What is the diagnosis and recommended management for an elderly female with intensely pruritic, cracked, xerotic skin on the hands and arms and a large weeping, erythematous plaque on the abdomen?

Diagnosis and Management of Elderly Female with Pruritic, Weeping Dermatitis

This elderly patient most likely has asteatotic eczema (xerotic eczema) with secondary impetiginization of the abdominal lesion, and should be treated immediately with high-lipid content emollients twice daily to all affected areas plus moderate-potency topical corticosteroids (hydrocortisone 2.5% or clobetasone butyrate 0.02%) applied 3-4 times daily for at least 2 weeks, while the weeping abdominal plaque requires urgent evaluation for secondary bacterial infection. 1, 2

Primary Diagnosis: Asteatotic Eczema (Xerotic Eczema)

The clinical presentation of itchy, cracked, dry hands and arms in an elderly female is classic for asteatotic eczema, which is the most common cause of pruritus in elderly patients. 1, 3 The British Journal of Dermatology specifically identifies xerosis as commonly associated with pruritic, cracked skin in elderly patients, and emphasizes that this condition requires immediate treatment rather than observation. 1

Key Diagnostic Features Supporting This Diagnosis:

• Age-related xerosis: Elderly skin has severely impaired barrier function and increased transepidermal water loss, making xerotic eczema extremely common in this population 2, 4, 5
• Distribution pattern: Hands, arms, and trunk involvement is typical for asteatotic eczema 3, 5
• Cracked, dry appearance: This is pathognomonic for xerosis and eczema craquelé 3

Critical Concern: The Weeping Abdominal Plaque

The large, inflamed, red, weeping plaque on the abdomen represents either severe asteatotic eczema with acute exudative changes OR secondary bacterial infection (impetiginization), which requires immediate assessment. 2

Urgent Evaluation Needed:

• Examine for surrounding warmth, tenderness, purulent discharge, or necrotic tissue that would indicate secondary infection 2
• If infection is suspected, obtain deep tissue specimens for culture (not surface swabs), as infections are typically polymicrobial 2
• Consider that bullous pemphigoid can rarely present with pruritus and weeping lesions in elderly patients, though this typically would show tense bullae 1, 4

Immediate First-Line Treatment Protocol

Topical Therapy (Start Immediately):

1. High-Lipid Content Emollients:

• Apply at least twice daily to ALL affected areas (hands, arms, abdomen) 1, 2, 4
• Elderly skin requires moisturizers with high lipid content specifically, as standard lotions are insufficient 1
• Continue indefinitely as maintenance therapy 2, 5

2. Moderate-Potency Topical Corticosteroids:

• Use hydrocortisone 2.5% or clobetasone butyrate 0.02% applied 3-4 times daily for at least 2 weeks 1, 2
• Low-potency corticosteroids (1% hydrocortisone) are often insufficient for established asteatotic eczema 2
• Apply to all inflamed, pruritic areas including the weeping abdominal plaque (unless infection is confirmed) 2

Systemic Therapy for Pruritus Control:

3. Non-Sedating Antihistamines:

• Add fexofenadine 180 mg daily OR loratadine 10 mg daily for symptomatic itch relief 1, 2, 4, 6
• These provide modest benefit but are safe in elderly patients 1

Skin Care Modifications:

4. Bathing and Hygiene Changes:

• Use only mild soaps with neutral pH (pH 5) and warm (not hot) water 2, 4
• Avoid excessive bathing and harsh cleansers that strip natural lipids 2, 5
• Pat skin dry gently rather than rubbing 2
• Keep nails short to minimize scratch damage 1

Critical Pitfalls to Avoid

Never prescribe sedating antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine) in elderly patients, as these increase fall risk, cause confusion, and may contribute to dementia (Strength C recommendation against use). 1, 2, 4, 6

Do not use:

• Crotamiton cream (proven ineffective, Level B recommendation) 2, 4, 6
• Calamine lotion (not recommended for elderly pruritus) 2, 4, 6
• Topical capsaicin (not indicated) 2, 4
• Alcohol-containing lotions or gels (worsen xerosis) 2

Reassessment Timeline and Second-Line Options

At 2 Weeks:

If no improvement after 2 weeks of emollients and topical steroids, the patient requires reassessment, as this may not be simple elderly xerosis. 1, 4

Second-Line Systemic Therapy:

• Gabapentin starting at 100-300 mg at bedtime, titrating to 900-3600 mg daily as tolerated, has specific efficacy for refractory elderly skin pruritus 1, 2, 4, 6
• This should be considered if pruritus persists after adequate topical therapy 1

Mandatory Referral Criteria

Refer to dermatology if:

• No improvement after 2-4 weeks of first-line therapy 1, 2, 4
• Diagnostic uncertainty exists (especially regarding the weeping abdominal plaque) 1, 2
• Skin biopsy with direct immunofluorescence is needed to exclude bullous pemphigoid, which can present with pruritus and weeping lesions in elderly patients before classic bullae appear 1, 4

Special Consideration: Bullous Pemphigoid

Maintain high suspicion for bullous pemphigoid in this elderly patient, as pruritus alone can be the presenting feature before blistering develops. 1 The weeping abdominal plaque could represent early bullous pemphigoid with ruptured bullae. 1 If standard therapy fails or if the clinical picture evolves, skin biopsy with direct immunofluorescence is essential to confirm or exclude this diagnosis. 1

Diagnostic Criteria for Bullous Pemphigoid to Consider:

• Age > 70 years (this patient qualifies) 1
• Severely pruritic lesions 1
• Linear IgG and/or C3 deposits on direct immunofluorescence would confirm diagnosis 1

Monitoring for Complications

• Assess regularly for progression to venous ulceration (occurs in approximately 6% of stasis dermatitis cases) 2
• Monitor the weeping abdominal lesion closely for signs of spreading infection 2
• Follow up within 2 weeks to assess treatment response 1, 2