As people age, skin becomes more fragile because of epidermal and dermal atrophy, decreased collagen content, and reduced lipid and water content.1
Reduced vascular supply and vessel damage, cellular turnover and immunity also contribute to slower healing and increase the risk of infection.
Extrinsic factors such as UV damage from cumulative sun exposure, environmental pollution, smoking and poor diet may accelerate the changes of ageing.2
Central and peripheral neuronal changes increase the risk of itching and neuropathic pain. 1, 3
This therapeutic brief reinforces the importance of educating your veteran patient to use emollients to maintain skin integrity, reduce itch and skin tears. An Australian study found that application of an appropriate emollient twice a day to the resident’s arms and legs reduced the incidence of skin tears by almost 50%.4 This therapeutic brief gives some simple tips for maintaining healthy skin. It provides an overview of the causes of itch, gives some treatment options and includes a practical insert on judicious use of topical corticosteroids.
Moisturisers are products used to add moisture to the skin. Moisturisers may contain emollients (see below), humectants (substances that attract moisture) or occlusives (oily substances that prevent moisture loss) as well other ingredients such as surfactants (cleansers), fragrances, and preservatives.5
Emollients are oily products used to soften and smooth the skin. They create a protective barrier and serve to keep moisture in. Although the terms emollient and moisturiser are often used interchangeably, emollients are actually a specific ingredient of moisturisers.5
There are many types of emollients. They can be classified according to how they are applied.6
Many products are available through the RPBS e.g.
Moisturising bath oils are also available on the RPBS (Alpha Keri Oil®, Hamilton Skin Therapy Oil®, QV Bath Oil®) but caution must be taken as they increase the risk of slipping and falling.
DVA can consider funding of different emollient products outside PBS criteria, on a case by case basis, where clinically justified.
*For further information about Veteran Cards and what they cover, see the DVA Basics Quick Guide
Apply emollient morning and night
The most important intervention is moisturising using emollients
Emollients are available in a range of different formulations, including creams, ointments and lotions. They act to moisturise the skin by either drawing water from the dermis to the epidermis or preventing water loss from the skin. They improve the barrier function of the skin.
Use as soon as possible after showering or bathing to prevent moisture loss from the skin.
Refrigeration may increase the cooling effect of emollient.
Patients may need to try different products before finding one that suits them best.
Do not use an emollient that contains sodium laureth sulfate (e.g. some aqueous creams and emulsifying ointments) as they may worsen irritation.7
Avoid soaps, shower gels and bubble baths
They may strip skin of natural oils.
Use soap free products such as Alpha Keri®, Hamilton®, QV® which are less likely to cause skin irritation and are available on the RPBS.
Reduce the time spent in the shower or bath
And avoid hot water which can cause lipid loss from the skin and skin irritation. Short tepid showers or baths are preferred.
Regular exercise improves blood flow (helping skin integrity and wound healing) and balance (reducing falls risk)
Maintain adequate hydration
Do not smoke
Eat a balanced diet, try to have fruit and vegetables daily
Aim to maintain a healthy weight range
People who are either obese or underweight are at increased risk of skin problems. Obesity is more associated with pressure ulcers and impaired wound healing. Underweight increases the risk of skin tears.
Keep fingernails short and smooth to avoid damaging skin and developing secondary infection
Apply cold packs
These may help reduce the discomfort of itch.
Minimise or avoid UV exposure
Wear sun-protective clothing (e.g. a broad-brimmed hat, long sleeves and trousers).
Apply very high sun-protection factor (SPF) broad-spectrum sunscreen to exposed skin – Sunsense® with a SPF of 50+ is available on the RPBS.
Elevate legs and use compression garments as prescribed if there is a history of venous insufficiency.
Itch or pruritis is the most common skin problem in people over 65.6 Incidence of chronic itch varies in studies of different cultural groups but is thought to be more than 50% of older Australians (>65 years old).2, 8, 9 It is most often due to dry skin.
Chronic itch can be diagnosed once symptoms exist beyond 6 weeks and may become a debilitating symptom that is difficult to treat.10, 11
Age-related skin dryness probably accounts for more than 50% of cases of itch in elderly people. Primary dermatologic conditions, e.g. atopic dermatitis and psoriasis, account for about 30% of itch.12
In up to 11% of elderly people experiencing itch, no cause will be found.12, 13
A thorough history and examination should guide treatment (see Box 1).12 Itch may be associated with primary skin diseases, secondary to systemic medical problems, medicines or psychological issues.10, 11, 12, 13, 14
Atopic dermatitis (AD or ‘eczema’) – is the most common primary inflammatory skin disease.15, 16 It commonly affects flexures, eyelids, face and neck16 and is frequently associated with an itch–scratch cycle that may exacerbate the problem by increasing inflammation.
Moisturising and judicious use of topical corticosteroids (TCS) remain the cornerstone of treatment. Emollients reduce itch, improve barrier function of the skin and increase the efficacy of topical corticosteroids. Apply an emollient liberally, preferably twice a day, particularly after bathing and even when skin appears less inflamed.5
For management of severe disease, newer biologic therapies offer further options.16
Psoriasis is a chronic inflammatory disease that most commonly causes scaly plaques to form on the elbows, knees, scalp and buttocks. Treatment depends on the type and extent of disease and response to previous therapy. TCS are frequently used. Dermatologists use specialised systemic treatment including biologic therapy in severe cases.17
Psoriasis may cause itch beyond the area affected by plaques so it is reasonable to try the topical or oral options listed below.
Contact dermatitis usually appears within a few days of contact with the offending substance and can be intensely itchy.
There are many causes but consider cosmetics, deodorants, metals in jewellery, wool and nylon clothing, animal hair, dust mites and plants. Short-term moderate to potent topical corticosteroids are often useful.12
Venous eczema from stasis is an increasing problem as people age.13 Venous return reduces and fluid collects in tissues triggering an immune response leading to inflammation.18 It is more commonly seen with varicose veins, deep venous thrombus and a history of cellulitis and is most often located on the lower leg above the ankle and associated with brownish discolouration and scale. Elevation and compression are important elements of treatment. Moisturising is critical.
Tinea affects the most superficial layer of the skin and usually produces a well demarcated rash with a red, scaly elevated border. Topical antifungals such as clotrimazole are the treatment of choice.12 Topical corticosteroids should be avoided.
Infestations such as scabies are more common in residential aged care facilities. Scabies can cause intense itch that is often worse at night. Mite eggs deposit in the epidermis triggering an immune reaction which causes rash and itch.13 Infection usually develops from skin-to-skin contact but can result from sharing infected clothing or linen. Permethrin 5% cream (PBS and RPBS) is the treatment of choice.19
Bullous pemphigoid is a rare autoimmune, subepidermal skin condition that mainly affects older people (predominantly aged 60 to 80). It usually starts with itchy red areas that progress to blistering lesions.13, 20 Treat mild disease with potent TCS. Seek specialist advice in more complicated cases.
Psychological issues such as anxiety, obsessive compulsive disorder, depression and hypochondria may predispose to itch. In some cases, people may develop phobias or delusions of skin infection or infestation leading to compulsive itching.21
Itching may also lead to psychological issues such as social withdrawal, depression and anxiety. The dermatology quality of life index can help practitioners better understand the effect skin problems are having on their patient’s life.
Older people are more likely to take medicines that may increase itch. These include some anti-microbial agents, diuretics, statins, ACE inhibitors, denosumab, anticonvulsants, allopurinol, chemotherapeutic agents and opioid analgesics.
Drugs with anticholinergic activity may increase the risk of skin dryness and itch.
See www.dermnetnz.org/topics/druginduced-pruritus for a longer list of possible medicine associations with itch.
Regular use of an emollient is the most important intervention. If regular use of an emollient is insufficient you can try adding a topical medicine.
Medicines available on the RPBS are listed below. There is no clear guidance on what medicine to try first. You may need to try different agents before finding one that suits your patient best.
Ichthammol with or without zinc oxide may ease itch as well as providing a moisturising effect.12
Egoderm® cream (icthammol 1%) and Egoderm® ointment (icthammol 1% and zinc oxide 15%) are RPBS listed.
Pine tar has been used for hundreds of years to treat common skin problems such as eczema and psoriasis. It acts by reducing DNA synthesis, stabilising keratinisation23 and has anti-itch, antibacterial and antifungal properties.
Pinetarsol® solution (2.3% + trolamine lauril sulfate 6% solution) is RPBS listed.
Urea 10% cream is an emollient and has hygroscopic (attracts water), keratolytic (softens outer skin layer) and anti-itch properties from a topical anaesthetic effect.24 It is usually well tolerated.
Aquacare H.p.® and Urederm® are RPBS listed.
Topical corticosteroids have a role only in diagnosed primary skin inflammatory conditions such as atopic dermatitis and psoriasis. They are not recommended for extended use in non-specific itch.
Menthol 1% or 2% in aqueous cream and similar proprietary or extemporaneously prepared products may provide a cooling sensation and ease itch.
Calamine lotion might provide short term relief of itch but tends to dry skin so is not recommended for long term use.24
Topical capsaicin (derived from capsicum) reduces substance P found in nerve endings. It can be used in post herpetic neuralgia and may be an option to ease itch thought to have a neuropathic component.12
Topical anaesthetics such as combination lidocaine 2.5% and prilocaine 2.5% (EMLA® non-PBS) have some evidence for benefit12 – specialist review is recommended before using such medicines for itch due to risk of developing contact dermatitis.
Less-sedating oral antihistamines may be effective if the pruritus is associated with an underlying allergic mechanism e.g. urticaria (hives), atopic dermatitis, insect bite.10
Cetirizine, fexofenadine or loratadine are RPBS listed.
Sedating oral antihistamines e.g. promethazine (non-PBS), may be of benefit if itch is causing sleep disturbance but should be used with caution in older people, particularly those at risk of falls or delirium.5 Check falls history before prescribing.
Colestyramine (Questran Lite®) may reduce pruritus due to cholestasis10 – seek specialist advice.
Tricyclic antidepressants e.g. doxepin, amitriptyline and gabapentinoids (e.g. pregabalin) have been used as second or third-line agents but the risks often outweigh benefits in older people due to risks associated with falls and delirium so they should be used with caution.12 Check falls history before prescribing.
In some circumstances a dermatologist may prescribe phototherapy to ease itch.12
Oral corticosteroids may cause short term and cumulative adverse effects. They may be used for very brief periods to control immune mediated skin problems such as urticaria, bullous pemphigoid or severe flares of AD, or as bridging treatment before systemic immunomodulating therapy can begin.14
In recent years, misinformation about the risks of topical corticosteroid (TCS) preparations propagated on social media has resulted in decreased treatment adherence.1, 2 People post negative personal experiences and describe side effects such as skin thinning, stretchmarks, hypopigmentation, delayed wound healing, sleep or mood changes, and increasing visibility of small blood vessels on the skin, as well as cortisol suppression.3
Such negative outcomes are rarely found in practice. Systematic reviews of the link between topical corticosteroids and adverse events in both adults and children showed that use of potent agents in patients with atopic dermatitis (eczema) does not cause significant skin thinning or cortisol suppression when use is limited to 4 weeks.4
Risk does increase with the duration of use. Treatment decisions should balance risk and benefit. It appears that high to very high potency topical corticosteroids are more effective than mild topical corticosteroids for moderate to severe atopic dermatitis (eczema) flares.5 Intermittent use for atopic dermatitis flares is probably safe over many years.6 There is a lack of good data to assess the safety of these agents beyond 4 weeks.4, 5
A useful review of choosing TCS available in Australia can be found at: www1.racgp.org.au/ajgp/2021/september/selection-of-a-corticosteroid 7
TCS have an important role in treating primary inflammatory skin conditions, like atopic dermatitis (eczema) and psoriasis, but should be avoided in non-specific itch.
Use TCS judiciously according to the extent and severity of disease. Use the least potent formulation that will control your problem.
Using the fingertip unit guide will assist you to use the appropriate amount. See figure 1 and https://resources.amh.net.au/public/fingertipunits.pdf 7
Once-daily application is as effective as twice-daily.5 Stepping therapy up and down with periods of time away from topical corticosteroids as well as daily use of moisturisers should reduce the risk of adverse effects.
People usually improve within 2 to 4 weeks. Explain that you will review treatment at this time and may consider a different approach or seek specialist advice if no improvement has occurred.
References for Therapeutic Brief Insert - A note about “steroid phobia” and topical corticosteroids