What is the management for Xeroderma?

Management of Xeroderma (Dry Skin)

The cornerstone of xeroderma management is regular application of emollients containing both rehydrating and lipid-replenishing components, with the lipid content increasing proportionally to skin dryness severity, preferably using water-in-oil formulations for very dry skin. 1

Immediate First-Line Management

Avoidance of Aggravating Factors

• Eliminate all soaps and detergents as they strip natural lipids from the skin surface 2
• Use dispersible cream as a soap substitute for cleansing 2
• Avoid extremes of temperature 2
• Wear cotton clothing next to skin; avoid wool and synthetic irritants 2
• Keep nails short to minimize trauma from scratching 2

Bathing Protocol

• Bathe in warm (not hot) water for at least 10 minutes using neutral pH, fragrance-free hypoallergenic cleansers 3
• Patients should determine their most suitable bath oil and bathing regimen 2
• Apply emollients immediately after bathing to lock in hydration and prevent transepidermal water loss 3

Emollient Selection Algorithm

Mild Xerosis (Grade 1)

• Soap-free shower gel and/or bath oil 2
• Urea- or glycerin-based moisturizer applied regularly 2
• Topical polidocanol cream for associated pruritus 2
• Reassess after 2 weeks 2

Moderate Xerosis (Grade 2)

• Continue Grade 1 measures 2
• For inflammatory lesions, add topical hydrocortisone cream 2
• Consider oral antihistamines (cetirizine, dimetinden, loratadine, fexofenadine, clemastine) for pruritus 2
• Reassess after 2 weeks 2

Severe Xerosis (Grade 3)

• Continue Grade 2 measures 2
• For xerotic dermatitis, escalate to higher-potency topical steroids (prednicarbate, mometasone furoate) 2
• Consider oral antibiotics if secondary infection suspected 2
• Monitor for change in severity 2

Evidence-Based Ingredient Selection

Urea has the strongest clinical evidence for xerosis treatment and should be preferentially used, with efficacy enhanced when combined with natural moisturizing components and ceramides 1. Select ingredients based on specific symptoms:

• Scaling: Urea 1
• Fissures/rhagades: Urea or dexpanthenol 1
• Erythema: Licochalcone A 1
• Pruritus: Polidocanol 1

Management of Fissures

Mild Fissures (Grade 1)

• Propylene glycol 50% in water for 30 minutes under plastic occlusion nightly, followed by hydrocolloid dressing 2
• Alternatively, antiseptic baths (potassium permanganate 1:10,000 or povidone-iodine) 2
• Topical silver nitrate solutions 2
• Reassess after 2 weeks 2

Moderate to Severe Fissures (Grade 2-3)

• Continue Grade 1 measures plus oral antibiotics 2
• For Grade 3, dose reduction of any causative medications may be necessary 2

Adjunctive Therapies

For Pruritus

• Sedating antihistamines (diphenhydramine, dimethindene, clemastine) are useful short-term during severe pruritus episodes 2
• Non-sedating antihistamines have minimal value 2
• Use at night to aid sleep; avoid daytime use 2
• Large doses may be required in children 2

For Lichenified Eczema

• Ichthammol 1% in zinc ointment or paste bandages 2
• Coal tar solution 1% (less irritant than crude coal tar) 2

Critical Pitfalls to Avoid

• Do not apply treatments more than twice daily; some newer preparations require only once-daily application 2
• Avoid tachyphylaxis with antihistamines by limiting duration of use 2
• When using topical corticosteroids, use the least potent preparation required to control symptoms and stop for short periods when possible 2
• Avoid alcoholic solutions on dry skin 2

Follow-Up Strategy

• Reassess every 2 weeks until improvement documented 2
• If worsening or no improvement at 2 weeks, escalate to next grade of treatment 2
• Monitor for secondary bacterial infection (crusting, weeping) or viral infection (grouped erosions, vesiculation) 2