What is xerosis, particularly in older adults over 60 years old?

What is Xerosis?

Xerosis is dry skin characterized by rough, scaly, cracked, and fissured skin that commonly causes itching (pruritus) and discomfort. 1, 2

Pathophysiology

Xerosis results from disturbed epidermal differentiation that impairs the stratum corneum's structure and function 3:

• Abnormal keratinization with modified stratum corneum architecture 4
• Impaired lipid bilayers in the intercellular spaces of the stratum corneum 3
• Reduced natural moisturizing factor leading to decreased water-binding capacity 3
• Altered water metabolism and increased transepidermal water loss 5, 4
• Changes in surface lipid content and sebum production 4

Clinical Presentation

The hallmark features include 2, 4:

• Rough or coarse skin texture as the primary characteristic 4
• Visible scaling and flaking of the skin surface 1
• Cracking and fissuring that can progress to painful breaks in the skin 2
• Pruritus (itching) that leads to scratching, excoriations, and risk of secondary skin infections 5, 1

Prevalence in Older Adults

Xerosis affects approximately 53% of older adults overall, with the highest rates occurring in nursing home residents. 6

• Age-related prevalence: 20% of those over 60 years and up to 50% of those over 70 years 5
• Equal distribution between males and females 6
• Most common location: lower limbs are most frequently affected 6
• Severity: mild xerosis is the most prevalent form 6

Risk Factors in Older Adults

Multiple factors contribute to xerosis in the elderly population 1, 4:

• Intrinsic aging changes: decreased keratinization and lipid content in aging skin 1
• Medications: diuretics and similar drugs that affect hydration 1
• Environmental factors: overuse of heaters or air conditioners that reduce ambient humidity 1
• Bathing practices: hot water, excessive soap use, and harsh cleansers 7
• Reduced peripheral circulation and slower skin cell turnover with age 5

Clinical Significance

Xerosis is the most common cutaneous finding in dialysis patients and the most common cause of pruritus in elderly patients. 5, 7

• Quality of life impact: causes unsightliness, discomfort, and negative effects on daily functioning 3
• Complication risk: untreated xerosis can progress to asteatotic eczema (eczema craquelé), stasis dermatitis, and ulcer formation 2
• Infection risk: scratching-induced excoriations create entry points for bacteria and other pathogens 1
• Permissive effect: even when not the primary cause, xerosis lowers the threshold for itch in other conditions 5

Associated Conditions

Xerosis occurs as a feature of multiple systemic and dermatologic conditions 5, 4:

• Atopic dermatitis: xerosis is a notable clinical finding and hallmark feature 5
• Renal disease: most common cutaneous sign in dialysis patients, though it doesn't necessarily correlate with pruritus severity 5
• Diabetes: part of diabetic dermatopathy requiring daily moisturizer use 8
• Other causes: infections, nutritional deficiencies, malignancies, endocrine disorders, and eating disorders 4

Management Principles

The American Academy of Dermatology strongly recommends regular moisturizer use based on moderate certainty evidence, with emollients being essential for nearly all xerosis management. 5

• Emollient application: at least once to twice daily with oil-in-water base creams or ointments preferred over alcohol-containing lotions 7
• Environmental modifications: increase ambient humidity and avoid excessive heating or air conditioning 1
• Bathing modifications: use mild soaps with neutral pH (pH 5), warm (not hot) water, and gentle patting to dry 7
• Petrolatum: recommended for its occlusive properties that prevent moisture evaporation, especially in very dry areas 7

Common Pitfalls

Xerosis is not a normal part of aging—it is a treatable condition that requires active management. 1

• Avoid skin sensitizers: lanolin, aloe vera, and parabens commonly found in emollients can cause delayed hypersensitivity reactions 1
• Don't use ineffective agents: crotamiton cream has been proven ineffective in controlled studies 7
• Avoid occlusive creams in patients at risk for folliculitis 7
• Recognize progression: untreated xerosis can lead to asteatotic eczema, requiring addition of moderate-potency topical corticosteroids like hydrocortisone 2.5% or clobetasone butyrate 7