Continuing Education Activity

This activity outlines the evaluation and treatment of asteatotic eczema and reviews the role of the healthcare team in managing patients with this condition. Asteatotic eczema is a dermatological condition that is characterized by dry, fissured skin that occurs from epidermal water loss. It is a common condition that affects mostly geriatric patients in dry, cold climates. Early recognition can lead to treatment and avoid secondary lesions and infections. This activity reviews the evaluation and treatment of asteatotic eczema and highlights the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

• Identify the etiology of asteatotic eczema.
• Review the evaluation of asteatotic eczema.
• Outline the treatment and management options available for asteatotic eczema.
• Summarize interprofessional team strategies for improving care coordination and communication to advance asteatotic eczema and improve outcomes.

Introduction

Asteatotic eczema, also known as eczema craquelé, is a common type of pruritic dermatitis. It can also be known as xerosis, which is dry skin. It characterized by dry, cracked, and scaling skin that is typically inflamed. It usually begins as dry skin, and as the disease becomes more severe, the skin can crack and cause fissures. These fissures are a result of epidermal water loss. The fissured skin occurs in a polygonal or curvilinear pattern. The irregular fissuring and scaling patterns are sometimes referred to as "crazing paving." Patients also report pruritis associated with dry skin.[1]

Asteatotic eczema occurs especially in winter months when the skin is more at risk for becoming dry. Asteatotic eczema is also more common in the elderly. The eruption can occur on any skin area but typically presents on the anterolateral aspects of the lower legs. Lesions can also occur on the back, trunk, and arms.

There have been several case reports of asteatotic eczema correlating with underlying systemic conditions. These included malignancy, hypothyroidism, and malnutrition. Several classes of medications also have demonstrated links to xerosis, including diuretics, retinoids, and antineoplastics agents.[2][3][4][5][6]

Etiology

Drying of the skin occurs due to epidermal water loss; this is common in winter months and cold, dry climates. Medications such as diuretics also can exacerbate the drying of the epidermis.[1]

Other factors that contribute to asteatotic eczema include decreased sebaceous and sweat glands in the elderly, friction, frequent prolong bathing in hot water, and the use of degreasing agents.

Less common causes include radiation, nutritional deficiencies (zinc, essential fatty acids), hypothyroidism, drugs such as diuretics and antiandrogen therapy, and malignancies.[7][8][9][2][10]

Epidemiology

Skin conditions affect up to seventy percent of the geriatric population. Among the commonest are those that are caused by or present as dry, itchy skin.[11] Asteatotic eczema is one of the top three subtypes of dermatitis with severe itching. It closely follows atopic dermatitis and widespread eczema.[12] Asteotitc eczema is the most common kind of eczema experienced in the elderly.[13]

Asteatotic eczema is most prevalent during winter months. In the United States, the frequency increases in the northern part of the country. This increase in prevalence is believed to be caused by heating, which reduces indoor humidity and contributes to dry skin.  

Typically, it is patients over 60 years old who develop asteatotic eczema. The median patient age at presentation is 69 years. However, asteatosis eczema can also occur in young people.

Pathophysiology

People with asteatotic eczema have a decreased amount of free fatty acids in the stratum corneum. Cutaneous loss of these lipids increases transepidermal water loss up to 75 times that of normal patients.[14] The geriatric population has decreased sebaceous and sweat gland activity.[2] This decrease predisposes patients to moisture depletion. To maintain its integrity, the keratin layer requires a significant water concentration, estimated to be 10 to 20%. Excess water loss from the epidermis causes the outer layer of skin, the stratum corneum, to split and fissure.[15] These fissures can be deep enough to affect dermal capillaries, which can ultimately lead to bleeding. The dryness also causes pruritis, which leads to scratching.  Scratching can produce excoriations, edematous patches, and lichen planus. Allergens and bacteria can also penetrate the skin through these fissures and cause allergic and irritant contact dermatitis or infection.[1]

Histopathology

Skin biopsy is not necessary to diagnose asteatotic eczema. However, a microscopic examination will reveal spongiotic dermatitis with intracellular edema that is common among other forms of eczema and dermatitis. There can be varying degrees of inflammatory infiltrate, but most commonly a mild subacute spongiotic dermatitis. Acanthosis, hyperkeratosis, and lymphocytic infiltrate are present. The stratum corneum is irregular and compact. 

History and Physical

History should consist of the timing of dermatitis, as it is more common in winter months. Pruritis and dry skin are hallmarks of the disease and therefore are common complaints. Ask about other controllable factors, e.g., frequency of bathing, types of soap used, diet, and medications.

The physical examination will reveal dry and scaly skin. Accentuation of the skin lines (xerosis) is a typical presentation. Red plagues with thin, long, horizontal superficial fissures appear with further drying and scratching. The fissures and scales occur in a curvilinear, polygonal, or curvilinear pattern as the short vertical fissures connect with the horizontal fissures. Fissures are often accompanied by secondary lesions of erythematous and edematous patches that result from rubbing or scratching. Bleeding can occur with disruption of dermal capillaries as the disease progresses or with excoriation. Similar patterns of inflammation may appear on the trunk and upper extremities as the winter progresses. 

Evaluation

The diagnosis of asteatotic eczema is clinical. A skin biopsy can be useful if the clinician is unsure or unable to differentiate from other skin lesions. A skin biopsy will reveal a subacute, eczematous patter with acanthosis. A superficial, perivascular, lymphocytic infiltrate may also occur.

Treatment / Management

Skin hydration is the primary treatment for asteatotic eczema. Patients should use lotions with high oil content. High water lotions can worsen the drying of the skin. Emollients should be applied twice a day and immediately after bathing to maintain hydration.[16]

Topical steroid use should be in conjunction with emollients. Low potency steroids are useful for mild disease. Low potency steroids include desonide and hydrocortisone. Patients with moderate disease should receive medium or high potency corticosteroids. These include fluocinolone, triamcinolone, and betamethasone. Emollients should continue to be used with corticosteroids if corticosteroids are required. It does not affect response whether corticosteroids or emollients are applied first.[16]

Other agents have been shown to be effective as well. Pimecrolimus cream 1% is effective in patients with asteatotic eczema and helps control pruritis.[17] Topical agents such as alpha-hydroxyl acid moisturizers are also beneficial when applied after warm water soaks or steroid ointment treatment.[18]

Patients can take other steps as well to prevent drying of the skin, including decreasing the frequencies or bathing, minimizing the use of soap, and using a humidifier in dry environments.[1]

N-palmitoylethanolamine (PEA) and N-acetylethanolamine (AEA) are phospholipids that belong to the endocannabinoid system. One study showed that emollients containing PEA and AEA improved skin barrier function and reduced itching; this is a possible future treatment option; however, more studies are necessary.[19]

Differential Diagnosis

Differential diagnosis included acute edema/cutaneous distension syndrome, myxedema, cellulitis, stasis dermatitis, allergic contact dermatitis, irritant contact dermatitis, and nummular dermatitis.[20][21][6]

Prognosis

Asteatotic eczema responds well to therapy but can relapse during winter months or without the removal of offending agents. 

Complications

The most severe form of asteatotic eczema has deep, wide, horizontal fissures that ooze and are often purulent. Pain rather than itching is often the chief complaint in more severe cases. Infection with an accumulation of crusts and purulent material can be present with scratching or using drying lotions.

Deterrence and Patient Education

Patients who present with asteatotic eczema should be comforted that it is likely a benign condition, although underlying malignancies have correlations with the disease. The importance of emollients is a point of emphasis for the patients. Patients also need to be educated on the risk of scratching. Scratching causes a break in the skin, which can lead to infection. Patients also need to understand that asteatotic eczema is likely to recur in the winter months. 

Enhancing Healthcare Team Outcomes

The majority of patients with asteatotic eczema first present to the primary care clinicians, including nurses, which is why an interprofessional team approach is the best means by which to address the condition. There is low awareness of this skin condition among nurses and pharmacists, which leads to undertreatment, causing a reduction in the well-being of the patients. This phenomenon is particularly noticed in the setting of long term care nursing facilities. For an accurate and efficient technique to detect asteatotic eczema, education should be provided, including a simple visual assessment method for dry skin. Clinicians and nurses should be in constant communication about the resident's/patient's rashes and skin lesions.[22]

It is crucial to educate the patient on the importance of hydration and apply oil-based moisturizers. The pharmacist should assess the medications and ensure that none is worsening the condition. If there are any questions regarding the treatment, a dermatologist consult is necessary. Close communication between interprofessional team members can help improve not only the patient's quality of life but improve outcomes. [Level 5]