Geriatric Skin Care in the Era of COVID‐19

To the Editor: As one of the most vulnerable groups of patients during the era of coronavirus disease 2019 (COVID‐19), the geriatric population must adhere to specific guidelines to reduce their chance of contracting this potentially fatal virus. Older patients who implement measures, such as frequent handwashing and sheltering in place, benefit most from the perspective of viral infectivity; however, paradoxically, this group is also the most vulnerable to dermatologic consequences associated with these preventative measures.

The use of hand sanitizer and handwashing have become particularly important during COVID‐19. Guidelines provided by the Centers for Disease Control and Prevention (CDC) recommend frequent handwashing multiple times a day and suggest the use of an alcohol‐based hand sanitizer that contains at least 60% alcohol when soap and water are not readily available. ¹ Frequent handwashing and alcohol‐based hand sanitizers are a common cause of dry skin and irritation in the general population, and skin changes associated with the aging process further predisposes older patients to these conditions.

Barrier function and recovery in aged skin (aged >80 years) is more readily disrupted than is young skin (aged 20–30 years), resulting in transepidermal water loss and altered permeability to chemical substances. ² Increased handwashing can further exacerbate this problem, leading to xerosis (i.e., skin dryness; Figure 1A) and increased susceptibility to irritant contact dermatitis (ICD) (Figure 1B). Xerosis is a common dermatologic problem in the older population, characterized by rough, flaky, and scaly skin, and is the most common cause of pruritus in older people. ³ ICD occurs on contact with an irritating chemical or physical substance to the skin, and patients present with a pruritic rash characterized by erythema, papules, fissures, and scaling. Pruritus characteristic of these dermatologic conditions is thought to occur secondary to abnormalities in cytokine levels, skin pH, keratinization, and surface lipid components. ⁴

Figure 1.

Cutaneous manifestations related to preventative measures of coronavirus disease 2019. (A) Xerosis (i.e., dull, flaky, rough skin) due to frequent handwashing and/or use of alcohol‐based hand sanitizers. (B) Irritant contact dermatitis due to frequent handwashing and/or use of alcohol‐based hand sanitizers. (C) Stasis dermatitis due to increased sedentary behavior and “shelter‐in‐place” mandates.

The mainstay of treatment for prevention of ICD is avoidance of the offending agent; however, this option is not feasible in the current climate, and emphasis should be placed on prevention. As a functional, protective cutaneous barrier exists at an acidic pH (4.0–6.0), prevention of barrier dysfunction characteristic of xerosis and ICD should include the use of low pH cleansers and moisturizers. ⁵ Alkaline bar soaps can be irritating to the skin and should be avoided. Other preventative measures include the use of barrier creams containing dimethicone and moisturizers rich in ceramides. ⁶ Treatment of ICD can be achieved through the use of topical corticosteroids; however, the clinician should be weary of increased risk for steroid‐induced atrophy in the geriatric population, in whom the skin is thin. Itch relief can be obtained with use of cold compresses.

The CDC and federal government have also recommended that Americans “shelter in place” as an emergency preparedness and response measure to COVID‐19. Individuals across the country are remaining inside their homes and being discouraged from engaging in outside activity due to risk for viral exposure. Older patients who are becoming more sedentary due to these measures are at risk for exacerbation of stasis dermatitis, a common condition seen in the geriatric population that results from aberrant venous drainage from the legs (Figure 1C). ⁷ Stasis dermatitis is a common cause of chronic pruritus in the lower extremities of older patients and can be extremely uncomfortable for patients. ⁸ To improve symptoms of this condition, geriatric patients should use elastic stockings and frequently elevate the legs to improve venous circulation.

The stress of surrounding COVID‐19 and social isolation can have significant negative effects on mental stress in older people. Psychological stress has an impact on many skin diseases and can play a substantial role in exacerbating disease activity. ⁹ One of the most common skin conditions in which psychological factors play a central role is seborrheic dermatitis (SD). SD is common in the older population, and especially in those with Parkinson's and Alzheimer's disease. ¹⁰ To help abate symptoms of SD, we recommend the use of topical antifungal shampoos, such as ketoconazole, as well as mild‐to‐moderate topical corticosteroids.