Abstract
The incidence of all types of malignant skin tumours, including both melanoma and non-melanoma types, has increased in recent decades, while basal cell carcinoma is the most common human malignancy in the Caucasian race. The aging of the skin is associated with an increase in both benign and malignant tumours. As the population ages and life expectancy extends, mostly in developed countries, dermatologists are likely to face growing numbers of patients seeking therapy for such abnormalities. It is primarily UV irradiation that is responsible for the development of skin cancers, although there are other risk factors, including air pollution and X-ray irradiation. Seborrhoeic keratosis, solar lentigo and other benign lesions, despite their harmless nature, may cause distress to patients, such as itching or aesthetic issues. This review article summarises the features of the most common benign and malignant lesions of aging skin.
Introduction
The aging of the skin not only causes structural and subsequent physiological changes to the skin but also leads to the development of benign and malignant tumours in elderly people.
The most common benign lesion is the solar lentigo (SL), which appears as a brownish, flat mark. Also known as “age spots” [1], solar lentigines develop on skin surfaces that are exposed to sunlight. Seborrhoeic keratoses (SK) are also extremely frequent. These have a brownish, dark-coloured, verrucous surface that protrudes from the skin [1, 2]. Although these cannot develop into malignancy, many patients seek treatment due to potentially extreme itching or for aesthetic reasons [3]. In addition to benign changes in the skin, there are several precancerous and malignant lesions that emerge with the aging process. The incidence of all types of malignant skin tumours, both melanoma and non-melanoma types, as well as precancerous lesions, increases with age [4–6]. The most common precancerous lesion is actinic keratosis (AK, also referred to as solar keratosis), which may affect up to 25% of the elderly population [4]. Without adequate treatment, AK can transform into squamous cell carcinoma (SCC), which can metastasise [4]. Among malignant lesions, basal cell carcinoma (BCC) is the most prevalent and is the most common human malignancy in the Caucasian race [7].
Benign lesions of the aging skin: characteristics and treatment options
During the aging process, the skin not only loses its constituent components but also reacts to UV and other environmental impacts, such as air pollution. These combined factors result in an increasing number of pigmented and non-pigmented benign tumours, as well as lesions of vascular origin. Seborrhoeic keratoses, which can vary widely in size from a few millimetres to several centimetres, are the most common benign lesions [3] (Fig. 1). They develop from keratinocytes and can take many different clinical forms. They may present as light brown to black in colour and can have an almost flat or extensively verrucous surface [3]. The diagnosis of SK is in general uncomplicated with the use of a dermatoscope. However, in the case of forms that are more darkly pigmented, or even black, it is important to distinguish SK from melanoma. In cases where no clear diagnosis can be established, surgical excision and histological examination are recommended [8]. Seborrhoeic keratoses can easily be removed using a variety of techniques, such as electrocautery or curettage with a Volkmann spoon or carbon dioxide (CO2) laser device [9]. Where histological examination is needed, curettage or in toto excision are the preferred procedures. In the case of the possible differential diagnosis of malignant melanoma (MM) versus SK, in toto excision is the only applicable technique [8]. However, in the event of a clear diagnosis it is not necessary to remove SK, as malignant transformation does not occur. If itching, inflammation, or other symptomatic issues develop, or if the patient requests the removal of SK due to aesthetic reasons, the need for treatment may be validated [10]. In outpatient care in the elderly population, the above techniques are equally applicable. In nursing homes, chronic general wards, or specialised units for elderly patients, cryotherapy is preferred. With this method, the chances of secondary infection are minimal, no wounds develop, and it can even be applied as a bedside procedure [11]. The differential diagnosis of SL (primarily the lentigo maligna subtype) versus melanoma can also give rise to issues [12]. In the event of a definite diagnosis, if the patient requests the removal of SL for aesthetic reasons, chemical peeling or retinoid creams with an exfoliating effect can be used in addition to the above-mentioned techniques [13]. Another common benign lesion of vascular origin is senile angioma, also known as cherry angioma or Campbell de Morgan spots, which likewise have no malignant transformation potential [14]. These lesions thus require no action, other than for aesthetic reasons, in which case they can be removed by electrocautery, CO2 lasers, and especially vascular lasers, such as diode, pulse dye (PDL) or Nd:YAG lasers [14]. In skin folds, such as the axilla, groin and neck area, irritation makes the skin vulnerable to the development of soft fibromas (also called skin tags or acrochordons). These are non-pigmented, benign lesions with no malignant potential. However, because of irritation and inflammation, and also for aesthetic reasons, many patients seek treatment for this condition [15]. These lesions can also be removed using electrocautery, CO2 laser or cryotherapy. Smaller lesions can even be removed with scissors, in which case the bleeding can be effectively controlled using a high concentration solution of ferric chloride or aluminium chloride [16].
Seborrhoeic keratosis, a benign skin growth on the ear, characterised by a light brown waxy, scaly, and raised verrucous surface
Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00055
Precancerous lesions of the skin: characteristics and treatment options
The most common precancerous lesion is AK, which may affect up to 25% of the elderly population [4]. Actinic keratosis appears as an erythematous, generally scaly, slightly infiltrated plaque. It is occasionally accompanied by subjective symptoms, such as itching or pain, but does not usually cause any complaints. As it can transform into SCC [17], it does require treatment. There are many therapeutic options available [18], including removal by cryotherapy or physical destruction using electrocautery or CO2 laser. Photodynamic therapy (PDT), as well as the “daylight” version of this technique, are being used increasingly to treat AK, and several lesions can be treated during a single session [19]. Topical therapies are also available, such as creams containing 5-fluorouracil (5-FU) or imiquimod (Aldara®), a Toll-like receptor 7 (TLR7) agonist, both of which are excellent options for the treatment of AK [19]. Cryotherapy offers the same advantage as in the case of SK, as it can be used as a bedside procedure. The topical creams referred to above can be applied by the patients themselves, supposing an adequate level of compliance. In the event of inadequate compliance, the cream can be administered by nursing staff, thus the medical human resources required for this procedure are minimal.
Other precancerous lesions of the skin, such as Bowen's disease and erythroplasia of Queyrat can also be treated using the same therapeutic modalities [20, 21].
Malignant lesions of the skin: characteristics and treatment options
The most aggressive and dangerous skin malignancy is MM, the incidence of which has increased significantly in recent decades, reaching 68.6 per 100,000 people in the U.S. in 2006 [22]. Malignant melanoma affects disproportionately more men than women in the U.S. (107 versus 41 cases per 100,000 people) [22]. In Hungary, the incidence almost doubled (12 versus 23 cases per 100,000 people) between 2001 and 2012, although MM affected moderately more women than men [23].
In cases of melanoma, surgical excision with an adequate safety margin is required. Depending on the depth of the melanoma lesion, known as the Breslow thickness, staging and further oncological treatment may be necessary [24]. In the presence of features identified on the basis of the ABCD rule — that is, asymmetry, irregular border, multiple colours, and a diameter greater than 6 mm — it is feasible to establish a suspected diagnosis of melanoma (Fig. 2). This should subsequently be confirmed by a dermatologist via dermoscopic examination. Furthermore, all newly formed pigmented lesions or existing pigmented lesions showing changes should be treated as potential melanomas. However, caution is required even in the case of newly formed “pinkish” non-pigmented lesions, which should be considered as melanomas and checked by dermoscopic examination [25, 26].
Malignant melanoma, a pigmented asymmetric tumour on the lower limb
Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00055
Squamous cell carcinoma (or so-called spinalioma) is the second most common human skin cancer after BCC and is able to metastasise [27]. The typical clinical features of SCC are a slowly or rapidly growing scaly or crusted plaque, nodule, or tumour, which is erythematous or greyish white in colour. As previously discussed, AK can transform into SCC and must therefore be treated early. The treatment of SCC follows the same principles as the treatment of melanoma, although a narrower safety margin of 5 mm is generally suitable [27]. Staging examinations are also required because of its metastatic potential [28]. Basal cell carcinoma has the highest prevalence among skin cancers and is also the most common human malignancy in the Caucasian race [7]. It is essentially non-metastatic, although its locally advanced form (laBCC) can lead to the severe destruction of surrounding tissue, and even to the death of the patient [29–32]. The clinical presentation is generally an erythematous, occasionally ulcerated, bleeding plaque or bump with a pearly shine [29] (Fig. 3). With the use of a dermatoscope, arborising telangiectasias can be observed and pigmented BCC can be distinguished from melanoma [33]. It can occasionally be difficult to diagnose BCC, mostly in the case of subtypes such as superficial or sclerodermiform BCC [34]. Careful observation and dermatological examination are therefore crucial for all wounds that do not heal after six weeks, especially in areas exposed to sunlight [7]. The gold standard treatment is surgical excision. Radiotherapy, cryotherapy, curettage combined with chemical surgery, electrocautery or CO2 laser, photodynamic therapy, or imiquimod topical therapy can also be used to remove BCCs [27]. In the facial area, and especially around the eyes, nose and ears, prompt and adequate treatment is of paramount importance. The basic principle is that if the BCC can be removed surgically or otherwise, this is the recommended option even where there is a chance of causing a moderate aesthetic defect. Although BCC lesions generally grow slowly, they can become enormous and laBCCs can develop, which represent a therapeutic challenge [29–31]. In several cases, surgical excision is not feasible or would result in severe functional and aesthetic issues. In such cases, the targeted small-molecule SMO inhibitors vismodegib or sonidegib may be the only choice of treatment. If the general condition of an elderly patient permits, this may be a good therapeutic option with significant, but in most cases manageable, side effects [30, 31]. Nevertheless, laBCCs can present a serious oncological dilemma in the elderly population. The optimal therapy must be determined taking into account a number of factors, including the size, the histological type of the BCC, comorbidities, and the life expectancy of the patient independent of the BCC. The severity and danger of the disease should not be underestimated solely because of the age of the patient, as this is a tumour that gradually and relentlessly destroys the surrounding organs, including the eyes, nose and ears, or even as far as the cranial bone. Tumours accompanied by regular bleeding and secondary superinfection cause a serious deterioration in quality of life over many years.
Basal cell carcinoma, an erythematous, ulcerated, pearly, shiny tumour on the forehead
Citation: Developments in Health Sciences 4, 4; 10.1556/2066.2022.00055
Conclusions
The prevention, prompt detection, and appropriate treatment of skin tumours are of particular importance in the elderly population. Essentially, annual screening is sufficient and requires only a dermatoscope, which is easily portable. Screening can thus be performed locally in nursing homes or in the chronic care units of hospitals, which is an important consideration for a significant proportion of the elderly patient population. Adequate dermato-oncological care can significantly reduce mortality and morbidity in the elderly population, thus its further development will remain an important objective in the future. However, in addition to malignant lesions, there may still be a significant need for the treatment of benign lesions in elderly patients. Whether for functional or aesthetic reasons, the importance of such treatment should be considered from a quality of life perspective.
Conflicts of interest/Funding
The authors declare no conflict of interest. No financial support was received for the preparation of this manuscript.
Authors' contribution
AB - writing original draft. Preparation, creation of the published work, specifically writing the initial draft. AG - writing original draft. Preparation, creation of the published work, specifically writing the initial draft. KG - preparation of the published work, contributed to the critical revision of the manuscript. PH - Critical review, including pre- or post-publication stages, supervised the study and finalized the manuscript.
Abbreviations
| AK |
actinic keratosis |
| BCC |
basal cell carcinoma |
| CO2 |
carbon dioxide |
| laBCC |
locally advanced basal cell carcinoma |
| MM |
malignant melanoma |
| PDT |
photodynamic therapy |
| SCC |
squamous cell carcinoma |
| SL |
solar lentigo |
| SK |
seborrhoeic keratosis |
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