Prevalence and Risk Factors of Dermatoporosis Among the Elderly in Western Rajasthan: A Cross-Sectional Study

Dear Editor, Until not long ago, skin aging was considered merely a matter of appearance. However, with people living longer and facing more environmental challenges, skin aging has taken on a new significance beyond just how it looks. This broader impact on the elderly population led Saurat in 2007 to introduce the term dermatoporosis (DP) capturing the various elements of ongoing skin deficiency conditions. DP is a form of chronic skin fragility disorder that arises from a decline in the skin’s protective barrier functions due to aging, prolonged sun exposure, and exposure to free radicals.[1,2] Early signs of DP, such as wrinkles and minor skin scrapes, appear between ages 40 and 60. The condition fully develops between 70 and 90 years. Epidemiological studies to date show a prevalence rate varying from 5% to 40% in individuals aged 55 and older.[3] It is more commonly seen in men than women (3:2). Key symptoms include skin thinning, age-related purple spots, mimic scars, and light skin wounds, often starting around age 70.[3,4] Factors contributing to its development include age-related degeneration, genetic factors, excessive sun exposure, and long-term corticosteroid use.[1] Dermatoporosis is categorized into various stages. In Stage I, the skin shows signs of thinning, age-related bruises, and false scar-like marks. Stage II is divided into two parts: Stage IIa, where the skin experiences small, localized tears less than 3 cm in size due to its fragility, and Stage IIb, characterized by larger tears exceeding 3 cm. Stage III also has two sub-stages: Stage IIIa involves superficial bruise-like formations under the skin, while Stage IIIb is marked by deeper bruise formations that do not lead to skin death. The final stage, Stage IV, is identified by extensive areas of dead skin, which can lead to severe, potentially fatal complications.[5] There has been a lack of clinical research assessing the prevalence of DP and related comorbidities in adults over 55 years. This study aimed to determine the prevalence among patients aged 55 and above in Western Rajasthan, India. We also intended to explore potential links of DP with comorbidities or medication use. This was a multi-centric, cross-sectional study carried out from November 2023 to December 2023. We included all patients over 55 who visited the general medicine outpatient department. Dermatologists at the center conducted dermatological examinations of the hands, forearms, and arms for each patient. Data collected included demographic data, history of another dermatological disease, sun exposure, diabetes, obesity, smoking status, chronic kidney disease, and drug history. The characteristics of patients with DP were compared to those without using Chi-square tests for qualitative variables. The study included 400 patients, with 210 (52.5%) females and 190 (47.5%) males. The mean age of patients was 73.4 ± 8.1 years (55–97 years). The prevalence of DP was 24% (96 patients, with 62 (64.6%) males and 34 (35.4%) females). The average age of DP in males (77.1 ± 7.8 years) was significantly lower than in females (83.7 ± 8.4 years) with a P value of 0.0004. Most DP cases were Stage 1 (n = 67; 69.8%) [Figure 1], while 21 patients (22.9%) had skin tears (Stage 2a) [Figure 2], and 8 (8.3%) had superficial hematomas (Stage 3a). Patients with DP were significantly older (median age 78 vs. 70 years, P < 0.0001) [Table 1].Figure 1: Dermatoporosis stage 1 with thinning of the skin, presence of pseudo-scars, and age-related purplish brown spots on the upper armFigure 2: Dermatoporosis stage 2, with accentuated skin fragility and localized skin tearsTable 1: Clinico-demographic profile of patientsThere was a statistically significant association between DP and older age (P = 0.0001), male gender (P = 0.0001), diabetes (P = 0.0009, CRF (P = 0.014), smoking (P = 0.0003), sun exposure (P < 0.001), airborne contact dermatitis (P = 0.002), and photodermatitis (P = 0.004). Given the advanced age of the study population, it was expected that many patients were on multiple drugs. The most frequently used drug classes among the study participants included antihypertensives (33%), antidiabetic agents (27.5%), anticoagulants (25.5%), lipid-lowering drugs (23.5%), and topical or systematic corticosteroids (22.7%). However, the use of 5 or more medications at the same time (polypharmacy) was only noted in 66 (16.5%) cases. On statistical analysis, the use of anticoagulants (P = 0.0002) and polypharmacy (P = 0.0001) were associated with a significantly higher risk of developing dermatoporosis. Our study confirms the link between age and DP and highlights the significant association of DP with the male gender. Similar to the observations made by Kluger and Impivaara and Mengeaud et al. we found occupational sun exposure to be a significant factor.[3,4] The combination of chronic kidney disease and the use of antiplatelet agents, or more than five medications at once, suggests that the frail elderly population with multiple comorbidities and polypharmacy is at increased risk of DP. The treatment of dermatoporosis is aimed towards addressing the symptoms and preventing complications such as skin tears and hematomas. In this study, the treatment modalities were offered were based on the severity of the condition. Most patients with Stage I DP were managed with topical emollients and occlusives containing coconut oil, paraffin, glycerine, or ceramides to enhance skin hydration and barrier function. For inflammatory symptoms, short-term, low-potency topical corticosteroids were used. Patients with Stage II or III DP received wound care with non-adhesive dressings, antiseptics, and antibiotics when necessary to prevent infection and aid healing. All patients were advised on sun protection, including using SPF 30+ and PA+++ sunscreens, wearing protective clothing, and avoiding peak sun hours between 11 AM and 4 PM. Lifestyle counselling included recommendations for smoking and alcohol cessation. Study limitations include the focus on upper limbs, the most common site for DP Stage 1, and the primarily rural demographic of the sample. This study offers new insights into DP prevalence, complications, and risk factors in the elderly population of Western Rajasthan. Further research is needed to explore the relationship between this syndrome and comorbidities for a deeper understanding. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.