How is asteatotic eczema managed?

Management of Asteatotic Eczema

The cornerstone of asteatotic eczema management is aggressive emollient therapy combined with avoidance of precipitating factors, particularly soap and hot water, with low-to-moderate potency topical corticosteroids reserved for inflammatory flares.

Understanding Asteatotic Eczema

Asteatotic eczema (also called eczema craquelé or xerotic eczema) is fundamentally a condition of severe skin barrier dysfunction resulting from dehydration of the stratum corneum 1. It most commonly occurs during winter months when decreased humidity increases transepidermal water loss 2, 1. The condition is characterized by dry, cracked skin with a distinctive "crazy paving" pattern 2.

First-Line Treatment: Emollients and Barrier Restoration

• Liberal and frequent application of emollients is the absolute foundation of treatment 3, 4, 5.
• Emollients provide a surface lipid film that retards evaporative water loss from the epidermis 3.
• Apply emollients immediately after bathing when the skin is still hydrated to maximize water retention 3, 4.
• Continue emollient use even when the condition appears controlled, as this prevents recurrence 4.

Critical Avoidance Measures

• Eliminate all soaps and detergents, as these remove natural lipid from the skin surface and worsen the already compromised barrier 3.
• Use dispersible cream as a soap substitute for cleansing 3.
• Avoid extremes of temperature, particularly hot water and overheated environments 3.
• Reduce bathing frequency if excessive, as this is a major contributing factor to barrier damage 1.
• Consider adding bath oils to bathing water for additional hydration 3, 5.

Topical Corticosteroids for Active Inflammation

• When erythema and inflammation are present, apply low-to-moderate potency topical corticosteroids (such as hydrocortisone 1%) to affected areas 3, 4, 6.
• Use the least potent preparation required to control symptoms 3, 4.
• Apply no more than twice daily 3, 4.
• Continue corticosteroids only until inflammation resolves, then implement "steroid holidays" 3, 4.
• Very potent preparations should be avoided or used with extreme caution for limited periods only 3.

Managing Secondary Complications

Bacterial Infection

• Watch for increased crusting, weeping, or pustules suggesting bacterial superinfection 3, 7.
• Prescribe oral flucloxacillin (or erythromycin if penicillin-allergic) while continuing topical corticosteroids 3, 7, 4.
• Bacteriological swabs are not routinely needed but may be necessary if patients fail to respond to treatment 3.

Pruritus Management

• Sedating antihistamines may provide short-term relief during severe itching episodes, primarily through their sedative properties at night 3, 4.
• Non-sedating antihistamines have little to no value and should not be used 3, 4.

Common Pitfalls to Avoid

• Do not undertreat with emollients - patients often apply insufficient quantities or frequency 4.
• Do not continue hot baths or frequent bathing - this perpetuates the barrier dysfunction 1.
• Do not allow patients to continue using regular soap - this is a primary aggravating factor 3.
• Do not use potent corticosteroids as first-line - mild-to-moderate potency is sufficient for most cases 3, 4, 6.

When to Consider Alternative Diagnoses

• If asteatotic eczema is treatment-resistant to standard therapy, consider underlying malignancy as a rare paraneoplastic syndrome 8.
• Glucocorticoid resistance in asteatotic eczema should prompt investigation for systemic disease 8.
• Early referral to dermatology is warranted for atypical presentations or treatment failure 8.

Special Considerations

• Asteatotic eczema can develop in areas of hypoesthetic skin or scars, where altered sensation may contribute to barrier dysfunction 2.
• In these cases, the distribution follows the borders of sensory loss rather than typical patterns 2.