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Senile gluteal dermatosis: The term “senile” is getting old and should be retired

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By Warren R. Heymann, MD, FAAD
Jan. 24, 2024
Vol. 6, No. 4

Dr. Warren Heymann photo
As my patients and I get older, inevitably I think more about geriatric dermatology. (1) There is a disorder I have seen on the gluteal region in mostly thin, older, sedentary patients — my recommendations of off-loading pressure and using mild keratolytics have been reasonable. What I have been unable to provide patients is a name for this condition, likening it to early pressure ulcers, which they are not. (2) It is always reassuring for patients when their disease has a name — increasingly the term “senile gluteal dermatosis” (SGD) has been utilized for this disorder. Honestly, it is better to have a name, rather than none. However, I am not keen on this appellation. I will explain why later in this commentary and will offer an alternative.

SGD, also known as “sitter’s sign,” was first reported in Japan in 1979. Most reports have been from Asian countries. (3) Despite the similarities of gluteal lichenification, SGD appears to be distinct from anosacral cutaneous amyloidosis (ACA); most cases of ACA are associated with lichen amyloidosis elsewhere on the body, and, by definition, display amyloid on biopsy, which SGD does not. (4)

Image for DWII on senile gluteal dermatosis
Image courtesy of Eve Lowenstein, MD, FAAD.
Liu et al evaluated 137 patients with SGD. These patients had a mean age of 79.4 ± 40.7 years and a mean BMI of 21.7 ± 10.8; they presented with either partial (n = 43, 31%) or full-blown (n = 94, 69%) SGD lesions characterized by the sign of so-called “three corners of a triangle”: brownish plaques on the gluteal cleft and each side of the buttocks. The male/female ratio was 130/7. Itching or pain of varying intensity was reported by 50 patients (36%) and 14 patients (10%), respectively. Eighty-six patients (53%) presented with horizontal hyperkeratotic ridges, a characteristic sign of SGD. Most patients spent a majority of the day sitting but reported no special way of sitting or lying. More than half of the patients with SGD claimed no response to topical steroids and/or keratolytics. The authors concluded that SGD is common, mostly affecting thin elderly patients. Friction, pressure, and long hours of sitting seemed to be important triggers for this dermatosis. (5) Moon et al reported that of their 37 SGD patients, the male/female ratio was 17/20. When compared to their control group, there was a significant positive correlation between SGD and lower lean body mass, a longer period of a sedentary lifestyle, use of a Korean-style mattress, and diabetes mellitus. Most patients were asymptomatic or had mild symptoms — of those that had complaints, vague discomfort (n = 7), mild itching (n = 6), pain (n = 5), pricking (n = 4), and tenderness (n = 2) were observed. (6) In my experience, the only patients bothered by SGD were those with some pain related to hyperkeratosis and/or superficial erosions.

The histological features of SGD are not specific. Orthokeratotic hyperkeratosis, acanthosis, vascular dilatation, and a sparse perivascular mononuclear infiltrate are observed. In severe cases, vascular proliferation and a dense inflammatory infiltrate may be appreciated. (7) Follicular plugging may be observed. (8) Dermoscopy may demonstrate follicular plugs surrounded by vessels that may display a white halo. (9) The main differential diagnoses for SGD include lichen simplex chronicus (which can be very pruritic), psoriasis (characteristic lesions elsewhere), and most importantly early pressure sores. Ota and Lowenstein observe that SGD presents as “hyperkeratotic lichenified plaques, which differ from early stages of pressure injury defined as nonblanchable erythema of the intact skin.” Additionally, pressure injury usually appears over bony prominences such as the sacrum or ischial tuberosities, while SGD does not necessarily do so. (3)

Although the pathogenesis remains to be elucidated, friction (more so than pressure) from sitting in thin patients are most important. Based on that presumption, reducing friction and off-loading pressure, while encouraging a more active lifestyle (if possible), are vital. Topical steroids are not especially useful in non-pruritic patients nor are keratolytics. Retinoids may be beneficial. (6) Calicipotriol was reported to be effective in a solitary case. (10)

When I began my career in dermatology, terms such as “senile keratoses” and “senile sebaceous hyperplasia” were still utilized. Appropriately, those terms have been retired. According to the Meriam-Webster Dictionary, senile is defined “of, relating to, exhibiting, or characteristic of old age/senile weakness — especially exhibiting a loss of cognitive abilities (such as memory) associated with old age.” (11) Although the term “senile gluteal dermatosis” is technically correct, I do not want to label my patients senile in any way, shape, or form, because of the colloquial connotation. I propose the term Frictional Gluteal Dermatosis instead of SGD, with the full realization that most patients with this disorder are elderly.

Point to Remember: Senile gluteal dermatosis is an underrecognized frictional dermatosis seen mostly in thin, elderly patients.

Our expert’s viewpoint

Eve Lowenstein, MD, PhD, FAAD
Clinical Professor of Dermatology
Director of Medical Dermatology
SUNY Downstate Medical Center

Decubiti and SGD: What is in a name?

Charles Darwin was the first acknowledged to use the terms lumpers and hair-splitters. The idea has been broadly applied and dermatology is no different. We dermatologists acknowledge points of view which respect either the perspective of organizing information in small groups (Splitters) or the perspective of larger categories (Lumpers). Decubitus and senile gluteal dermatosis (SGD) is one such area. Little has been published on SGD in the U.S. because lumpers view it as a variation on the decubitus ulcer/pressure ulcer/bedsore theme. Decubiti involve a primary etiopathology of skin and soft tissue injury that result from prolonged or uninterrupted pressure exerted on the skin. These lesions occur mostly in people who are immobilized or of limited mobility. Incontinence associated dermatosis is an independent risk factor for decubiti. Wearing pull ups or diaper use is similarly associated with decubiti. SGD shares all these factors in common with decubiti. Both conditions are improved by offloading. So how are these diagnoses distinct such that splitting could be conceptually/therapeutically useful?

Most decubiti pressure ulcers begin due to subcutaneous changes and are difficult to detect early on, regardless of the various stages at presentation. By contrast, SGD begins superficially and is easily identified as an early lesion, presenting with lichenification.

Decubiti have been linked with higher mortality and severe illness. This is why the French physician Jean-Martin in the 19th century named this lesion “decubitus ominous,” where he found mortality linked inevitably after decubitus development. SGD is more frequently encountered in patients who are more sedentary, but not bed bound and have better overall prognoses.

Decubiti tend to occur over bony prominences, whereas SGD occurs primarily where skin encounters friction against skin or other surfaces. SGD does not progress to full thickness necrosis. Curiously, in the cases I have seen, I have not noted an increased prevalence in lower BMI individuals as has been described in the literature.

Decubitus care emphasizes ulcer debridement and wound dressing. Offloading with equipment such as air mattresses is recommended as part of the care of decubiti, whereas SGD primarily stresses offloading (such as donut seat) as THE major intervention. Chemical or blade debridement play little to no role in SGD.

Finally, I agree with Dr Heymann regarding disbanding terms such as senile purpura and SGD for less offensive terms. For the splitters in the audience, perhaps Sitter’s sign is a preferable moniker that is descriptive and easily memorable.

  1. Heymann WR. Geriatric dermatology: Grow old along with me! J Am Acad Dermatol. 2022 May;86(5):1000-1001. doi: 10.1016/j.jaad.2022.02.046. Epub 2022 Mar 1. PMID: 35245564.

  2. Heymann WR. The pressure to prevent pressure ulcers. Dermatology World Insights and Inquires, 2022, Vol 4, No 34. https://www.aad.org/dw/dw-insights-and-inquiries/archive/2022/pressure-to-prevent-pressure-ulcers

  3. Ota K, Lowenstein EJ. Senile Gluteal Dermatosis: An Underreported Condition in Elderly Patients. Skinmed. 2022 Apr 30;20(2):149-151. PMID: 35532772.

  4. Wang WJ, Huang CY, Chang YT, Wong CK. Anosacral cutaneous amyloidosis: a study of 10 Chinese cases. Br J Dermatol. 2000 Dec;143(6):1266-9. doi: 10.1046/j.1365-2133.2000.03899.x. PMID: 11122031.

  5. Liu HN, Wang WJ, Chen CC, Lee DD, Chang YT. Senile gluteal dermatosis: a clinical study of 137 cases. Int J Dermatol. 2014 Jan;53(1):51-5. doi: 10.1111/j.1365-4632.2012.05702.x. Epub 2013 May 15. PMID: 23675693.

  6. Moon SH, Kang BK, Jeong KH, Shin MK, Lee MH. Analysis of clinical features and lifestyle in Korean senile gluteal dermatosis patients. Int J Dermatol. 2016 May;55(5):553-7. doi: 10.1111/ijd.12838. Epub 2015 Jul 31. PMID: 26234159.

  7. Liu HN, Wang WJ, Chen CC, Lee DD, Chang YT. Senile gluteal dermatosis - a clinicopathologic study of 12 cases and its distinction from anosacral amyloidosis. J Eur Acad Dermatol Venereol. 2012 Feb;26(2):258-60. doi: 10.1111/j.1468-3083.2011.04045.x. Epub 2011 Mar 24. PMID: 22280513.

  8. Niiyama S, Sakurai S, Katsuoka K. Hyperkeratotic lichenified skin lesion of gluteal region. J Dermatol. 2006 Nov;33(11):779-82. doi: 10.1111/j.1346-8138.2006.00186.x. PMID: 17073993.

  9. Errichetti E, Stinco G. Dermoscopy of senile gluteal dermatosis: an observational study. Int J Dermatol. 2020 Dec;59(12):e460-e462. doi: 10.1111/ijd.15057. Epub 2020 Jul 19. PMID: 32686115.

  10. Wu X, Chong WS. Not something to sit on: A case of senile gluteal dermatosis responding to calcipotriol ointment. Australas J Dermatol. 2022 Aug;63(3):e282-e284. doi: 10.1111/ajd.13863. Epub 2022 May 4. PMID: 35510336.

  11. https://www.merriam-webster.com/dictionary/senile. Accessed October 15, 2022.

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