What is the best treatment plan for a 61-year-old male patient with widespread dry, thickened, darkened, and rough skin changes, scaling, and cracking on both arms and legs, along with dermatitis and symmetrical involvement?

Treatment Plan for Widespread Eczematous Dermatitis with Xerosis

This patient requires immediate initiation of intensive topical corticosteroid therapy combined with aggressive emollient use to restore skin barrier function and control the widespread eczematous dermatitis.

Initial Assessment and Diagnosis

This clinical presentation is consistent with severe atopic dermatitis (eczematous dermatitis) with extensive xerosis and secondary lichenification. The symmetrical distribution, dry thickened skin with scaling and cracking, and dermatitis signs are pathognomonic for this condition 1, 2.

Key diagnostic features to confirm:

• Symmetrical distribution on extremities 1
• Xerosis (dry skin) with scaling and cracking 3
• Thickened, darkened skin suggesting chronic scratching and lichenification 4
• Absence of well-demarcated thick silvery plaques (which would suggest psoriasis) 5

Critical evaluation needed:

• Look for crusting, weeping, or honey-colored exudate indicating secondary bacterial infection (likely Staphylococcus aureus) 5, 6
• Check for grouped vesicles or punched-out erosions suggesting herpes simplex superinfection 5, 6

Immediate Treatment Regimen

Topical Corticosteroid Therapy

For trunk and extremities (excluding flexures):

• Apply mometasone furoate 0.1% ointment twice daily to all affected areas 6
• Mometasone is a medium-potency (Class IV) corticosteroid with negligible systemic bioavailability, making it appropriate for widespread use 6
• Continue twice-daily application until significant improvement is achieved (typically 2-4 weeks) 6

For facial involvement and flexures:

• Use hydrocortisone 1% or prednicarbate 0.02% cream for no more than 2-4 weeks due to risk of skin atrophy and telangiectasia 5, 6
• Avoid prolonged corticosteroid use on the face 5

Intensive Emollient Therapy (Critical Component)

Barrier restoration protocol:

• Apply urea-based moisturizers (10-20% urea) at least once daily to the entire body, not just affected areas 5, 3
• Urea dissolves the intracellular matrix, loosening hyperkeratotic skin and promoting normal healing 3
• Apply fragrance-free emollients containing petrolatum or mineral oil immediately after bathing to damp skin 5, 6
• Reapply moisturizer every 3-4 hours throughout the day 5

Cleansing Protocol

• Use mild, pH-neutral (pH 5) non-soap cleansers or dispersible creams as soap substitutes 5, 1, 2
• Bathe with tepid water only (avoid hot water which worsens xerosis) 5
• Pat skin dry with clean towels rather than rubbing 5
• Apply emollients within 3 minutes of bathing to trap moisture 5

Management of Secondary Infection (If Present)

If crusting, weeping, or honey-colored exudate is present:

• Add oral flucloxacillin as first-line antibiotic for Staphylococcus aureus 5, 6
• Alternative: erythromycin if penicillin allergy 6
• Treat for 7-10 days concurrent with topical corticosteroid therapy 6

If grouped vesicles or punched-out erosions are present:

• Suspect herpes simplex superinfection 5
• Initiate oral acyclovir immediately for 5-7 days 7, 8

Adjunctive Measures

For Severe Pruritus

• Short-term sedating antihistamines (first-generation) at bedtime only for severe pruritus affecting sleep 5, 8
• Avoid non-sedating antihistamines as they provide no benefit in atopic dermatitis 6, 1

For Palmar Involvement with Cracking

• Apply 50% propylene glycol in water under plastic occlusion for 30 minutes nightly, followed by hydrocolloid dressing 5
• This accelerates healing of fissures and cracks 5

Critical Avoidance Measures

Products to avoid:

• All alcohol-containing preparations (worsen facial dryness) 5
• Harsh soaps and detergents (remove natural lipids) 5
• Greasy or occlusive creams (promote folliculitis) 5
• Hot water for bathing 5
• Perfumes, deodorants, and fragranced products 5

Maintenance Phase (After Initial Control)

Once significant improvement is achieved (typically 2-4 weeks):

• Transition to twice-weekly mometasone application to previously affected areas for up to 36 weeks to prevent relapses 6
• This proactive maintenance approach achieves 68% remission rate over 36 weeks 6
• Continue daily emollient use indefinitely 6, 1

When to Refer to Dermatology

Immediate referral indicated if:

• No improvement after 4 weeks of appropriate first-line therapy 5
• Diagnostic uncertainty or atypical presentation 5
• Suspected severe drug reaction (DRESS or Stevens-Johnson syndrome) 7
• Need for systemic immunosuppressive therapy (cyclosporine, methotrexate, azathioprine) 7

Consider phototherapy referral:

• Narrowband UVB phototherapy is effective for refractory cases not responding to topical therapy 7, 5
• Requires dermatology supervision 7

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia: Use appropriate potency corticosteroids for adequate duration, then taper 5, 6
• Overuse of non-sedating antihistamines: These have no value in atopic dermatitis 6, 1
• Inadequate emollient use: Emollients must be applied liberally and frequently, not just to affected areas 5, 6
• Using ointments on scalp: If scalp is involved, use shampoos, gels, or solutions instead 5
• Confusing persistent mild itching with treatment failure: Mild burning or itching from inflammation can persist for days after control is achieved 5