Dermatology

Xerosis (Dry skin)

Xerosis [synonyms Dry skin]

Are You Confident of the Diagnosis?

Xerosis is dry skin resulting from dehydration of the stratum corneum (Figure 1, Figure 2, Figure 3). The outer keritanized skin layers require 10-20% of water by volume to compensate for evaporative loss and maintain structural integrity. Pathological loss of lipids in the stratum corneum results in dramatic transepidermal dehydration, up to 75 times that of healthy skin.Dry skin may appear at any age, and provides the basis for the development of atopic dermatitis (AD). Scratched, itchy skin tends to develop eczema.

Figure 1.

Xerosis of the face in a geriatric patient.

Figure 2.

Xerosis of lower legs.

Figure 3.

Xerosis of feet.

Eczema comes in various manifestations. Three common forms are nummular eczema, asteototic eczema, and xerotic eczema, or xerosis. While these eczematous skin conditions have their own peculiar characteristics, they nevertheless have some features in common. They commonly present in the elderly, all decrease the integrity of the skin barrier, all benefit from the application of topical medications, and they can all be improved by changes in skin care habits, including the use of nonfragranced and hypoallergenic skin care products.

A common manifestation of xerosis is pruritus. It is important to treat the pruritus when present to prevent secondary complications such as lichen simplex chronicus and impetigo. Since underlying systemic disease, such as Hodgkin's lymphoma, hyperthyroidism, and HIV infection, can also produce pruritus, nonresponders to conservative treatment should be worked up.

Who is at Risk for Developing this Disease?

Eczema, in its various manifestations is a common dermatologic condition that affects people in all age groups, and is related to a defective skin barrier. Eczema involves damage to the intercellular lipids and can be exacerbated by irritating skin care products. Intercellular lipids contain ceramides that are necessary to form a waterproof barrier with the corneocytes to protect underlying skin tissues. Many of the above principles are applied in combination to successfully treat nummular eczema, asteototic eczema, and xerotic eczema.

  • Prevalence and predisposing factors

While xerosis may appear at any age, it is most common in the elderly, and occurs most frequently during the winter months. Progression of xerosis is especially rapid during winter because, to the surprise of many patients, indoor heating has an intrinsic dehumidifying effect. Patients with xerosis may experience an intense pruritus,often involving the anterolateral lower legs, the back, flank, abdomen, and waist. The skin becomes dry and scaly and the skin lines appear accentuated.

What is the Cause of the Disease?

In healthy skin, skin cells called corneocytes detach from neighboring cells and are replaced by younger cells from deeper skin layers. This orderly process, called desquamation, leads to corneocyte or skin cell loss from the skin surface. Desquamation is controlled primarily by two intercellular components - corneodesmosomes and lipids. The intercellular actions of these components help preserve tissue thickness. Corneodesmosomes bind the corneocytes to maintain intercellular cohesion and tissue integrity.

Effective desquamation requires that corneodesmosomes eventually be broken down. Although this process, called corneodesmolysis, effectively eliminates the corneodesmosomes in healthy skin, this is not the case with xerotic skin. Corneodesmosomes persist and disrupt the orderly desquamation process. In chronic and acute dry skin conditions, this disturbed process is manifested by the formation of visible, powdery flakes on the skin surface.

Another important consideration is that free water is necessary to control the corneodesmolysis process. Adequate lipid content is required to retain the free water. Inadequately hydrated skin cannot provide this free water. Therefore, deficits in both skin hydration and lipid content play a key role in xerosis. Consequently, the skin’s inability to retain moisture and provide an effective barrier directly impacts the development of xerosis in aged skin.

These processes are in dynamic equilibrium with other mechanisms in the skin, such as keratin production, sweat gland activity, fatty acid metabolism, and sebaceous excretion. Diseases that alter this dynamic equilibrium, such as in many types of thyroid disease, neurologic disease, and certain forms of cancer, may cause xerosis. Therapeutic interventions, particularly antiandrogen therapy through the use of Cimetidine, can also induce xerosis.

Systemic Implications and Complications

Elderly patients are more susceptible to xerosis because of preexisting disease states, therapies, and medications. These include end-stage renal disease, nutritional deficiency (especially zinc and essential fatty acids), thyroid disease, neurological disorders with decreased sweating, human immunodeficiency virus, malignancy, radiation, anti-androgen medications, and diuretic therapy.

Treatment Options

  • General measures

Proper hygiene of nails

Wearing light and loose clothing

Humidification

Reduction of bathing/shower time and temperature

Stopping the use of alcohol-based soap (clear soaps and gels) on affected areas

  • Topical Treatments

Moisturizers, emollients, or barrier creams with low pH

Topical corticosteroids

Topical immunomodulators

Menthol

Capsaicin

Local anesthetics

Topical salicylic acid

  • Systemic treatments

Antihistamines

Antidepressants

Opioid Agonists and antagonists

Neuroleptics

  • Physical treatment

Phototherapy

Optimal Therapeutic Approach for this Disease

Skin lubricants should be applied frequently during the day and immediately after bathing. Excessive bathing, frequent use of soap, dry environments, topical irritants (eg, synthetic or wool clothing, topical anesthetics), and vasodilators (eg, caffeine, alcohol, exposure to hot water) will worsen xerosis. Use of hypo-allergenic and non-fragranced skin products, cotton or silk clothing helps.

Use of topical corticosteroids should not be prolonged due to risk of skin atrophy. Lotions containing menthol and camphor (Sarna lotion), and Pramoxine (Pramasone) are helpful. Mild exfoliators such as LacHydrin 12% lotion are effective. Oatmeal baths (Aveeno) are soothing.

Systemic antihistamines such as Zyrtec 10mg daily or Hydroxyzine (Atarax) 25mg three times daily may be used to decrease itching, but may cause adverse reactions, particularly in elderly patients. Intense scratching can result in secondary lichen simplex chronicus, or prurigo nodularis. This condition can be treated with a capsaicin cream (Zostrix) applied 4-6 times daily for 2-8 weeks.

Draelos et al showed in a study on xerotic eczema with desquamation, erythema, and pruritus that this common skin condition can be caused or worsened by skin cleansing. The study showed that synthetic detergent bar soap applied with a washcloth is more irritating even when treated with a strong corticosteroid. In contrast, washing with a petrolatum-delivering body wash applied with a polyethylene puff is a more therapeutic means of caring for moderate xerotic eczema, even when used with a weaker medium strength corticosteroid such as triamcinalone 0.1% cream.

Patient education should be provided in replacing puffs frequently (about once every 3-4 weeks), since a variety of bacteria and fungi may reside on the puffs, and can result in opportunistic infections.

  • Nummular eczema, asteototic eczema, and xerotic eczema

Soak and Smear Treatment

These dermatological conditions are common inflammatory skin conditions that cause a compromised skin barrier and may be associated with pruritus, fissuring, or scaling. In a study by Gutman et al, these conditions respond well to a "Soak and Smear” treatment. The treatment is a plain water 20-minute soak followed by smearing of mid- to high-strength corticosteroid ointment such as triamcinalone 0.1% ointment onto the wet skin. The treatment is done at bedtime. A cream of the same strength (triamcinalone 0.1% Cream) is also applied in the morning to the affected areas. The patient is also educated to avoid washing of the skin with soaps, and to use moisturizers after any washing.

This treatment is done for up to 2 weeks. In more severe cases, the patient may use the ointment only at night for 2 more weeks. When the patient has cleared, he may be switched to the soak and smear therapy with only white petroleum jelly. Eventually the patient can go to using moisturizer lotion only after showers and before bedtime as maintenance. In the study, the soak and smear therapy is often successfully done with the same topical corticosteroid that failed in the patient in the past when it was simply applied topically even with occlusion, but without prior soaking. In the study, if the corticosteroid was continued for a month or longer, purpura at sites of trauma, usually of the upper extremities, was seen; so it is important to do patient teaching, and make the change over to petroleum jelly, and then to moisturizers.

Soaking removes crust and scale, and hydrates the damaged stratum corneum, promoting desquamation. Smearing traps the moisture in the stratus corneum, and delivers the topical medication in the ointment. Smearing after showering, shorter soaks, or soaking in chlorinated pools or hot tubs does not produce the same improvements, and can lead to irritation. By using the soak and smear technique, often systemic medications can be avoided.

Patient education

When using the soak and smear treatment, part of the maintenance therapy is also educating the patient regarding the need to reduce the use of soap and increase the use of moisturizers. These patients may have flares of the eczema, but, having been educated about the cause and treatment, they can re-do the soak and smear treatment and find relief.

  • Ceramides and skin function

As reported by Coderch et al, ceramides are the major lipid present in the stratus corneum, and are necessary to maintain the water permeability and barrier functions of the epidermis. Coderch and his team found that most dermatology conditions with decreased barrier function have ceramide deficiency and alteration. Therefore skin lotions with ceramides and ceramide precursors can improve the barrier function of the skin, and help treat skin conditions with impaired barrier function.

Achcroft et al reports that topical pimecrolimus is less effective than moderate and potent corticosteroids and 0.1% tacrolimus. In a small study by Birnie, et al, no evidence of benefit was found for antimicrobial interventions for patients with atopic eczema, and it was acknowledged that further larger studies are needed to form conclusive long-term outcomes.

Many commonly used skin moisturizers do not correct the stratus corneum ceramide deficiency that is responsible for the impaired skin barrier in inflammatory dermatoses. Since glucocorticoids and other immunosuppressive agents do have a risk of toxicity, a ceramide-dominant barrier repair emollient gives a safe treatment for atopic dermatitis and other inflammatory dermatoses that are characterized by impaired skin barrier.

Moisturizers such as Cerave were found to improve the skin barrier function. Dry skin is often linked to an impaired skin barrier, as seen in xerosis, and asteototic eczema. Petrolatum and ceramides have a barrier-repairing effect, without the odors that may be found objectionable to some people. 5% urea makes skin less susceptible to breakdown and damage from sodium laurel sulfate. Treatments improving the skin barrier relieve may even prevent episodes of many dermatological conditions.

Staphylococcus aureus is frequently found in the lesions of patients with eczematous skin conditions. A study conducted by Gong et al found that early topical treatment of moderate to severe eczematous skin conditions benefited from a combination of muporicin plus a topical corticosteroid, and reduced colonization of S aureus. An antibiotic-corticosteroid combination and corticosteroid alone both gave good therapeutic effect in eczema and in atopic dermatitis, and both reduced colonization by S aureus. Early combined topical therapy is beneficial to patients with moderate to severe eczema and atopic dermatitis and it is unnecessary to use antibiotics at later stages of disease or in mild eczema.

Some new skin care lotions and cleansers contain ceramides. In a study Draelos compared the use of fluocinonide 0.05% cream plus ceramide-containing liquid cleansers and moisture creams versus fluocinonide 0.05% cream plus bar soap in the treatment of mild to moderate eczema. The study showed that the high-potency corticosteroid cream, when used with ceramide-containing skin care products enhanced the treatment outcome in mild to moderate eczema when compared to the use of the corticosteroid cream used with bar soap. Therefore, ceramide containing skin care products can help when used in the treatment regimen for mild to moderate eczema.

Additionally, in a study of adult patients with atopic dermatitis, Nakagawa found that the most prevalent adverse reactions to tacrolimus 0.1% ointment were local application site irritations, which generally resolved with continued therapy. The findings suggest that 0.1% tacrolimus ointment is an effective and safe nonsteroidal therapy for adult patients with atopic dermatitis.

Patient Management

Xerosis generally responds well to therapy. Although there can be multiple underlying causes of xerosis, the main goal of therapy is to reduce the inflammation of pruritis associated with it and conserve moisture in the skin. Since xerosis is more common in elderly patients, a caretaker should monitor clothing, nail length, and other general precautions to prevent worsening. Geriatric patients generally have comorbid complications along with xerosis. Topical therapy is the mainstay of treatment, but systemic therapy is also beneficial. The clinician should be aware of all complications with the patient before starting systemic therapy to prevent counter actions with other medication or conditions.

Unusual Clinical Scenarios to Consider in Patient Management

In patients who do not respond to routine maneuvers, it is important to remember to rule out any potential factors that may be contributing to the disease process. Consider evaluating for any or all of the following: end-stage renal disease, nutritional deficiency (especially zinc and essential fatty acids), thyroid disease, neurological disorders with decreased sweating, human immunodeficiency virus, malignancy, radiation, anti-androgen medications, and diuretic therapy.

What is the Evidence?

Ashcroft, DM, Chen, LC, Garside, R, Stein, K, Williams, HC. "Topical pimecrolimus for eczema". Cochrane database of systematic reviews. 2007.

(This study by Ashcroft et al aims to assess the effects of topical pimecrolimus as an alternative to topical corticosteroids for treating eczema and other eczematic conditions including xerosis. It was concluded that topical pimecrolimus is less effective than moderate and potent corticosteroids and 0.1% tacrolimus treatments.)

Birnie, AJ, Bath-Hextall, FJ, Ravenscroft, JC, Williams, HC. " Interventions to reduce Staphylococcus aureus in the management of atopic eczema. Cochrane database of systematic reviews online". John Wiley & Sons, Ltd. vol. Volume.3. pp. CD003871.

(The study by Birnie et al, no evidence of benefit was found for antimicrobial interventions for patients with atopic eczema, and it was acknowledged that further larger studies are needed to form conclusive long-term outcomes.)

Coderch, L, López, O, de la Maza, A, Parra, JL. "Ceramides and skin function". Am J Clin Dermatol. vol. 4. 2003. pp. 107-29.

(Coderch et al shed light on ceramides as the major lipid present in the stratus corneum, and elaborate on their ability to maintain the water permeability and barrier functions of the epidermis. Coderch and his team found that most dermatology conditions with decreased barrier function have ceramide deficiency and alteration.)

Draelos, ZD, Ertel, K, Hartwig, P, Rains, G. "The effect of two skin cleansing systems on moderate xerotic eczema". J Am Acad Dermatol. vol. 50. 2004. pp. 883-888.

(This study investigated the effect of two cleansing systems: a synthetic detergent bar soap applied with a cotton washcloth and a petrolatum-delivering body wash applied with a polyethylene puff as part of a topical treatment approach to moderate xerotic eczema.)

Gong, JQ, Lin, L, Lin, T, Hao, F, Zeng, FQ, Bi, ZG. "Skin colonization by Staphylococcus aureus in patients with eczema and atopic dermatitis: A double-blind muliticentre randomized controlled trial". Br J Dermatol. vol. 155. 2006 Oct. pp. 680-7.

(In this study conducted by Gong et al found that early topical treatment of moderate to severe eczematous skin conditions benefited from a combination of muporicin plus a topical corticosteroid, and reduced colonization of S aureus that is commonly found in patients affected by eczematous conditions.)

Gutman, AB, Kligman, AM, Sciacca, J, James, WD. "Soak and smear: a standard technique revisited". Arch Dermatol. vol. 141. 2005. pp. 1556-9.

(This study described a simple, inexpensive, effective topical treatment with an accompanying patient educational sheet. Hydration for 20 minutes before bedtime followed by ointment application to wet skin and alteration of cleansing habits was shown to be an effective method for caring for several common skin conditions.)

Nakagawa, H. "Comparison of the efficacy and safety of 0.1% tacrolimus ointment with topical corticosteroids in adult patients with atopic dermatitis: review of randomized, double-blind clinical studies conducted in Japan". Clin Drug Investig. vol. 26. 2006. pp. 235-46.

(This study compared the efficacy and safety of 0.1% tacrolimus ointment with topical corticosteroids in atopic patients. Nakagawa suggests that 0.1% tacrolimus ointment is an effective and safe nonsteroidal alternative therapy for adult patients with atopic dermatitis.)

Akimoto, K, Yoshikawa, N, Higaki, Y, Kawashima, M, Imokawa, G. "Quantitative analysis of stratum corneum lipids in xerosis and asteatotic eczema". J Dermatol. vol. 20. 1993. pp. 1-6.

(This article is significant because it quantifies the cellular pathology of xerosis. The authors found that the loss of lipids in the stratum corneum results in global water loss throughout the entire epidermal region. Furthermore, the authors quantify that this water loss can be as high as 75 times that of normal skin.)

Greist, MC, Epinette, WW. "Cimetidine-induced xerosis and asteatotic dermatitis". Arch Dermatol. vol. 118. Apr 1982. pp. 253-4.

(This study shows that cimetidine, a drug used in antiandrogen therapy, can alter the dynamic equilibrium between exocrine sebaceous secretion and the development of xerosis.)
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