Continuing Education Activity

Xeroderma refers to “dry skin,” and is a common condition which results in skin roughness, tightness, flaking, and scaling. It can cause pruritus, leading to excoriations and an increased risk of skin infections. xeroderma is multifactorial in etiology and may occur in response to changes in the environment, underlying diseases, medications, or advanced age. This activity reviews the evaluation and management of xeroderma and highlights the role of the interprofessional team in managing patients with this condition.

Objectives:

• Identify the etiology of xeroderma.
• Outline the evaluation of xeroderma.
• Review the management options available for xeroderma.

Introduction

Xeroderma refers to “dry skin” and is a common condition which results in skin roughness, tightness, flaking, and scaling.[1] It can cause pruritus, leading to excoriations and an increased risk of skin infections. xeroderma is multifactorial in etiology and may occur in response to changes in the environment, underlying diseases, medications, or advanced age.[2] Cleansing the skin with lukewarm water and applying a thick moisturizer immediately after bathing may repair the epidermal skin barrier function and restore hydration.[3]

Etiology

The majority of people worldwide will experience xeroderma at some stage in their lives due to the loss of lipids in the skin.[4][2] Xeroderma can be acute or chronic in nature, and its various causes are detailed below:

External Causes

• Skin cleansing: taking frequent, long, hot showers. Using harsh, alkaline soaps
• Environmental factors: cold weather, low humidity, dry indoor heat, intense exposure to sunlight
• Occupational factors: contact with irritant agents (i.e., chemicals used in hairdressing or housekeeping)

Endogenous Causes

Skin diseases

• Inflammatory skin disorders: atopic dermatitis, allergic contact dermatitis, irritant contact dermatitis, dyshidrotic eczema, seborrheic dermatitis, psoriasis, etc 
• Infectious skin disorders (in the chronic phase): scabies, bacterial, or fungal infections
• Genodermatoses: xeroderma pigmentosum, ichthyoses (harlequin, etc.)
• Neoplasms: cutaneous T-cell lymphoma

Internal/Systemic diseases

• Endocrine or metabolic: diabetes mellitus, hypothyroidism, hyperthyroidism, primary biliary cholangitis, cholestasis, hyperparathyroidism, renal failure
• Inflammatory: Crohn's disease, ulcerative colitis
• Infections: human immunodeficiency virus (HIV), hepatitis B or C virus
• Hormonal: pregnancy, menopause
• Hematologic: myeloproliferative disorders, multiple myeloma, Hodgkin’s and Non-Hodgkin’s lymphoma

Psychiatric diseases

• Obsessive-compulsive disorders: excess skin washing
• Eating disorders: anorexia
• Addictions: alcohol or drug abuse

Dietary

• Dehydration: excess perspiration, insufficient water intake
• Malnutrition: vitamin A or vitamin D deficiency, zinc or iron deficiency

Medication-related

• Drug adverse effects: diuretics, beta-blockers, contraceptives, retinoids, long-term use of topical steroids, lipid-lowering agents, radiation therapy, etc.

Epidemiology

While the exact incidence of xeroderma is not known, it commonly affects both males and females of all age groups. Studies have shown that there is an increased prevalence in older patients, particularly over the age of 60 years. Moreover, it is commonly seen in those with underlying diseases (i.e., diabetes mellitus, renal failure, hypothyroidism, etc.) or in those taking associated medications.[5] 

Xeroderma may occur alone, in the setting of other dermatologic conditions (i.e., atopic dermatitis, irritant contact dermatitis, etc.), or in individuals with a family history of dry skin.

Pathophysiology

Xeroderma is caused by a lack of natural moisturizing factors (lactic acid, sugars, amino acids, urea), abnormalities in the stratum corneum (skin's superficial barrier), and impaired keratinocyte differentiation. Natural moisturizing factors are crucial for the skin's water-binding capacity. Moreover, the stratum corneum contains lipids (ceramides, cholesterol, free fatty acids) that play a significant role in maintaining hydration; Decreased lipid levels results in dry skin secondary to transepidermal water loss and dehydration. Xeroderma may also involve a reduction in keratinocyte proliferation. Clinically, dry skin will appear dull, rough, scaly, and tight, with associated fissuring, itching, and bleeding.[6][7][8]

Histopathology

In the majority of cases, xeroderma can be diagnosed clinically with a thorough history and physical examination. However, a skin biopsy can be performed if needed to distinguish from similar-appearing conditions.[7]

History and Physical

A comprehensive history and focused physical examination are sufficient to appropriately diagnose xeroderma. 

When obtaining a history, it is important to discuss:[2]

• History of atopy (allergies, atopic dermatitis, asthma)
• External factors (occupational exposure, environment, diet, skincare regimen)
• Age (higher likelihood with older age)
• Pregnancy/menopause (hormonal influence)
• Comorbidities (renal failure, chronic kidney disease, thyroid disease, diabetes mellitus, inflammatory bowel disease)
• Medications (diuretics, lipid-lowering agents, etc.)
• Prior history of xeroderma and any previous treatments tried.
• Symptoms (itching, burning sensation, pain, skin tightness)
• Duration (acute or chronic)
• Timing (intermittent, constant, coinciding with any triggers)

When examining the skin, close attention should be paid to:

• Cutaneous scaling, fissuring, erythema
• Distribution (hands/feet, extremities, etc.)

Evaluation

The xeroderma diagnosis is clinical; history and physical examination are sufficient to recognize this common condition accurately. Healthcare providers may use laboratory testing to assess underlying causes, such as thyroid hormone levels, vitamin levels, etc. A skin biopsy may be obtained in rare cases to distinguish from mimicking conditions.

Treatment / Management

Treatment of xeroderma should focus on restoring physiologic lipids in the epidermis, enhancing skin moisturization, optimizing skin barrier function, and promoting epidermal differentiation.[7][9] Commonly recommended strategies include:

• Infrequent bathing and using lukewarm water: Individuals should avoid aggressive skin washing and hot water, which are harsh and strip the skin of protective oils.
• Use of mild cleansers: synthetic detergent cleansers are preferred due to their acidic pH, which closely resembles the skin's natural pH. Syndet cleansers are less irritating than traditional soaps, and their low pH has been shown to downregulate pruritus.[10][11] Traditional soaps should be avoided as they alkalinize the skin, leading to worsening dry skin and itching. 
• Routine use of skin moisturizers: Oil-based creams are thicker in consistency than water-based lotions and are more effective in providing moisturization. Ointments are greasier in texture and particularly useful for preventing transepidermal water loss.[8] Moisturizers should be applied to damp skin immediately after bathing, as this will decrease evaporation.
• Utilizing room humidifiers, especially during the winter months
• Staying hydrated with adequate fluid intake

Products containing the following active ingredients may improve skin texture and hydration:[12]

• Humectants promote water transfer from the dermis to the epidermis. Examples include glycerin, urea, ammonium lactate, hyaluronic acid, and gelatin.
• Occlusives create a hydrophobic layer over the skin, preventing water loss. Examples include lanolin, paraffin, petrolatum, cholesterol, and stearyl alcohol.[8]
• Emollients can fill gaps and fissures in the skin. Examples include petrolatum, dimethicone, and propylene glycol.[13]

Clinicians may also prescribe topical corticosteroids or calcineurin inhibitors if xeroderma is accompanied by pruritus or dermatitis.[14]

Differential Diagnosis

• Ichthyosis vulgaris
• Atopic dermatitis
• Stasis dermatitis
• Irritant contact dermatitis
• Allergic contact dermatitis
• Nummular dermatitis
• Scabies
• Tinea corporis
• Psoriasis
• Cutaneous T-cell lymphoma

Prognosis

Xeroderma is generally benign and may persist for years. The prognosis is favorable with avoidance of triggers and incorporating a skincare regimen focused on gentle cleansing and adequate moisturizing. In some instances, dry skin may occur as part of a genetic disorder (i.e., xeroderma pigmentosum, ARCI-lamellar ichthyosis, etc.) with further sequelae, such as an increased risk of skin cancer.

Complications

Xeroderma may cause pruritus, which leads to an increased risk of skin infections when microorganisms enter via a break in the skin surface. Other complications include food allergies (association between filaggrin mutations and atopy) and allergic contact dermatitis (due to compromised skin barrier function).

Deterrence and Patient Education

Xeroderma can be acute or chronic in nature, with many individuals experiencing life-long dry skin. Most cases can be managed conservatively with gentle cleansing and adequate moisturization. Patients should recognize and avoid triggers, including harsh soaps/detergents, extreme climate, rough/tight clothing, excess alcohol, spicy foods, citrus fruits, and stress.

Enhancing Healthcare Team Outcomes

Xeroderma is a common condition that can be identified by various members of a healthcare team, including nurses, physician assistants, nurse practitioners, podiatrists, primary care providers, and dermatologists. Each provider is important in diagnosing dry skin and educating patients on effective treatment strategies.

For example, pharmacists can verify if xeroderma is medication-related (i.e., adverse effect, inappropriate dosing). Pharmacists can also formulate creams containing active ingredients that optimize emollient and humectant qualities. Nursing staff can demonstrate proper cleansing and moisturization techniques, as well as the application of occlusive dressings. Primary care providers and specialists may collaborate when addressing patients' comorbidities and systemic diseases. Although xeroderma is generally a benign condition, interprofessional communication and care coordination are imperative for high-quality care and patient satisfaction. [Level 5]