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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 14-19

Histopathological spectrum of skin lesions in the elderly: Experience from a tertiary hospital in Southeast Nigeria


1 Department of Anatomic Pathology and Forensic Medicine, Nnamdi Azikiwe University, Nnewi Campus, Nnewi, Nigeria
2 Department of Internal Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
3 Department of Morbid Anatomy, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
4 Department of Morbid Anatomy, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
5 Department of Histopathology, Enugu State University Teaching Hospital, Enugu, Nigeria

Date of Submission18-Oct-2021
Date of Decision15-Dec-2021
Date of Acceptance19-Dec-2021
Date of Web Publication24-Mar-2022

Correspondence Address:
Dr. Chinedu Onwuka Ndukwe
Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jascp.jascp_27_21

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  Abstract 


Background: There are only a few epidemiological studies published on skin disorders in the elderly within the Nigerian context and none from the Southeast Region of the country. In addition, none of these studies has considered the pattern and frequency of histopathologically diagnosed geriatric skin lesions. Hence, we attempted to determine the frequency as well as the age and gender distributions of histologically diagnosed dermatological diseases in geriatric population from skin biopsies submitted to the histopathology department of a tertiary care hospital in Southeast Nigeria. Materials and Methods: This is a cross-sectional retrospective hospital-based study involving all skin biopsies of patients 60 years and above, received at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, from January 2004 to December 2019. Results: During the study period, 751 skin biopsies were received in the histopathology department. Of these, 142 were from patients who were older than 60 years. Thus, the overall share of geriatric patients was 18.9%. The mean age at presentation was 71.1 ± 8.6 years. The M: F was 1:1, and most of the patients belonged to the age group of 60–69 years (69 cases, 48.6%). The mean age of the male patients was 72.1 ± 9.5 years. In the female patients, it was 70.1 ± 7.5 years. The most common disease category was neoplasms (91, 64.1%). Most neoplasms were malignant. There were 67/142 (47.2%) malignant lesions. The most common was Squamous cell carcinoma (SCC) (30 cases) which is 21.1% of all geriatric skin biopsies and 44.8% of malignant skin biopsies. This is closely followed by melanoma (29 cases). Conclusion: Malignant neoplasms, benign neoplasms, and papulosquamous disorders are the three most common histologically diagnosed skin lesions in our geriatric population. The most common skin malignancies in this group of patients are SCC and malignant melanoma.

Keywords: Geriatrics, histopathology, Nigeria, skin lesions


How to cite this article:
Ndukwe CO, Ndukwe CC, Uzoigwe JC, Eni AO, Nnamani CS, Nwokoro OC, Chiemeka ME. Histopathological spectrum of skin lesions in the elderly: Experience from a tertiary hospital in Southeast Nigeria. J Appl Sci Clin Pract 2022;3:14-9

How to cite this URL:
Ndukwe CO, Ndukwe CC, Uzoigwe JC, Eni AO, Nnamani CS, Nwokoro OC, Chiemeka ME. Histopathological spectrum of skin lesions in the elderly: Experience from a tertiary hospital in Southeast Nigeria. J Appl Sci Clin Pract [serial online] 2022 [cited 2022 May 17];3:14-9. Available from: http://www.jascp.com/text.asp?2022/3/1/14/340882




  Introduction Top


Globally, there is a rapid growth in the proportion of persons aged 60 years and above.[1],[2] This may be attributed to the rapid improvement in health care and control of chronic diseases, which have led to a significant increase in average life expectancy at birth in recent years.[2],[3] This in turn has brought with it the unique challenge of finding solutions to the physiological and pathological changes associated with aging.[3] Dermatoses contribute a considerable proportion of the diseases seen in the elderly and may not present as classically as they do in younger populations.[3],[4] In addition, other peculiarities in the elderly, such as polypharmacy, comorbidities, delay in seeking medical care, poor hygiene, sensory, and cognitive impairments, may confound the management of dermatoses in this population.[5],[6] Skin diseases also cause psychosocial morbidity and decrease in quality of life in the elderly.[5]

Cutaneous aging results from both endogenous and exogenous processes.[5],[6] Some of these endogenous processes include inheritance, metabolism, and hormonal changes in the body and may manifest as early as the age of thirty and peaking at age of 60 years.[5] The exogenous factors that contribute to skin aging include Ultraviolet (UV)-light exposure, smoking, and various environmental insults.[5]

Studies have noted that the pattern of skin diseases in a given community is influenced by genetic constitution, climate, socioeconomic status, occupations, level of education, hygiene standards, cultural practices, and quality of health care.[4] These factors give each community its unique pattern and account for the wide variation reported from different regions of the world and even in the same country.[4] It has been reported that the frequency of skin diseases increases with age so that, by age 70 years, 70% have had significant skin diseases.[1] However, there are only a few epidemiological studies published on skin disorders in the elderly within the Nigerian context and none from the Southeast Region of the country. In addition, none of these studies has considered the pattern and frequency of histopathologically diagnosed geriatric skin lesions.

With this background, we attempted to determine the frequency as well as the age, gender, and site distributions of histologically diagnosed dermatological diseases in geriatric population from skin biopsies submitted to the histopathology department of a tertiary care hospital in Southeast Nigeria.


  Materials and Methods Top


This is a cross-sectional retrospective hospital-based study involving all skin biopsies of patients 60 years and above, received at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, from January 2004 to December 2019. This 440-bed hospital is one of the three federal government-owned teaching hospitals in the entire southeast region (one of the six geopolitical zones of Nigeria). It is also one of the largest hospitals in this region. Its catchment area comprises mainly Anambra state and parts of neighboring states. As per the last official census in 2006, Anambra state had a population of 4,177,821 and a population growth rate of 2.8%, with 35.6% of her population aged 0–14 years, 60.5% aged 15–64 years, and 3.9% aged 65+ years.

The histopathological diagnoses were made by consultant anatomical pathologist using routine hematoxylin and eosin-stained (H and E) slides. Furthermore, Special stains such as Ziehl-Neelsen, Periodic Acid Schiff, and Fite-Faraco were used whenever required. All relevant demographic data and provisional clinical diagnoses were obtained from the histopathology laboratory requisition forms provided with the skin specimens. All these skin lesion cases were reviewed by the principal investigator to corroborate the diagnoses and classify them into groups according to the International Classification of Diseases -10 Version 2019 for disorders of skin and subcutaneous tissue for ease of analysis and comparison with other skin studies. The skin lesions classes include neoplasms, infectious disorders, bullous disorders, dermatitis/Eczema group, papulosquamous disorders, urticaria/erythema group, radiation-related disorders, disorders of skin appendages, and other categories/miscellaneous group.

The data generated were entered into SPSS v. 23.0 (SPSS Statistics for Windows, Version 23.0. IBM Corp. Armonk, NY, USA) to perform its statistical analysis. The Chi-square test was applied to determine associations and was considered significant when the P < 0.05.

Ethical approval for the study was waived, as this was analysis of retrospectively collected data, without the researchers having any access to identifying information.


  Results Top


During the study period, 751 skin biopsies were received in the histopathology department. Of these, 142 were from patients who were older than 60 years. Thus, the overall share of geriatric patients was 18.9%. The mean age at presentation was 71.1 ± 8.6 years. Most of the patients belonged to the age group of 60–69 years (69 cases, 48.6%), followed by 70–79 (47 cases, 33.1%) and 80–89 (22 cases, 15.5%) years [Figure 1]. This was significant (P < 0.001). Seventy-one (50.0%) were males and 71 (50.0%) were females, giving an M: F of 1:1 [Figure 1]. The mean age of the male patients was 72.1 ± 9.5 years. In the female patients, it was 70.1 ± 7.5 years. This difference in mean age between the two sexes was not significant (P = 0.172).
Figure 1: Age-Sex Distribution of Patients

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The most common disease category was neoplasms (91 cases, 64.1%), followed by papulosquamous disorders (13 cases, 9.2%), disorders of skin appendages (11 cases, 7.7%), dermatitis and eczema (9 cases, 6.3%), infections (4 cases, 2.8%), and both bullous disorders and radiation-related disorders (1 case, 0.7%) each. Miscellaneous/other disease category including sarcoidosis, calcinosis cutis, and seborrheic keratosis had a share of 8.5% (12 patients) [Table 1].
Table 1: Mean age, sex distribution and proportions of the various disease categories

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Most neoplasms were malignant. There were 67/142 (47.2%) malignant lesions. The most common was squamous cell carcinoma (SCC) (30 cases), which is 21.1% of all geriatric skin biopsies and 44.8% of malignant skin biopsies. This is closely followed by melanoma (29 cases) and basal cell carcinoma (BCC) (three cases) [Table 2]. The mean age for SCC was 70.0 ± 7.1 years, and for melanoma, it was 75.4 ± 10.0 years.
Table 2: Mean age, sex distribution and proportions of the various neoplasms

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Psoriasis (8 cases) was the most common among papulosquamous diseases, followed by lichen planus (5 cases) [Table 3].
Table 3: Mean age, sex distribution and proportions of the various nonneoplastic lesions

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The lower limb was the most frequent site of all lesions (43.6%) in general and malignant neoplasms (56.3%) in particular [Table 4]. In fact, roughly two-third (27/41 cases) of the lower limb lesions were malignant, with melanomas the most common histological type (15/41 cases). The head-and-neck region was the second most common site involved in this study, accounting for 30 (31.9%) cases in total. Ten of these were malignant, with SCC being the most common cancer at this site (6/10; 60.0%). Site of lesions was unspecified in 48 cases. Nonexposed sites such as the trunk and pelvic area were the least frequent sites involved.
Table 4: Site distribution of various categories of skin lesions

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  Discussion Top


This is the first study that investigates the frequency and age and gender distribution of histologically diagnosed skin diseases in the elderly patients in Nigeria.

In this study, roughly one in every five skin biopsies in our record are from elderly patients. This may be due to the increasing proportion of the elderly in the general population, increased of skin diseases in the elderly, increased health-seeking behavior by the elderly, or increased access to health care.[7] It however means that elderly patients are becoming an increasing subject for clinicians and pathologists and hence the importance of this study.

In our study, the most frequent disease group was neoplasms (64.1%). This is similar to some previous studies.[8] Malignant skin neoplasms constitute a problem of particular importance in elderly groups.[9] The frequency of malignant skin tumors in our study was 47.2%, while that of benign neoplasms was 15.5%. These are significantly higher than some previous studies. In those previous studies, the frequency of malignant tumor was between 2.1% and 29.8%, and the incidence of benign tumor ranged from 1.7% to 13.8%.[6],[9],[10] The significantly higher fraction of neoplasms in this study can be explained by the fact that this is a histopathology-based study, whereas the earlier studies were clinical studies. Many skin lesions may be diagnosed clinically without resort to biopsy. However, clinicians are more likely to biopsy lesions when a malignant diagnosis is entertained. Hence, a histopathology-based study such as this may see an over-representation of neoplastic lesions. Furthermore, many of the previous studies included patients seen only in the dermatology clinic. However, this study includes skin biopsies from both dermatology and plastic surgery clinics. In many hospitals in Nigeria, the patients with suspicious malignant lesions are referred to the plastic surgery department instead of dermatology, which may be another reason for the higher frequency of neoplasms in this study compared with previous studies.

The risk of developing malignant skin lesions significantly increases with aging. This is related to several factors including decreased DNA-repair capacity, decreased immunosurveillance, and accumulation of carcinogenic material during aging.[10] The most important etiologic factor for skin cancer is sunlight exposure and the elderly develop more damage against UV light due to decreased melanocytes.[10] Furthermore, chronic ulcers and inflammatory lesions play a significant role in the etiology of SCC.[11] These factors are much more common in this environment, hence the relative greater incidence of squamous carcinomas in this study compared to studies from other climes which report a predominance of BCC.[12]

The incidence of psoriasis ranges from 1% to 11.2% in various studies.[13] In our study, psoriasis (5.6%) was the most common papulosquamous disease (9.2%). This was similar to a study from Nepal that reported an incidence of 8.5% for psoriasis and 11.8% for papulosquamous disease.[14]

Dermatitis and eczematous lesions (6.3%) form the fourth most common dermatoses in our study. A previous clinical-based study from Nigeria reported eczema as the most common geriatric skin disorder making up 20.5% of their series.[7] This stark discordance stems from the fact that the diagnoses of most of these eczematous lesions are clinical; hence, only few difficult cases are biopsied. Spongiotic dermatitis was the most common in this category.

In the present study, cutaneous infections were presented in 2.8% of patients, and they were all viral infections (warts). While this agrees with some studies[15],[16] that noted a predominance of viral infections, it is at variance with many clinical studies that reported a predominance of fungal infections.[17],[18] This is understandable as most superficial fungal infections are unlikely to be biopsied. Alramaity et al. in Libya and Ali et al. in India also noted viral warts as the commonest viral infection, while Kshetrimayum et al. also in India and Amadi et al. in Nigeria reported herpes zoster as the most common viral infection in their geriatric population.[7],[15],[17],[19] Several factors, including impaired immune function, thinning of skin, dryness, decreased blood flow, and associated medical conditions such as diabetes may predispose elderly patients to infective dermatoses.[13]

In this study, the lower limbs were the most frequent site of skin lesions in general and malignancies in particular. Lower limbs are usually exposed to UV radiation from the sun and are a common site of chronic ulcerative lesions, which are a common precursor of skin cancers.[11] Conversely, the paucity of lesions on the trunk and pelvic area can be attributed to limited UV exposure and a lesser frequency of trauma in comparison to the limbs.

The frequency and proportion of many dermatoses encountered in this study show some variation with earlier studies probably because earlier studies analyzed clinical data while this study examined histopathological data. This is a major limitation in this study as dermatoses that are less likely to be biopsied are under-represented. It is also possible that ethnic, regional, national, and skin type differences between different study populations accounted for the differences in study outcomes. In addition, our study is a hospital-based cross-sectional study and may not reflect the true demographic pattern of skin diseases in the geriatric population. Whatever the case, these epidemiologic data are useful for monitoring changes in disease trends in geriatric patients and for planning health care programs for this group.[13]


  Conclusion Top


Malignant neoplasms, benign neoplasms, and papulosquamous disorders are the three most common histologically diagnosed skin lesions in our geriatric population. The most common skin malignancies in this group of patients are SCC and malignant melanoma. Health education programs about skin diseases need to be shaped to include general awareness, preventive information, and early presentation to hospitals. It is also important that health-care practitioners be trained to screen for the most important and significant dermatological conditions and biopsy any suspicious lesion for histological diagnosis.[20] This is especially important for skin cancers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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