Within our aging population, there is a growing prevalence of dermatological concerns within the elderly. One of the primary concerns of geriatric dermatology is the presentation of pruritus, which becomes more common with advancing age.1 With approximately 40% of all dermatology clinic visits regarding a patient over the age of 65, the management of pruritus is highly relevant to all dermatologists.2

Pruritus in elderly patients often presents without visible morphological changes, making diagnosis and management more challenging. Fortunately, new advancements in understanding the pathophysiology of age-associated itch assist us in targeting the multifactorial etiology of itch. The process of aging, often referred to as “inflammaging,” occurs through three key mechanisms: immunologic, neuropathic, and primary cutaneous.

Immunologic changes are believed to occur via the senescence-associated secretory phenotype (SASP) of cells, which promotes the release of pro-inflammatory and tissue-remodelling factors.3,4 This contributes to a shift toward a Th2-dominant immune state in aging skin. In addition, skin barrier recovery slows with age, primarily due to reduced epidermal lipid synthesis, which occurs at only two-thirds the rate seen in younger individuals.5 The neuropathic component must also be considered, as aging is associated with autonomic dysfunction and a decline in neuroplasticity.6

Diagnosis of chronic itch in the elderly can be difficult due to the absence of rash and nonspecific presentation. History taking is key including duration, description of symptoms, intensity, ameliorating factors, and exacerbating factors.7 A careful review of medical history and medications are needed to identify triggers such as chronic kidney disease and drug abuse. To exclude infectious causes of itch such as scabies, it is important to ask if any close contacts and family have similar symptoms. A further complete physical exam, dermatologic exam, and skin biopsy are recommended to exclude other etiology of itch. Recommended laboratory tests in the context of the examination includes a complete blood count, metabolic profile, liver function tests, thyroid function tests, and erythrocyte sedimentation rate.7

Effective treatment of pruritus in the elderly should address all three contributing domains. This can be achieved through therapies that act via shared mechanisms or by combining agents that target distinct pathways (see Table 1). For instance, to address both immunologic and neuropathic components, one might use a topical corticosteroid alongside pramoxine, or a JAK inhibitor in combination with doxepin.

As clinicians, we are entrusted to care for the elderly population, many of whom suffer from pruritus without visible skin changes. Understanding the multifactorial pathophysiology of aging helps us create an effective management plan. By approaching pruritus in the elderly through this lens, we can more effectively improve quality of life of these patients.