Managing Atopic Dermatitis in the Elderly

Key highlights

The elderly population is defined by the OECD as individuals aged 65 years and over, while the United Nations defines an older person as someone over 60 years of age. Atopic dermatitis in the elderly presents unique challenges in diagnosis due to its varied presentation. Also, when considering treatment in this population, it’s essential to account for the patient’s overall medical condition, current medications, and their general physical and mental health status.

Article of interest:

Tanei R. Atopic Dermatitis in Older Adults: A Review of Treatment Options. Drugs Aging. 2020 Mar;37(3):149-160

Prevalence of AD in the Elderly

AD is prevalent in the elderly, with onset and clinical course varying¹. It may present as a new disease in older adults (senile onset), as a recurrence of childhood AD (outgrowth-recurrence form), or as a continuation and/or recurrence of adolescent/adult AD². The prevalence in the elderly varies from 1.2% to 17.1% in studies, with a recent UK study showing a prevalence of 8.2% in adults aged 75-99 years¹.

Incidence and Ethnic Differences

The incidence of AD in the elderly is 8 in 1000 person-years for individuals over 80 years, compared to 174 in 1000 person-years in children under 1 year in the UK. Senile onset AD is higher in males and in Black and Asian populations compared to White ethnic groups and is associated with lower socioeconomic status¹.

Clinical Presentation in the Elderly

AD in the elderly does not have a single presentation¹. It often manifests as chronic lichenified eczema on the upper body, similar to that seen in adolescents and young adults². The "reverse sign," where the typical distribution of eczema is reversed, is more common in the elderly. AD in the elderly is less likely to affect the face and scalp and more likely to affect the buttocks or genitals. Refractory facial erythema, loss of the lateral eyebrows (Hertoghe sign), Dennie–Morgan infraorbital folds, and neck dermatitis are also observed².

Diagnostic Challenges

Diagnosing AD in the elderly can be challenging due to the lack of clear diagnostic criteria. Traditional criteria, such as the UK Working Party or Hanifin and Raika, should be used². When diagnosing AD in the elderly, it is essential to exclude other pruritic skin disorders, such as cutaneous T-cell lymphoma, asteatotic dermatitis, nummular eczema, contact dermatitis, chronic prurigo, adverse drug reactions, scabies, Ofuji disease (in Japanese), chronic eczematous eruption of aging, and eczematous variants of bullous pemphigoid². Extra attention to treatment of refractory disease is needed, and cutaneous T cell lymphoma must be ruled out by histopathology, since this diagnosis should be excluded before initiating any systemic therapy^2,4.

Immune Mechanisms

Adult-onset AD patients may be less likely to have IgE-specific allergies and filaggrin mutations compared to childhood-onset AD¹. In elderly patients with high serum total IgE, Th2 cytokines (IL-4, IL-5, and IL-13) dominate in peripheral blood, while Th1 cytokines (IFN-γ) dominate in those with low serum total IgE. In the skin, elderly patients with AD show decreased Th2 and Th22 cytokines and increased Th1 cytokines in lesional skin compared to adult AD patients².

Considerations for Treatment

When choosing therapies for elderly patients, considerations include cognitive ability, functional independence, ability to self-administer medication, renal function, comorbidities, polypharmacy, and drug interactions^2-4. Data supporting treatment choices for elderly patients with AD are limited due to their exclusion from trials (upper age limit or comorbidities). A systematic review of randomized controlled trials (RCTs) from 2020 of systemic immunomodulatory treatments for AD, found that in the trials reporting proportion of participants aged 65 or older, 4% were 65 or older⁵.

Comorbidities such as heart disease, cerebrovascular disease, diabetes mellitus, chronic renal disease, and osteoporosis and pharmacological interactions must be considered when starting systemic treatment³.

1. Topical therapies

Basic treatment is similar to other age groups, however, applying sufficient topical medication may be difficult or even become a burden. Therefore, solutions to this challenge should be considered, including help from relatives or community-based caregivers².

2. Phototherapy

Phototherapy may be burdensome or even impossible for some elderly patients due to the number of visits needed per week^2,3.

3. Systemic Therapies

Traditional systemic therapies are effective in the elderly, but due to comorbidities, the risk of skin cancer, and the risk of infection, cyclosporine, azathioprine, and mycophenolate mofetil are not the best choices. Methotrexate may be considered, but it is advised to use a lower starting dose^2-4,14-17.

4. Biologics

Biologics such as dupilumab and tralokinumab are reasonable treatment options, with data showing similar efficacy in the elderly as in other age groups^6,8. These treatments are well tolerated, no routine screening and monitoring are required, and no interactions are known^9,10.

5. Janus Kinase Inhibitors

JAK inhibitors are indicated for elderly patients with AD, but caution is needed in patients over 65 years of age due to the higher risk of serious infections, cardiovascular disease, malignancies, thromboembolic events, and mortality. For those patients, a lower starting dose is indicated, and careful monitoring is recommended, alongside with screening for risk factors such as increased cardiovascular events, increased risk of cancer, and smoking^11-13.

Conclusion