted in the study by Beauregard and Gilchrest

(47%)(60). In males it was 11.6% and in females it was 7%.

INFECTIONS AND INFESTATIONS

Infections and infestations were the second most common pathological

dermatoses in our study population and as much as 27.5% of them were suffering

from it. Fungal infections were by far the commonest infections and were present

in 10% of the subjects. This could be attributable to the fact that our study area

being a coastal location is hot and humid which favours excessive sweating and

this in turn predisposes to fungal infection. It was more common in patients who

were wearing tight occlusive clothing which lead to maceration of the skin due to

the warm environment.

Leena Raveendra et al(58) had found an incidence of 11% and DP Thapa,

AK Jha et al(17) had documented an incidence of 11.5% which were similar to our

findings. Joan Felicita Samson, Mariam Philip et al(8) had documented a 25%

incidence of fungal infections in their study which was a bit higher compared to

our study. Among the fungal infections, Dermatophytosis was the commonest and

84
was found in 6.5% followed by Candidal infections (2%) and Onychomycosis

(1.5%).

Bacterial infections were the next most common and they were present in

9% of the study subjects. Leprosy was the commonest and was noted in 2.5%

followed by pitted keratolysis which was seen in 2%. Furunculosis and pyoderma

was seen in 1.5% each. Folliculitis, erythrasma and lupus vulgaris occurred in one

individual each.

The incidence of Leprosy was in similar lines to the results of Leena

Raveendra(58) who reported an incidence of 6%. It might be because of

overcrowding, migrant population and poverty prevalent in our study population

most of which is composed of daily wage labourers.

Pyoderma was seen in 4% of their study population while it was 1.5% in

our study. The study by Joan Felicita Samson, Mariam Philip et al(8) had 18%

incidence of bacterial infection which was marginally higher compared to our

study but the split up of bacterial infection was in similar lines to our study. DP

Thapa, AK Jha et al(17) had reported a 2.1% of bacterial infection which was quite

low. Interestingly, other than Leena Raveendra et al(58) no other studies had

documented Leprosy in their study population.

Viral infections were found in 6% of our study population and Herpes

zoster was the commonest viral infection encountered in our patients. It was

diagnosed in 4% of the study population and the commonest location was over the

thoracic and cervical dermatomes. Warts were seen in 1.5% and the most common

were plantar warts. This might be because of the habit of bare-foot walking

85
practiced by the daily wage labourers who were the predominant participants in

our study.

Pavithra S, Shukla P et al(57) had found a similar incidence of viral

infection (3.4%) and the study by DP Thapa, Ak Jha et al also reported 7%

incidence. The study by Leena Raveendra(58) had also a similar incidence (8%)

whereas the study by Joan Felicita Samson, Mariam Philip et al(8) had documented

a higher incidence (25%).

Among parasitic infections, Scabies was the only one present in 2% of our

study subjects. Leena Raveendra(58) reported an incidence of 3%, Pavithra S et

al(57) had documented an incidence of 4.9% and DP Thapa et al(17) 4.5%. All these

are comparable to our study. Intertrigo was present in 0.5% of our study

population.

PAPULOSQUAMOUS DISORDERS

Papulosquamous disorders were noted 4.5% of the study population and

Psoriasis was the commonest papulosquamous disorder noted (3%). Lichen

Planus was present in 1% and corn foot was noted in 0.5%. This incidence of

papulosquamous disorders was a bit low in comparison with the studies done by

Pavithra S, Shukla P et al(57) (12.4%), Leena Raveendra(58) (12%) and in

accordance with the study by Thapa DP, AK Jha et al(17) (3.3%). Abbas Darjani et

al had also documented a high incidence of 35.3%.

Weismann K, Krakauer R et al(18) also reported a similar incidence of

psoriasis (2.9%). Leena Raveendra et al(58) documented an incidence of 5% which

correlates with our study. Joan Felicita Samsom, Mariam Philip et al(8) and Abbas

86
Darjani et al recorded a slightly higher incidence (12.8% and 12.3% respectively).

In males 4.6% had papulosquamous disorders and Psoriasis was diagnosed

in 2.3% of them. Lichen planus and corn foot were present in 1 person each. In

females, 4.22% had papulosquamous disorders and psoriasis was present in 2

individuals and lichen planus in1 person.

BULLOUS DISORDERS

Bullous disorders were seen in 3.5% of the study population and it was in

accordance with Leena Raveendra et al(58) (1.5%), Pavithra S, Shukla P et al(57)

(4.4%) and VP Thapa, JK Jha et al(17) (1.8%). Pemphigus vulgaris was seen in

2.8% of the female subjects. Bullous pemphigoid was seen in 3.1% males and

1.4% females.

ECZEMA

Eczema was noted in 20.5% of the study subjects. Lichen simplex

chronicus was seen in 4.5% individuals, hand eczema in 3%, stasis eczema and

asteatotic eczema in 2.5% and chronic eczema in 1.5%. Contact dermatitis to

paint and turmeric were seen in 1.5%. Nummular eczema, phytophotodermatitis,

stasis ulcer and atopic dermatitis were noted in 1 individual each.

Joan Felicita Samson, Mariam Philip et al(8) (15%) and Pavithra S, Shukla

P et al(57) (19.2%) had reported a similar incidence of eczema whereas Leena

Raveendra et al(58) (31%) and DP Thapa, AK Jha et al (35.8%) reported a higher

incidence. The sub classification of incidence of eczema in our study closely

matches the study done by Pavithra S, Shukla P et al(57).

87
 Males had a almost similar incidence of eczema (21.7%) to females

(18.3%). Stasis eczema and asteatotic eczema were common in males (2.5%)

followed by airborne contact dermatitis, contact dermatitis to cement and paint

(1%). Atopic dermatitis, phytophotodermatitis, nummular eczema and prurigo

nodularis were seen in 1 individual each. Females had a higher incidence of hand

eczema and Lichen simplex chronicus (8.5%). Contact dermatitis to turmeric,

chronic eczema and photodermatitis were seen in 1 person each.

PIGMENTARY DISORDERS

Pigmentary disorders were seen in 7% of the study subjects and Vitiligo

was the commonest pigmentary disorder as per our study (4%) followed by

melasma (3%). Weismann K, Krakauer R et al(18) had reported a similar incidence

of vitligo (1.2%) whereas Leena Raveendra et al(58) had reported a higher

incidence (8%). Melasma was also reported at 5% incidence by Leena Raveendra.

Vitilgo was noted in 4.6% of males in our study population 2.8% of females.

PELLAGRA

Pellagra was noted exclusively in males in our study and 1% had this

disease. DP Thapa, AK Jha et al(17) had reported a similar incidence (1.9%). Other

studies had not documented about this disease.

COMORBID CONDITIONS

Overall, 43.5% of the study population were suffering from comorbid

conditions. 7 subjects had more than 1 comorbid condition. Analyzing the

comorbid conditions further, it was found that Diabetes Mellitus was the

88
commonest (31.5%) comorbid disease affecting both male and female study

subjects. The next commonest comorbid condtion was hypertension affecting 5%

of the study population. Varicose vein, hypothyroidism and ischaemic heart

disease were seen in 1.5% of the study population. Chronic obstructive pulmonary

disease was found in 1% of the patients. Carcinoma cervix, schizophrenia and

chronic renal failure was noted in 1 patient each.

Patange SV, Fernandez RJ et al(30) had also that 35% of their study

population had comorbid condition and diabetes mellitus was the commonest

comorbid condition affecting 9 % of their study population followed by

hypertension, asthma, ischaemic heart disease, asthma and tuberculosis. Leena

Raveendra et al(58) had reported 54% of her study population were suffering from

comorbid diseases. South Indian population was prone to the development of

diabetes mellitus and metabolic syndrome X was supposed to be common among

them because of their genetic makeup. Hence these comorbid diseases play a

crucial role in the development of geriatric dermatoses.

Diabetes mellitus was present in 29.5% of the male study population,

hypertension in 5.43% and varicose vein in 2.32%. 35% of the females had

diabetes, 4.2% had hypertension and hypothyroidism and one person had chronic

obstructive pulmonary disease.

DURATION OF DERMATOSES

Majority of the study population had dermtoses which were present for

more than a year indicating chronicity. The reason for this high proportion of

chronic nature of the disease could be due to the fact that majority of the geriatric

89
dermatoses usually don’t contribute to morbidity and mortality. So they were

neglected for quite some time before seeking medical help. Also, most of these

elderly people were dependent someone else to avail professional medical help

which might not be in the offing easily.

GRAYING OF HAIR

Graying of hair of the study population was assessed and as per our study

grade III graying of hair was prevalent among 48.5% of the study population.

21.5% of the study population had grade IV graying and 17.5% had grade V

graying of hair. 10% of the population had grade II graying and only 1% had

grade I graying. Pavithra S, Shukla P et al(57) had recorded 96.8% incidence of

graying of hair although the grading of graying was not mentioned in that study.

On examining male hair, again grade III graying was the commonest

accounting for 55% of the individuals screened followed by grade V which was

seen in 20.9% individuals. Grade IV graying was seen in 18.6%, grade II in 3.1%

and grade I graying in 2.32% study subjects.

Grade III graying was common in females too and was noted in 36.6%

female subjects. Grade IV was the next commonest with an incidence of 26.76%

and grade II in 22.5% individuals. Grade V graying was seen in 11.3% and grade I

was seen in 2.8% persons.

NAIL CHANGES

On checking for nail changes, loss of lustre was found to be most common

which was present in as much as 20% of individuals included in the study

90
followed by subungual hyperkeratosis which was present in 6%. Beau’s lines

were noted in 5%, paronychia in 4%, pitting of nails in 3%, ridging in 2.5% and

splinter haemorrhage in 1%. Dystrophy of nails were also noted in 2 individuals.

These nail changes correlates with the results of Leena Raveendra et al(58)

who had documented 44% incidence of loss of lustre. Ridging was the commonest

nail finding in their study and subungual hyperkeratosis was reported in only 1%

of their study population. Onychomycosis and paronychia had a similar incidence

when compared with our study.

Patange SV, Fernandez RJ(30) had also reported loss of lustre as the

commonest nail change (20.5%) in their study followed by longitudinal ridging

(19.5%). Subungual hyperketatosis was found to have 7% incidence which

correlates well with our results. The other findings noted in their study were

discolouration (16%), onychorrhexis (8%) and ebonization (6.5%).

In males included in our study too, loss of lustre was the commonest nail

finding accounting for 23.25% incidence followed by Beau’s lines (6.2%).

Subungual hyperkeratosis and ridging were found in 5.4% individuals. Other

findings noted were onycholysis, paronychia, splinter haemorrhage and

dystrophy.

Loss of lustre was noted in 14.1% females followed by paroncyhia which

was observed in 9.9%. Subungual hyperkeratosis was noted in 7% of the female

study population.

91
CONCLUSION
 CONCLUSION

 A total of 200 geriatric patients were analysed in this study.

 The number of male patients with geriatric dermatoses was 129 (64.5%).

 The number of female patients with geriatric dermatoses was 71 (34.5%).

 The male : female ratio was 1.8 : 1.

 Mean age of the population was 66.8 years.

 Among the physiological dermatoses crinkles were the commonest seen in

this study (73%) in both sexes.

 Benign tumours were the commonest pathological geriatric dermatoses

seen (48%) in both sexes and among them the most frequent was

Dermatosis Papulosa Nigra.

 The next commonest pathological geriatric dermatoses were infections and

among the infections fungal infections were common in both sexes.

 No malignant cutaneous tumours were reported in our study.

 Grade III graying of hair was the commonest hair change seen in the study

population (48.5%) in both sexes.

 Loss of lustre was found to be the commonest nail change in our study

population (20%) in both sexes.

 Diabetes Mellitus was the most common comorbid condition present

among the study group (31.5%).

 Most of the geriatric dermatoses were present for more than a year (44%).

92
 Majority of these dermatoses were diagnosed by clinical examination alone

(88.5%).

 The dermatological practice of the near future will certainly see a surge in

geriatric patients and hopefully the geriatric dermatoses highlighted in this

study might shed some light in understanding the cutaneous problems

faced by elderly individuals.

93
ANNEXURES
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 PROFORMA

A clinical study of Geriatric Dermatoses

Case No :

Name : Age : Sex:: OP No :

Address : Occupation :

Chief Complaints:

Duration :

Family History :
Treatment History :

Marital and Sexual history:

Past history :

Co-morbid conditions :

Hypertension

Diabetes

TB

Atopy

Immunosuppressive therapy

HIV

Transplant recipients

Malnutrition

Endocrine diseases
General examination : Sensorium

Pallor

Icterus

Cyanosis

Lymphadenopathy

Edema

Vital parameters :

Pulse Rate :

BP :

RR :

Systemic Examination : CVS

RS

Abdomen

CNS

Others
DERMATOLOGICAL EXAMINATION:

Site of involvement:

Morphology of the lesion:

Examination of hair:

Examination of nails:

Investigations:

1. Blood haemogram

2. Blood sugar

3. RFT

4. LFT

5. Blood lipid profile

6. HIV ELISA, VDRL for syphilis

7. Potassium hydroxide mount

8. Biopsy

TREATMENT GIVEN: Topical:

Systemic:
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இந் ஆராய்ச்சிய என்ை ேசர்த் ெகாள் சம்மதிக்கிே.

• நான எனக் அள�க்கப்ப ஒப்�த ப�வத்ைத� தகவல்கைள�

ப�த்� ��ந் ெகாண்ேட.

• ஒப்�த ப�வத்தி உள் தகவல்க பற்ற எனக் வ�ளக்கி

�றப்பட். ஆய்வ� தன்ை பற்ற எனக் வ�ளக்கப்பட.

• என்�ைட உ�ைமகைள�ம ெபா�ப்�கைள� ஆராய்ச்சியா

வ�ளக்கி �றினார.

• நான இ�வைர எ�த்�ள / எ�த்� ெகாண்��க் அைனத் வ�தமான

சிகிச்ை �ைறகைள�ம ஆராய்ச்சியாள� �றி�ள்ேள.

• இந் ஆராய்ச்சின ஏற்ப வாய்ப்� பாதிப்�க பற்ற வ�ளக்கப்ப.

• நான ஆராய்ச்சியாள� ஒத்�ைழப்ே என்� எனக் ஏற்படக்�

அசாதரணமான நிகழ்�க பற்றி� உடன�யாக ஆராய்ச்சியாள�

ெத�வ�ப்ேப என் உ�தி ��கிேறன.

• நான கடந் ............................. மாதங்களா ேவ� எந்தவ�தமா

ஆய்�கள�� பங்ேகற்கவ�ல.

• இந் ஆய்வ�லி�ந எப்ேபா ேவண்�மானா� எக்காரண�

�றாம�ம என்ை வ��வ�த்� ெகாள்ளலா என்பை அறிேவன.

மற்� இதனால எனக்� தரப்ப� சிகிச்ைசக எந் பாதிப்� வரா�

என்பை அறிேவன.

• ஆராய்ச்சியாளர இந் ஆய்வ� என� பங்கள�ப் எந் ேநரத்தி�,

எக்காரண� �றாமல என சம்மத இல்லாம� என்ை வ�லக்கிவ�

���ம என்பை அறிேவன.

• என்ன�ட இ�ந் ெபறப்ப� தகவல்கை அர�, வைர�ைற

அதிகா�கள ஆகிேயார்க�ட பகிர்ந ெகாள் ஆராய்ச்சியாளர்க

அ�மதி அள�க்கிேற. என்�ைட தஸ்தாேவஜுகைள பார்ைவய�

அவர்க�க உ�ைம உண்.

• என்ன�ட ெபறப்ப� தகவல்க ெபா�வாக ப�ர��க்கப்பட்,

என்�ைட அைடயாளம இரகசியமாக ைவக்கப்ப என்பை

அறிேவன.

• எனக் தி�ப்தியள�க் வைகய�ல நான ேகட் ேகள்வ�க�க் பதில

அள�க்கப்பட. இந் ஆராய்ச்சிய பங்ேகற தன்ன�ச்ைசய

��மன�டன நான சம்மதிக்கிே.

• இந் ஆய்வ� ேபா� எனக் என் சந்ேதக ஏற்பட்டா

ஆராய்ச்சியாளை ெதாடர் ெகாள்ளலா என்பை அறிேவன.

• இந் ஒப்�த ப�வத்தி ைகெய�த்தி�வதி �லம இங் தரப்ப�

அைனத் தகவல்க� ெதள�வாகக �றப்பட என்னா ��ைமயாகப

��ந் ெகாள்ளப்பட என்பைத சான்றள�க்கிே. இந் ஒப்�த

ப�வத்தி நகல என்னா ெபற்� ெகாள்ளப்பட.

பங்ேகற்பவ ைகெயாப்ப ஆய்வாள� ைகெயாப்ப:

/ கட்ைடவ�ர ேரைக:
ஆய்வாள� ெபயர :
இடம : ம�.எம.ைவரப�ரபா ேதவ�
ேததி :
இடம :
பங்ேகற்பவ ெபயர /
ேததி :
வ�லாசம:
 PATIENT CONSENT FORM

Title of the study: Clinical study of geriatric dermatoses

Name of the Participant:

Name of the Principal investigator: Dr.VAIRAPRABHA DEVI M.

Name of the Institution: Rajiv Gandhi Government General Hospital, Chennai

Documentation of the informed consent

I ___________________________ have read the information in this form (or it has been

read for me). I was free to ask any questions and they have been answered. I am over 18

years of age and exercising my free power of choice, hereby give my consent to be

included as a participant in the study.

1. I have read and understood this consent form and the information provided to me.

2. I have had the consent document explained to me.

3. I have been explained about the nature of the study.

4. My rights and responsibilities have been explained to me by the investigator.

5. I have informed the investigator of all the treatments I am taking or have taken in the

past.

6. I agree to cooperate with the investigator and I will inform her immediately if I suffer

unusual symptoms.

7. I have not participated in any research study at any time .

8. I am aware of the fact that I can opt out of the study at any time without having to give

any reason and this will not affect my future treatment in this hospital.

9. I hereby give permission to the investigators to release the information obtained from
me as a result of participation in this study to the sponsors ,regulatory authorities,

Governmentt agencies and IEC. I understand that they are publicly presented.

10. My identity will be kept confidential if my data are publicly presented.

11. I have had my questions answered to my satisfaction.

12. I have decided to be included in this research study.

13. I am aware that if I have any question during this study, I should contact at one of the

addresses listed above. By signing this consent form I attest that the information given in

this document has been clearly explained to me and apparently understood by me. I will

be given a copy of this consent document.

Participant’s initials:_______________

Name and signature/thumb impression of the participant (or legal representative if

participant incompetent)

_______________ _________________ _________________

Name Signature Date

Name and signature of impartial witness (required for illiterate patients):

________________ __________________ _________________

Name Signature Date

Address and contact number of the impartial witness:

Name and Signature of the investigator or his representative obtaining consent:

________________ __________________ ________________

Name Signature Date

PLAGIARISM REPORT
Digital Receipt
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inf ormation regarding your submission.

T he f irst page of your submissions is displayed below.

Submission author: Vairaprabha Devi M 201530001

Assignment title: 2015-2015 plagiarism
Submission title: Clinical Study of Geriatric Dermato…
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 ABBREVIATIONS

CBC - Complete blood count

COPD - Chronic Obsrtuctive Pulmonary Disease

CRF - Chronic Renal Failure

DPN - Dermatosis Papulosa Nigra

ELISA - Enzyme Linked Immunosorbent Assay

ESR - Erythrocyte Sedimentation Rate

HIV - Human Immunodeficiency virus

HPE - Histopathological Examination

IGH - Idiopathic Guttate Hypomelanosis

IL - Interleukin

KOH - Potassium hydroxide

LSC - Lichen Simplex Chronicus

LFT - Liver Function Test

RGGGH - Rajiv Gandhi Government General Hospital

RFT - Renal Function Test

SK - Seborrheic keratoses

TFT - Thyroid Function Test

VDRL - Venereal Disease Research Laboratory

 Addition Addition Addition Comorbi
Mode of
Occupati Diagnosi al al al d Graying
Sl No. Name Age Sex Duration Location diagnosi Wrinkles Nails
on s Diagnosi Diagnosi Diagnosi conditio of hair
s
s s2 s3 n
1,
Plantar 6 Right
1 Raja 60 M Cooly IGH Clinical Tempora Crinkles
wart months Sole
l
3,
Seborrhe
Tempora
Acrocho ic Diabetes
2 Farhan 65 M Driver 5 years Neck DPN Clinical l, Crinkles
rdon keratose Mellitus
Occipita
s
l

Diabetes
Seborrhe
Mellitus, 2,
ic 6 Senile
3 Arun 68 M Artist Face DPN Xerosis Ischemic Clinical Tempora Crinkles
keratose months Pruritus
Heart l
s
Disease

Asteatoti Left 1,
4 Jeeva 62 M Labourer c 3 years Lower xerosis Clinical Tempora Crinkles
eczema limb l
3,
Policem Stasis Right Tempora
5 Suresh 64 M 2 years xerosis Clinical Crinkles
an eczema leg l,
Parietal
4,
Seborrhe
temporal
Vasanth ic Glyphic
6 66 M Farmer 3 years Face Clinical ,
an keratose wrinkles
parietal,
s
vertex
Contact
2,
Vinotha dermatiti Legs, Glyphic
7 62 M Mason 2 years Clinical Tempora
n s to Arms wrinkles
l
cement
Seborrhe
4, All
Palaniap Watchm ic Diabetes
8 69 M 5 years Face DPN IGH Clinical over the Crinkles
pan an keratose Mellitus
scalp
s
Right 5, All
Chithras Furuncul Diabetes Linear Beau's
9 70 M Vendor 1 week Gluteal IGH Clinical over the
enan osis Mellitus Furrows Lines
region scalp

Right 1,
Marimut Stasis Acrocho Diabetes Glyphic Beau's
10 65 M Cooly 1 year medial Clinical Tempora
hu Ulcer rdon Mellitus wrinkles Lines
leg l

Contact Dermato
2,
Jeyanthi Housewi dermatiti 6 sis Diabetes
11 72 F Neck IGH Clinical Frontal, Crinkles
Kumar fe s to months Papulosa Mellitus
Parietal
turmeric Nigra
Sujatha Senile 2,
12 Chiranje 65 F Cooly Comedo 1 year Face IGH Clinical Frontal, Crinkles
evi ne Parietal
Lichen 3,
Leelatha Simplex Right Diabetes Tempora Dystrop
13 70 M Cooly 1 year IGH Clinical Crinkles
ran Chronic leg mellitus l, hic nails
us Parietal
2,
Gopinat Acrocho Legs, Cherry Loss of
14 65 M Vendor 5 years IGH COPD Clinical Tempora Crinkles
han rdon Arms angioma lustre
l
seborrhe
Bhackial Housewi ic Face, 2,
15 60 F 1 year Clinical Crinkles
akshmi fe keratose scalp Frontal
s
4, All
Pandiya Acrocho neck and
16 66 M Plumber 4 weeks IGH Clinical over the Crinkles
n rdon axilla
scalp
neck, 5, All
6 Acrocho Beau's
17 Dhanraj 62 M Cooly Pellagra dorsal Clinical over the Crinkles
months rdon Lines
hand scalp
 3,
Pitted Tempora
Sasiman 6 Sole, Diabetes Loss of
18 62 F Driver Keratoly Clinical l, Crinkles
i months plam Mellitus lustre
sis Parietal,
vertex
Dermato 4,
sis Diabetes frontal,
19 Meera 64 F Cooly 1 year face Clinical Crinkles
Papulosa Mellitus parietal,
Nigra vertex
4,
temporal
Benjami Watchm Senile 4 Cherry Schizopr Beau's
20 63 M Trunk xerosis Clinical , Crinkles
nvasan an Pruritus months angioma enia Lines
parietal,
vertex
Asteatoti Left 2,
Krishna 6 Cherry Diabetes Beau's
21 65 M Landlord c lower Xerosis HPE Tempora Crinkles
moorthy months angioma Mellitus Lines
eczema Limb l

2,
Housewi 6 Diabetes
22 Kamala 62 F Melasma face Clinical Frontal, Crinkles
fe months Mellitus
Parietal

5, All
Janardha Senile All over Diabetes
23 65 M Cooly 1 year DPN Clinical over the Crinkles
nan Pruritus the body Mellitus
scalp

2,
Gunasel Cherry 6 Trunk, Diabetes Glyphic
24 65 F Maid DPN Clinical frontal,
vi angioma months thighs Mellitus wrinkles
vertex
4,
temporal
Senile All over Diabetes Glyphic
25 Rajaram 65 M Labourer 2 years xerosis DPN Clinical ,
Pruritus the body Mellitus wrinkles
parietal,
vertex
3,
Dermato
Tempora
chinnad sis 6 Loss of
26 66 M Cooly face IGH Clinical l, Crinkles
urai Papulosa months lustre
parietal,
Nigra
vertex
Seborrhe
2,
Umavath ic Diabetes
27 62 F Maid 10 years neck Clinical frontal, Crinkles
y keratose Mellitus
parietal
s

Hypothy
roid,
Diabetes 4, All
Sangeet Housewi Pustular All over
28 65 F 1 week Mellitus, Clinical over the Crinkles Pitting
ha fe Psoriasis the body
Hyperte scalp
nsion,
COPD

4,
Lichen Dermato
Frontal,
Simplex Right sis
29 Stella 66 F Cooly 1 month Clinical parietal, Crinkles
Chronic ankle Papulosa
vertex,
us Nigra
temporal
3,
Senile Tempora
Dhanase Cherry Trunk,
30 63 M Cooly 1 year xerosis Lentigen Clinical l, Crinkles
karan angioma thighs
es parietal,
vertex
Seborrhe
Senile 5, all
Rajaseka ic face, Acrocho
31 74 M cooly 2 years comedo Diabetes Clinical over the Crinkles
ran keratose neck rdon
nes scalp
s
3, subungu
Marimut Tinea Cherry Tempora al
32 68 M cooly 1 month Trunk Diabetes Clinical Crinkles
hu corporis angioma l, hyperker
Parietal atosis
subungu
Rt big 5, all
Kamaldo Onycho al
33 67 M Vendor 1 month toe, 4th IGH Diabetes Scraping over the Crinkles
ss mycosis hyperker
toe scalp
atosis
 Dermato
4, All
Vasanth Housewi Centrofa sis
34 65 F Melasma 2 years Clinical over the Crinkles
y fe cial Papulosa
scalp
Nigra
Seborrhe
ic face, 2,
35 Priscilla 66 F maid 5 years DPN Clinical Crinkles
keratose neck Frontal
s
3,
Nagaraja Tinea Tempora
36 65 M finance 2 weeks Groin Clinical Crinkles
n cruris l,
Parietal
5, all
Erythras
37 Sam 62 M cooly 1 month Axilla Diabetes Clinical over the Crinkles
ma
scalp
4,
right Frontal,
Shenbag Housewi Loss of
38 69 F IGH 5 years lower Diabetes Clinical parietal, Crinkles
adevi fe lustre
limb vertex,
temporal
5, all
Venmad Hand 6 both
39 63 F Maid Clinical over the Crinkles
hi eczema months hands
scalp
4,
Post
Right temporal
herpetic
40 Zohana 65 F Maid 1 month lateral Diabetes Clinical , Crinkles
neuralgi
chest parietal,
a
vertex
5, all
Glyphic
41 Sathya 66 M Cooly Vitiligo 1 year both legs Diabetes Clinical over the
wrinkles
scalp
3,
Watchm acral, frontal,
42 Solomon 68 M Vitiligo 3 years Clinical Crinkles
an mucosal parietal,
vertex
Lichen 3, subungu
Padmash Housewi simplex nape of frontal, al
43 68 F 1 month DPN IGH Clinical Crinkles
ree fe chronicu neck parietal, hyperker
s vertex atosis
subungu
5, all
Lichen both al
44 Priyanka 65 F Vendor 1 month Clinical over the Crinkles
planus forearm hyperker
scalp
atosis
3,
Valarma Hand Right frontal, Glyphic Beau's
45 64 F Vendor 1 month IGH Clinical
thy eczema palm parietal, wrinkles Lines
vertex
Pitting,
trunk, 4, All subungu
kalaiselv HT, Clinical,
46 69 M Cooly Psoriasis 6 years elbow, over the Crinkles al
an diabetes biopsy
knee scalp hyperker
atosis
3,
Dermato
Tempora
Kothai Auto sis Glyphic
47 64 M 1 month face HT, IHD clinical l,
Raja driver Papulosa wrinkles
parietal,
Nigra
vertex
5, all
real Lower Senile Glyphic
48 Mohan 65 M Xerosis 1 year IGH Diabetes clinical over the
estate limb Pruritus wrinkles
scalp
vulvova 3,
Esakiam
ginal 6 vulvova frontal, Paronyc
49 mal 60 F Maid Diabetes clinical Crinkles
candidia months ginal parietal, hia
Rose
sis vertex
Dermato 3,
Pushpar
Housewi sis frontal,
50 ani 68 F Melasma 5 years malar clinical Crinkles
fe Papulosa parietal,
Kumar
Nigra vertex
3,
Ganga Tempora
Electrici Senile All over Glyphic
51 Muruga 66 M 1 month xerosis Diabetes clinical l,
an Pruritus the body wrinkles
n parietal,
vertex
 Pitting,
3,
subungu
Parames Pustular All over frontal, Glyphic
52 64 M Foreman 15 days Clinical al
hwaran Psoriasis the body parietal, wrinkles
hyperker
vertex
atosis
3,
Face, Tempora
Mahesw Vitiigo
53 69 M Painter 2 years trunk, clinical l, Crinkles
ar vulgaris
arms parietal,
vertex
5, all
Karupas acral, Linear
54 75 M Landlord Vitiligo 8 years clinical over the
amy mucosal Furrows
scalp
3,
Nandhak Senile Lower diabetes, Tempora Loss of
55 78 M clerk 1 month xerosis IGH clinical Crinkles
umar Pruritus limb HT l, lustre
Parietal
3,
Lower Tempora
Venkate Linear
56 76 M Vendor Vitiligo 10 years limb, clinical l,
sh Furrows
trunk parietal,
vertex
4,
Frontal,
Housewi Tinea abdome Linear Loss of
57 Chandra 74 F 2 weeks IGH Diabetes clinical parietal,
fe corporis n Furrows lustre
vertex,
temporal
Dermato
4, All
Senile All over sis
58 Kavitha 74 F maid 1 month Xerosis Diabetes clinical over the Crinkles
Pruritus the body Papulosa
scalp
Nigra
web
space, 4, All
Vaijaynt Housewi
59 64 F scabies 4 days peri clinical over the Crinkles
hi fe
umbilica scalp
l
3,
Housewi frontal,
60 Eswari 66 F IGH 1 week both legs clinical Crinkles
fe parietal,
vertex
oral,
Pemphig 2,
genital,
61 Jeniffer 65 F Maid us 15 days diabetes clinical frontal, Crinkles
upper
vulgaris parietal
trunk
3,
Pitted Tempora
Muthuk both Paronyc
62 65 M Plumber Keratoly 1 month xerosis clinical l, Crinkles
umar Sole hia
sis parietal,
vertex
3,
Tempora
Corn 6 Right
63 Balaji 62 M finance clinical l, Crinkles
foot months foot
parietal,
vertex
Pitting
and
3, all
shop Psoriasis Palmopl subungu
64 Rawther 65 M 5 years Diabetes clinical over the Crinkles
owner vulgaris antar al
scalp
hyperker
atosis
3,
Extensor
Tempora
aspect of
65 Rajiv 69 M Vendor Psoriasis 5 years clinical l, Crinkles Pitting
extremiti
parietal,
es
vertex
4,
Bullous trunk, temporal
Glyphic Paronyc
66 Nagaraj 68 M cooly pemphig 1 month extremiti diabetes biopsy ,
wrinkles hia
oid es parietal,
vertex
Prurigo Both 3, all
Anandha Electrici
67 64 M nodulari 1 month Lower clinical over the Crinkles
m an
s limb scalp
 4,
Seborrhe
temporal
ic 6
68 Kesavan 65 M cooly Face IGH DPN clinical , Crinkles
keratose months
parietal,
s
vertex
Favre 3,
raucoch Tempora
Raghava Glyphic
69 64 M Vendor ot 1 year face clinical l,
n wrinkles
syndrom parietal,
e vertex
3, all
Senile Left
70 Kathick 65 M 1 month clinical over the Crinkles
purpura forearm
scalp
Bullous 4, All Nail
Dillibab Watchm 6 extremiti Hyperte
71 62 M pemphig clinical over the Crinkles dystroph
u an months es nsion
oid scalp y
3,
cutis
Tempora
Bakthav rhomboi Glyphic
72 85 M Painter 1 year neck clinical l,
atchalam dalis wrinkles
parietal,
nuchae
vertex
3,
Seborrhe
Bullous Tempora
retired 3 extremiti ic Nail
73 Kannan 65 M pemphig Diabetes clinical l, Crinkles
lineman months es, trunk keratose ridging
oid parietal,
s
vertex
Retired Bullous trunk, 3, all
Marimut
74 64 M govt pemphig 1 month extremiti clinical over the Crinkles
hu
servant oid es scalp
5, all
Acrocho neck, Linear
75 Prabhak 76 M 1 year clinical over the
rdon axilla Furrows
aran scalp
4, All
Sugandh Housewi Herpes 5 Ca Paronyc
76 66 F T9 clinical over the Crinkles
i fe Zoster days cervix hia
scalp
Diabetes
Pemphig 5, all
6 , Paronyc
77 Geetha 65 F maid us oral clinical over the Crinkles
months Hyperte hia
vulgaris scalp
nsion
4, All
Shakila Lower Senile Onycho
78 66 F maid Xerosis 1 month IGH Diabetes clinical over the Crinkles
Banu limb Pruritus mycosis
scalp
vulvova subungu
KOH 2,
Housewi ginal al
79 Kavina 64 F 1 month genital IGH Diabetes examina frontal, Crinkles
fe candidia hyperker
tion parietal
sis atosis
3,
left
Tempora
Housewi thumb, Senile Paronyc
80 Lakshmi 69 F Xerosis 1 month clinical l, Crinkles
fe index Pruritus hia
parietal,
finger
vertex
5, all
Herpes
81 Devendr 65 M finance 2 days T5, 6 clinical over the Crinkles
Zoster
an scalp
Post
5, all
Srinivas real herpetic
82 68 M 1 month L3, 4 clinical over the Crinkles
an estate neuralgi
scalp
a
Left 3, all
Vajith Verruca 3
83 69 M finance forearm xerosis clinical over the Crinkles
Ali vulgaris months
wrist scalp
3,
Tempora
Muruga real Herpes
84 63 M 3 days lower lip CRF clinical l, Crinkles
n estate Labialis
parietal,
vertex
3, all
Kumares Herpes
85 64 M business 3 days L2, 3 clinical over the Crinkles
an Zoster
scalp
4,
temporal
real Tinea
86 Gopi 62 M 2 weeks Groin clinical , Crinkles
estate cruris
parietal,
vertex
 3,
Balasbra Tinea Tempora
87 64 M clerk 2 weeks Trunk clinical Crinkles
manian corporis l,
Parietal
Seborrhe
3, all
Venkate shop Acrocho Neck, ic
88 62 M 1 month DPN clinical over the Crinkles
san assistant rdon axilla keratose
scalp
s

v area of 3, all
Maykan Watchm 6
89 61 M Pellagra neck,dor xerosis IGH clinical over the Crinkles
nan an months
sal hand scalp

Both 5, all
Senile Glyphic Loss of
90 Jeyakum 71 M Plumber 1 month Lower IGH Xerosis clinical over the
Pruritus wrinkles lustre
ar limb scalp
5, all
Conduct Stasis Varicose Loss of
91 Jacobraj 62 M 1 year Left leg clinical over the Crinkles
or ® eczema vein lustre
scalp
Seborrhe
3, all
Purushot Hand 3 Right ic Linear Beau's
92 76 M Cook clinical over the
haman eczema months hand keratose Furrows Lines
scalp
s
3,
Airborne
Face, Tempora
Gardern contact Acrocho Glyphic
93 Babu 72 M 1 year trunk, IGH clinical l,
er dermatiti rdon wrinkles
arms parietal,
s
vertex
Allergic
contact Arms, 5, all
Glyphic
94 Kesavan 73 M Mason dermatiti 3 years legs, clinical over the
wrinkles
s to trunk scalp
cement
3,
Stasis Varicose Tempora
95 Nagaraj 68 M clerk ® 1 year legs clinical Crinkles
ulcer vein l,
Parietal
5, all
Vijayala Housewi Furuncul Right
96 66 F 2 weeks xerosis diabetes clinical over the Crinkles
kshmi fe osis thigh
scalp
vulvova
KOH 4, All
ginal vulvova Glyphic
97 Selvi 65 F maid 1 month diabetes examina over the
candidia ginal wrinkles
tion scalp
sis
3,
Banumat Housewi frontal,
98 63 F Melasma 3 years malar IGH clinical Crinkles
hy fe parietal,
vertex
Lichen subungu
5, all
simplex Glyphic al
99 Seetha 68 F maid 1 year left leg xerosis clinical over the
chronicu wrinkles hyperker
scalp
s atosis
3,
chronic frontal,
100 Kamala 60 F vendor 2 years right leg clinical Crinkles
eczema parietal,
vertex
3,
frontal,
101 Kavitha 62 F Vendor IGH 1 year right leg DPN clinical Crinkles
parietal,
vertex
Pitted 5, all
Glyphic Beau's
102 Abiya 64 F cooly Keratoly 1 month sole diabetes clinical over the
wrinkles Lines
sis scalp
3,
shop frontal,
103 Anandhi 68 F scabies 1 week fingers clinical Crinkles
keeper parietal,
vertex
face,
Dhanala Housewi 1,
104 66 F Vitiligo 4 years trunk clinical Crinkles
kshmi fe frontal
arm
Dermato 3,
Housewi sis face, frontal,
105 Sunitha 65 F 2 years IGH clinical Crinkles
fe Papulosa neck parietal,
Nigra vertex
 2,
Seeniam Senile All over
106 69 F cook 1 month xerosis IGH clinical frontal, Crinkles
mal Pruritus the body
parietal
atopic 3, all
6
107 Vadivel 65 M cooly dermatiti flexures clinical over the Crinkles
months
s scalp
3,
Lichen subungu
Tempora
simplex 6 Acrocho Glyphic al
108 Jacob 68 M Vendor right leg Xerosis diabetes clinical l,
chronicu months rdon wrinkles hyperker
parietal,
s atosis
vertex
4,
Contact lichen
temporal
Marimut Dermatit both simplex Loss of
109 65 M Painter 1 month clinical , Crinkles
hu is to hands chronicu lustre
parietal,
paint s
vertex
4,
temporal
Hand 6 right Loss of
110 Selvaraj 62 M cook xerosis clinical , Crinkles
eczema months hand lustre
parietal,
vertex
Asteatoti 3, all
shop
111 Jayaraj 61 M c 1 year both legs clinical over the Crinkles
owner
eczema scalp
5, all
Arockias real Senile Loss of
112 65 M 20 days both legs xerosis diabetes clinical over the Crinkles
amy estate Pruritus lustre
scalp
3,
Housewi Senile All over frontal,
113 Kavitha 68 F 1 month IGH Xerosis clinical Crinkles
fe Pruritus the body parietal,
vertex
right 4, All
Housewi Tinea
114 Sariga 69 F 15 days forearm, diabetes clinical over the Crinkles
fe corporis
trunk scalp
Both
Lower
Bullous
6 limb, 1,
115 Mohana 62 F finance pemphig diabetes clinical Crinkles
months right frontal
oid
upper
limb
3,
both paronyc
Amarava Senile frontal,
116 63 F maid Xerosis 20 days lower clinical Crinkles hia, Loss
thy Pruritus parietal,
limbs of lustre
vertex
3, all
real Senile lower Loss of
117 Jamal 68 M 1 month xerosis IGH diabetes clinical over the Crinkles
estate Pruritus limbs lustre
scalp
4,
Left temporal
Parandh Electrici folliculit
118 62 M 10 days Lower diabetes clinical , Crinkles
aman an is
limb parietal,
vertex
3, all
Parthiba Acrocho
119 65 M cooly 2 years neck diabetes clinical over the Crinkles
n rdon
scalp
3,
Tempora
Mohame shop Senile 6 All over Linear Loss of
120 79 M IGH Xerosis clinical l,
d owner Pruritus months the body Furrows lustre
parietal,
vertex
Airborne
3, all
Manimo contact 6 face,
121 63 M finance clinical over the Crinkles
zhian dermatiti months trunk
scalp
s
4,
Seborrhe
temporal
Sakthika ic
122 82 M cooly 2 years face IGH Xerosis clinical , Crinkles
nnan keratose
parietal,
s
vertex
upper trophic
back ulcer in
2, Koilony
Subhash Housewi with lateral
123 65 F Leprosy 5 years clinical frontal, Crinkles chia,
ree fe right ankle of
parietal Ridging
claw right
hand foot
 cutis
3, all
Vadamal Gardern rhomboi Linear Loss of
124 86 M 5 years neck clinical over the
lian er dalis Furrows lustre
scalp
nuchae
3,
Santhak Watchm senile 5 all over Tempora Linear Loss of
125 74 M IGH Xerosis clinical
umar an pruritus months the body l, Furrows lustre
Parietal
4,
Frontal,
Sentham senile all over Loss of
126 79 M Landlord 1 year xerosis clinical parietal, Crinkles
izh pruritus the body lustre
vertex,
temporal
3,
Vijayash Hand Right Cherry frontal, Loss of
127 68 F maid 4 years clinical Crinkles
ree eczema hand angioma parietal, lustre
vertex
4,
Frontal,
Plantar right Paronyc
128 Seetha 65 F vendor 1 year clinical parietal, Crinkles
wart sole hia
vertex,
temporal

right 3, subungu
Rajeswa Housewi Onycho third and frontal, Glyphic al
129 64 F 2 years xerosis Scraping
ri fe mycosis fourth parietal, wrinkles hyperker
toe vertex atosis
vulvova
KOH 4, All
ginal vulvova Acrocho Paronyc
130 Meena 64 F maid 1 month DPN diabetes examina over the Crinkles
candidia ginal rdon hia
tion scalp
sis
3,
Muthula Centrofa frontal, Glyphic
131 65 F cooly Melasma 4 years IGH clinical
ksmi cial parietal, wrinkles
vertex
4,
Seborrhe
Frontal,
shop ic Acrocho
132 Deepa 69 F 4 years face DPN clinical parietal, Crinkles
owner keratose rdon
vertex,
s
temporal
3,
Psoriatic Onychol
Vetriviz 6 All over frontal,
133 72 F vendor Erythrod diabetes clinical Crinkles ysis and
hi months the body parietal,
erma Pitting
vertex
3,
Tempora
Mozhiar Acrocho Neck, cherry Linear
134 77 M cooly 2 years DPN IGH diabetes clinical l,
asan rdon axilla angioma Furrows
parietal,
vertex
4,
temporal Transver
Sivaram Stasis Glyphic
135 69 M maid 2 years left leg diabetes clinical , se
an eczema wrinkles
parietal, ridging
vertex
3, all
pyoderm
136 Premaraj 66 M cooly 10 days face diabetes clinical over the Crinkles
a
scalp
4,
Seborrhe
temporal
Rajlaksh ic Cherry Acrocho
137 65 M cooly 2years face clinical , Crinkles
mnan keratose angioma rdon
parietal,
s
vertex
Asteatoti Both 3, all
138 Amalan 66 M Painter c 2 years lower biopsy over the Crinkles
eczema limbs scalp
3,
Usha
Housewi Tinea abdome frontal, Glyphic Loss of
139 Aruljoth 70 F 1 month clinical
fe corporis n parietal, wrinkles lustre
i
vertex
Pitting
face, 2,
and
140 Revathi 68 F maid Vitiligo 3 years trunk diabetes clinical frontal, Crinkles
Onychol
arm parietal
ysis
 Lichen 3,
Kavimoz simplex 3 Acrocho frontal,
141 62 F maid left leg clinical Crinkles
hi chronicu months rdon parietal,
s vertex
Seborrhe 3,
Housewi ic Acrocho frontal,
142 Indhu 64 F 2 years face DPN clinical Crinkles
fe keratose rdon parietal,
s vertex
Pitted 2,
Kalaivan Housewi Cherry acrochor Glyphic Loss of
143 62 F Keratoly 1 month left sole DPN clinical frontal,
i fe angioma don wrinkles lustre
sis parietal
upper
5, All
Sandhya 6 arms, V Dystrop
144 61 M cooly pellagra clinical over the Crinkles
raj months area of hy
scalp
neck
3,
Asteatoti both Tempora
Sharath 6 senile Glyphic Loss of
145 69 M Landlord c lower xerosis IHD clinical l,
mani months pruritus wrinkles lustre
eczema limbs parietal,
vertex
3,
Tempora
real 6 Loss of
146 Suresh 68 M IGH left arm xerosis clinical l, Crinkles
estate months lustre
parietal,
vertex
4,
seborrhe
temporal
real ic Loss of
147 Sheik 68 M 1 year face xerosis diabetes clinical , Crinkles
estate keratose lustre
parietal,
s
vertex
senile 3, all
kathikey both
148 67 M vendor lentigen 2 years DPN clinical over the Crinkles
an forearms
es scalp
4, All Splinter
Housewi Tinea Hyperte Linear
149 Devi 78 F 15 days Chest clinical over the Haemorr
fe corporis nsion Furrows
scalp hage
3,
both
Sivasank Senile frontal, Loss of
150 67 F maid Xerosis 1 year lower IGH clinical Crinkles
ari Pruritus parietal, lustre
limbs
vertex
seborrhe
3, all Longitu
Muthusa ic face,
151 65 M mason 2 years diabetes clinical over the Crinkles dinal
ravanan keratose neck
scalp ridging
s
trophic
ulcer in
Leproma 3, all Onychol
Subrama Lepra lateral
152 67 M Plumber tous 2 years clinical over the Crinkles yis and
ni facies ankle of
leprosy scalp ridging
right
foot
ichthyoti 3,
Borderli
Surya c patch Tempora
ne trophic Beau's
153 Elavaras 66 M vendor 2 years over clinical l, Crinkles
lepromat ulcer Lines
an back of parietal,
ous
trunk vertex

ichthyoti
c patch
Leproma 4, All
Priya over trophic Beau's
154 68 M vendor tous 2 years clinical over the Crinkles
Prakash right ulcer Lines
leprosy scalp
gluteal
region

ichthyoti
Arimuth
Leproma c patch 3, all
u shop Acrocho Loss of
155 69 M tous 1 year over the DPN diabetes clinical over the Crinkles
Eswarak assistant rdon lustre
leprosy leftglute scalp
annan
al region

3,
right Tempora
Santhos senile acrochor
156 70 M cooly 1 month lower xerosis DPN diabetes clinical l, Crinkles
h pruritus don
limb parietal,
vertex
 5, all
Electrici intertrig cherry Linear
157 Satish 74 M 2weeks groin DPN Xerosis diabetes clinical over the
an o groin angioma Furrows
scalp
invertor 5, all
Meganth chronic 6 Onycho
158 73 M technicia left leg IGH clinical over the Crinkles
an eczema months mycosis
n scalp
left ring subungu
3, all
Saravana onycho finger, al
159 76 M Landlord 1 month IGH diabetes scraping over the Crinkles
n mycosis middle hyperker
scalp
finger atosis
tinea trunk 5, all
Jambuli Linear Loss of
160 78 M vendor corporis, 14 days and clinical over the
ngam Furrows lustre
cruris groin scalp
3, all
stasis Hyperte Loss of
161 Benny 65 M cooly 1 year left leg xerosis clinical over the Crinkles
eczema nsion lustre
scalp
3,
Kalpana
Housewi herpes frontal,
162 venkates 65 F 4 days L3,4 diabetes clinical Crinkles
fe zoster parietal,
h
vertex

ulnar
3,
aspect of
Housewi frontal, Loss of
163 Indhu 67 F scabies 4 days forearm, xerosis clinical Crinkles
fe parietal, lustre
webspac
vertex
e

Viji 2,
Housewi tinea upper Loss of
164 Purushot 62 F 2 weeks IGH clinical frontal, Crinkles
fe corporis chest lustre
haman parietal
3,
Tempora
pyoderm
165 Rajesh 72 M cooly 1 week left leg diabetes clinical l, Crinkles
a
parietal,
vertex
3, all Splinter
Raghava Acrocho neck, Senile Hyperte
166 70 M cooly 2 years DPN Xerosis clinical over the Crinkles Haemorr
n rdon axilla Pruritus nsion
scalp hage
5, all
Saravana tinea Cherry Glyphic Loss of
167 70 M cooly 2 weeks face DPN clinical over the
n faciei angioma wrinkles lustre
scalp
tinea 3, all
Appanra chest, Glyphic Onycho
168 69 M vendor corporis, 2 weeks clinical over the
j groin wrinkles mycosis
cruris scalp
both 5, all
Santhosa Senile
169 68 M Painter xerosis 1 year lower clinical over the Crinkles
m Pruritus
limbs scalp
5, all
real herpes
170 Nagaraj 65 M 4 days T 7,8 clinical over the Crinkles
estate zoster
scalp
3, all
Thirugn real tinea Glyphic Loss of
171 66 M 10 days trunk IGH clinical over the
anam estate corporis wrinkles lustre
scalp
3,
Senile Tempora
Vishwan tinea upper Loss of
172 62 M business 15 days Lentigen clinical l, Crinkles
athan corporis arm lustre
es parietal,
vertex
subungu
both 4, All
Lichen 6 al
173 Agilan 60 M finance lower clinical over the Crinkles
planus months hyperker
limbs scalp
atosis
3,
Left Tempora
Parthiba lupus 3 Cherry
174 64 M Landlord dorsum biopsy l, Crinkles
n vulgaris months angioma
of foot parietal,
vertex
4,
seborrhe
temporal
Priyadha ic Loss of
175 61 M business 4 weeks face DPN Xerosis clinical , Crinkles
rshan keratose lustre
parietal,
s
vertex
3, all
Seethala 4 all over Senile Loss of
176 68 M cooly xerosis clinical over the Crinkles
kshman months the body Pruritus lustre
scalp
 4,
seborrhe
Senile temporal
Vijayaku ic face, Cherry Glyphic
177 67 M vendor 1 year Lentigen clinical ,
mar keratose neck angioma wrinkles
es parietal,
s
vertex
3, all
chronic 6 Onycho
178 Ramesh 64 M Painter left leg clinical over the Crinkles
eczema months mycosis
scalp
Lichen 3,
Viswana simplex Tempora
179 69 M Plumber 1 year right leg clinical Crinkles
than chronicu l,
s Parietal
4, All
senile neck, hypothyr
180 Shobana 68 F finance 1 year xerosis clinical over the Crinkles
pruritus axilla oidism
scalp
2,
Housewi 5 all over Senile hypothyr Glyphic Loss of
181 Sheeba 72 F Xerosis clinical frontal,
fe months the body Pruritus oidism wrinkles lustre
parietal
4,
Frontal,
Prabhav Housewi
182 60 F Melasma 1 year forehead xerosis clinical parietal, Crinkles
athy fe
vertex,
temporal
2,
Housewi photoder 6 left Glyphic Onycho
183 Ranjani 60 F clinical frontal,
fe matitis months forearm wrinkles mycosis
parietal
3,
Tempora
Madhura Housewi furuncul right Cherry
184 68 M 1 week diabetes clinical l, Crinkles
i fe osis thigh angioma
parietal,
vertex
right 5, all
pyoderm Glyphic
185 Muthu 69 M vendor 5 days lower clinical over the
a wrinkles
limb scalp
3,
Dermato
Tempora
sis Cherry
186 Manohar 64 M cooly 20 days face clinical l, Crinkles
Papulosa angioma
parietal,
Nigra
vertex
Nummul right 5, all
Glyphic Loss of
187 Chandru 63 M cooly ar 1 year lower clinical over the
wrinkles lustre
eczema limb scalp
contact dorsum 3, all
shop Loss of
188 Raju 62 M dermatiti 1 month of both clinical over the Crinkles
assistant lustre
s foot scalp
phytoph 5, all
face, Glyphic
189 Kalidoss 61 M cooly otoderm 1 year clinical over the
trunk wrinkles
atitis scalp
post
3, all
Watchm herpetic Loss of
190 Raman 70 M 1 month T5,6 xerosis pruritus diabetes clinical over the Crinkles
an neuralgi lustre
scalp
a
face,
5, all
trunk, Linear
191 Kandan 72 M clerk vitiligo 8 years clinical over the
extremiti Furrows
scalp
es
right and 3,
shop tinea left Cherry Hyperte Tempora Loss of
192 Sajid Ali 69 M 15 days clinical Crinkles
assistant glutealis gluteal angioma nsion l, lustre
region Parietal
3, all
all over senile Glyphic Loss of
193 Sundar 65 M cooly xerosis 1 year IGH clinical over the
the body pruritus wrinkles lustre
scalp
4,
temporal
Sadasiva web Glyphic
194 67 M cooly scabies 4 days clinical ,
m spaces wrinkles
parietal,
vertex
Lichen 3,
Muthum Housewi Simplex 6 frontal, Glyphic
195 65 F right leg clinical
eena fe Chronic months parietal, wrinkles
us vertex
 5, all
Julie Housewi hand 6 both
196 66 F clinical over the Crinkles
Samson fe eczema months hands
scalp
4,
seborrhe
Frontal,
Thanga ic
197 68 F maid 3 years face IGH clinical parietal, Crinkles
meena keratose
vertex,
s
temporal
seborrhe
5, all
ic 6 Cherry
198 Kamala 62 F maid face clinical over the Crinkles
keratose months angioma
scalp
s
Left 3, all
Ramanuj stasis 10 Cherry varicose Linear Loss of
199 72 M vendor lower clinical over the
am eczema months angioma veins Furrows lustre
limb scalp
4,
seborrhe
temporal
Santhan Watchm ic face,
200 68 M 1 year xerosis IGH clinical , Crinkles
araj an keratose neck
parietal,
s
vertex
Figure 17: Linear Furrow - Crow’s Feet

Figure 18: Favre Racouchot syndrome

 Figure 19: Melasma

Figure 20: Dermoscopic view of Melasma - Reticular pattern - global feature seen in

all melasma lesions (Black arrow)

 Figure 21 : Idiopathic Guttate Hypomelanosis

Figure 22: Dermoscopic view of IGH - Amoeboid (Black arrow) and Feathery
pattern (Red arrow)
 Figure 23: Sagging of skin

Figure 24: Asteatotic Eczema

 Figure 25: Seborrheic keratosis

Figure 26: Dermoscopic view seborrheic keratosis - Pigmented SK - sharp

border,milia like cysts

 Figure 27: Seborrheic Keratoses

Figure 28: Dermoscopic view of SK- numerous curvilinear hypopigmented ridges

which are called Fat-Finger like structures

 Figure 29: Vitiligo

Figure 30: Dermoscopic view of vitiligo showing Polka Dot Pattern

Figure 31: Lupus vulgaris

Fig 32: Yellow orange patches

Figure 33: Apple Jelly nodules

Figure 34: Pellagra

Figure 35: Pellagra

 Figure 36: Lichen Planus

Figure 37: Dermoscopic view of Lichen Planus - Wickham’s Striae

Figure 38: HPE of Seborrheic keratoses

Figure 39: HPE of Lupus vulgaris