What is asteatotic eczema?

Asteatotic Eczema: Clinical Overview

Asteatotic eczema (also called eczema craquelé or xerotic eczema) is a common inflammatory skin condition characterized by intensely itchy, dry, rough skin with a distinctive cracked or "crazy paving" appearance, most frequently occurring in elderly patients during winter months when low humidity causes excessive water loss from the stratum corneum. 1, 2

Clinical Presentation

The hallmark features include:

• Dry, erythematous plaques with fine crackling or fissuring that resembles cracked porcelain or dried riverbed 2
• Intense pruritus that can significantly impact quality of life 1
• Scaling and roughness of affected skin 3
• Most commonly affects the lower legs, but can occur anywhere on the body 2
• In unusual presentations, may develop specifically within areas of hypoesthetic (reduced sensation) skin or scars 2

Pathophysiology

The condition results from:

• Impaired skin barrier function with increased transepidermal water loss 3, 4
• Dysfunction of sebaceous and sweat glands, particularly age-related decline 4
• Environmental triggers including low humidity, cold weather, and excessive bathing with harsh soaps that strip natural lipids 1, 4
• Rarely, may present as a paraneoplastic syndrome associated with underlying malignancy, characterized by glucocorticoid resistance 5

Risk Factors

• Age over 65 years (commonly called "pruritus in the elderly" or "Willan's itch") 1
• Winter season with decreased environmental humidity 2
• Excessive bathing with hot water and harsh soaps 1, 4
• Underlying systemic diseases or certain medications 4
• Areas of altered sensation following trauma or scarring 2

Management Approach

First-Line Treatment

Patients should receive emollients and topical steroids for at least 2 weeks as initial therapy. 1

• Replace all soaps with dispersible cream cleansers to prevent further lipid stripping 1
• Apply emollients liberally and frequently, ideally immediately after bathing when skin is most hydrated 1, 3
• Moisturizers with high lipid content are preferred in elderly patients 1
• Use lukewarm water for bathing and limit duration to prevent excessive drying 1

Topical Anti-inflammatory Therapy

• Topical corticosteroids are effective for controlling inflammation 1
• Pimecrolimus cream 1% has demonstrated efficacy, reducing disease severity by 62% after 4 weeks compared to 21% with vehicle (P=0.013), with particular benefit for pruritus control 6
• Novel emollients containing N-palmitoylethanolamine (PEA) and N-acetylethanolamine (AEA) show superior improvement in skin barrier function and can normalize sensory thresholds within 7-14 days 3

Systemic Therapy

• Gabapentin may benefit patients who don't respond to topical therapy alone 1
• Avoid sedating antihistamines in elderly patients due to fall risk and limited efficacy 1
• Non-sedating antihistamines can be tried but have limited value 1

Critical Clinical Pitfalls

• Treatment-resistant cases warrant investigation for underlying malignancy, particularly if glucocorticoid-resistant 5
• Reassessment is mandatory if patients don't respond to initial 2-week treatment course 1
• Refer to secondary care if diagnostic doubt exists or primary management fails to relieve symptoms 1
• In hypoesthetic skin, asteatotic eczema may develop in unusual distributions—borders of affected areas correspond precisely to areas of reduced sensation 2

Preventive Strategies

• Keep fingernails short to minimize scratching damage 1
• Wear cotton clothing next to skin, avoiding wool and synthetic irritants 1
• Avoid extremes of temperature which exacerbate symptoms 1
• Maintain adequate environmental humidity during winter months 2