A 91-year-old woman is mortified when a friend comments on the “age spots” on the skin of her neck.
“In the first place,” the patient retorts while recounting the story, “I’m not that old. And in the second place, I don’t see anything there—what’s she talking about?”
She is truly upset about what she feels were uncalled-for comments. But more than that, she has no idea what her friend could be referring to. No one else has ever said anything negative about her skin—in fact, everyone who meets her marvels at how young she looks for her age.
On examination, her skin is quite fair and shows extensive signs of sun damage. There is extreme widespread mottling, in colors ranging from yellow to orange, and exceptionally pronounced wrinkling on sun-exposed areas of her face, neck, arms, and chest. Notably, the area of the anterior neck shaded by her chin is pristine and white. Fortunately, no cancerous or other worrisome lesions are seen.
This case illustrates a number of related phenomena. For example, it was shocking that this patient–one of most sun-damaged I’ve ever seen–was unaware of such obvious changes. But these changes had been present for so long and manifested so gradually that they escaped her notice. (Not to mention, the eyesight of a 91-year-old is probably not what it once was.)
Furthermore, when informed that her skin’s condition was a result of sun exposure, she was sure we had lost our minds, because she had not been in the sun “at all” for many, many years. According to her daughter, this was true. But the patient had overlooked the fact that she had grown up on a farm, worked in the fields, played outside, swam and fished, all the while getting a great deal of sun exposure, until she married in her late teens, had children, and moved to town. Being so busy and so fair, she had neither the time nor the inclination to get outdoors much, and that was that—or so she thought. This is a very common set of circumstances for dermatology patients.
Little did she realize that it takes decades (30 to 40 years) for the accumulated effects of sun damage to show up, in the form we see here. This type of “aging” is an example of what we call extrinsic aging. Besides sun, it can be worsened by the effects of wind, low humidity, smoking, alcohol intake, obesity, and some medical conditions. Intrinsic aging, which includes wrinkles, sagging, and general loss of elasticity, is influenced by age, heredity, and ultimately, gravity.
From our standpoint as medical providers, perhaps the most significant issue with this patient is her increased risk for sun-caused skin cancer, specifically basal cell carcinoma (BCC), squamous cell carcinoma (SCC), or melanoma (the three most common forms). Her risk for development of the first two is huge, arguably a certainty given her age, extremely fair skin, and degree of sun damage. Melanomas are different in many ways, actually becoming less likely (statistically) at her age than at age 50. They are also not as much the result of the accumulated effects of sun exposure as are BCC/SCCs.
So, perhaps the most significant outcome of this visit was to get the patient scheduled to see us biannually for skin checks. In our system, that means twice-yearly reminder phone calls to ensure that this actually happens.
TAKE-HOME LEARNING POINTS
• It takes three to five decades for sun damage to eventuate in dermatoheliosis/basal cell carcinoma/squamous cell carcinoma.
• Melanoma is different, since it appears to be related to episodic, poorly tolerated, intense sun damage early in life; the average age of melanoma patients is about 40.
• Aging can be intrinsic (“normal” loss of elasticity, plus the effects of gravity, modified by heredity) in nature.
• Aging can also be extrinsic, caused by UV exposure, smoking, alcohol consumption, wind, and decreased humidity, eventuating in telangiectasias, actinic keratoses, solar elastosis, solar lentigines, atrophy, purpura, poikilodermatous changes, and sun-caused skin cancers.
• Older patients are often incredulous about the role of childhood sun exposure in the eventual development of dermatoheliosis.