Department of Dermatology, Peking Union Medical College Hospital: What should we do if the elderly have itchy skin?

"Doctor, every night after I take off my clothes and get into bed, I start to itch all over my body. Sometimes it's my arms, sometimes my back, and sometimes my legs. The itch is so severe that I want to scratch all the skin off my body! I finally fall asleep, but it doesn't take long before I wake up again because of the itch. Not only do I toss and turn all night because of the itch, but my wife can't fall asleep because of the noise I make. Why am I so itchy? What should I do!"

The dermatologist at the outpatient clinic patiently listened to 64-year-old Aunt Zhao complaining about the unbearable itching in a sobbing voice. Aunt Zhao took off her coat, revealing the scratches and blood scabs on her skin. There are many elderly people like Aunt Zhao who are troubled by skin itching. Foreign epidemiological studies have shown that the prevalence of itching in the elderly is estimated to be between 11.5% and 41.0% [1]. Itching may not be a "serious disease", but the symptoms of itching not only cause repeated scratching, causing secondary damage to the skin and affecting life and sleep, but there may also be some potential "killers" behind the itching, which elderly friends need to pay attention to.

What is senile skin pruritus?

Elderly people over 60 years old who only have itchy skin without obvious primary rash and who experience itching symptoms every day or almost every day for more than 6 weeks can be diagnosed with senile pruritus[2]. This itching often worsens at night and in winter. In addition to strip-like scratches, blood crusts, and pigmentation or hypopigmentation, it may develop into eczematous and lichenoid changes over time, and may also be followed by various infections such as folliculitis, furunculosis, and lymphadenitis.

Why do I itch?

When elderly people experience itching, they should first check whether there are skin changes (primary rashes), such as papules, nodules, patches, plaques, etc., or secondary skin lesions caused by scratching due to itching, such as strip scratches, blood scabs, and pigmentation or loss. You also need to carefully observe whether there are some skin diseases that you have not noticed before, or you need to recall more carefully whether there is a history of medication or a certain underlying disease.

Dry skin is the most common

The most common cause of itching is dry skin. On the surface of the skin, there is a protective film formed by sebum secreted by sebaceous glands, lipids produced by keratinocytes, sweat secreted by sweat glands, and shed keratinocytes after low-temperature emulsification on the skin surface. It is called the sebum film, which is weakly acidic and plays an important role in protecting the skin barrier, moisturizing the skin, resisting infection, and neutralizing damage from alkaline substances. The skin of the elderly undergoes degenerative atrophy and becomes thinner. The sebaceous glands are hypofunctional, and the secretion is significantly reduced. The formation of the sebum film is damaged, the barrier and moisturizing functions of the skin are degraded, and the skin is prone to dry skin. Frequent scrubbing, hot water washing, and the use of overly alkaline soaps will further damage the sebum film and aggravate the dryness of the skin. At the same time, stimuli such as dryness, coldness, and static electricity are also more likely to induce skin itching. Mood swings, temperature changes, and friction of clothes can cause itching to occur or worsen.

Don’t ignore drug factors

The second most common cause of pruritus is medication. It has been reported that more than 100 drugs may cause pruritus through different mechanisms. For example, angiotensin-converting enzyme inhibitors (a commonly used antihypertensive drug) can induce urticaria and cause pruritus. Hydroxyethyl starch used in cardiac surgery can cause severe itching that lasts for a long time without obvious skin damage. In addition, drugs such as aspirin, barbiturates, penicillin, opioids, chemotherapy agents, certain antifungal solutions, and intravenous contrast agents may also cause pruritus. Therefore, the medication history should be reviewed in detail to find the temporal correlation between the onset of pruritus and medication [3].

Three system diseases need attention

It is worth noting that when itchy skin symptoms occur, we should also be alert to potential systemic diseases, such as diabetes, cholestasis, iron deficiency anemia, multiple sclerosis, kidney and liver diseases, thyroid diseases, polycythemia vera, neuropathy, and even tumors. Therefore, when the elderly have sudden itching, they also need to undergo a systematic physical examination to rule out potential diseases.

Among these systemic diseases, diabetic pruritus is very common. About 30% of diabetic patients have skin changes, and the incidence of pruritus in diabetic patients is 2 to 3 times that of the normal population. Skin manifestations may be a precursor to diabetes and are a predictive marker for assessing the risk of diabetes. They also have a certain predictive significance for assessing the success rate of treatment [4]. The cause of diabetic pruritus is the combined effect of multiple factors and their mutual influence. Although the surface seems to have no skin lesions, there are actually obvious changes. The glucose levels in the blood and skin of diabetic patients are at high levels, which will lead to important metabolic and immune changes in the body, microvascular lesions and neuropathy, etc., which will reduce the blood flow of skin tissue, reduce the water content of the skin, and cause abnormal sweat discharge, leading to dry skin. In addition, the pH value of the skin of diabetic patients is higher, which promotes bacterial colonization and disrupts the normal flora on the skin surface. In addition, the dry and itchy skin is easy to be scratched, which increases the chance of skin infection and complicates the disease.

What should I do if itching occurs?

Skin itching often brings a huge burden to the elderly, making them unable to sleep and have difficulty eating and sleeping, which seriously affects their quality of life. Therefore, we need to pay attention to the discomfort on the skin, find the possible causes behind the itching, and actively treat it. If there are certain underlying diseases, we should actively treat them. Improving the symptoms of systemic diseases is conducive to the relief of skin itching. Record your daily medication so that the doctor can help you analyze which drug causes the itching.

01. Improve your lifestyle

It is recommended that you choose pure cotton products for your underwear and home textiles, wear loose clothes, and reduce direct contact with woolen and chemical fiber products; avoid scrubbing, scalding, and excessive washing of the skin, avoid using alkaline soap, and fully moisturize the skin to keep it moist and hydrated;

02. Avoid scratching as much as possible

Prevent the vicious cycle of "itch-scratch-itch" and use anti-itch topical ointment if necessary;

03. Eat a balanced diet

Eat a balanced diet, eat more fresh fruits and vegetables, meat and eggs, drink plenty of water, and ensure adequate nutrient intake; relax, lead a regular life, and keep bowel movements smooth.

04. Seek medical advice

If the itching symptoms still cannot be relieved, it is recommended that you seek medical attention in a timely manner for a detailed physical examination and necessary system examinations. Under the guidance of a doctor, oral antipruritic drugs or physical therapy can be used to improve skin itching.

This issue's text: Jin Hongzhong and Qian Yuetong, Department of Dermatology, Peking Union Medical College Hospital

Editor of this issue: Li Yuanyuan

This issue's reviewer: Kang Lin