Diagnostic Hallmarks-Skin Disorders

Distribution: legs and hands Minute, thin fissures Minimal inflammation Clinical Presentation

Xerotic eczema is closely related in appearance and pathophysiology to solvent-type weak-irritant contact dermatitis. The difference lies in the fact that the patient with xerotic eczema is biologically unable to provide an adequate lipid layer, whereas in weak-irritant contact dermatitis the lipid layer is removed by contactants. The end result, too little epidermal lipid, is the same for both conditions. The patches and barely elevated plaques of xerotic eczema are nummular (coin shaped) in configuration. They are 2 to 5 cm in diameter and are usually very sharply marginated.

Mild inflammation may be present within the plaques, but the only visible redness is often that associated with the tiny fissures that encircle and crisscross the surface of the plaque. These cracks do not usually penetrate the full thickness of the epidermis, and thus there is little weeping and crusting. A small amount of scale, particularly along the edges of the fissures, is usually present. Excoriations are seldom numerous.

The plaques of xerotic eczema can occur anywhere on the body, but they are found most commonly on the legs. Burning and stinging usually accompany the moderately severe pruritus that is present.

The diagnosis of xerotic eczema is made on a clinical basis. Biopsy is not helpful. Course and Prognosis

Xerotic eczema, once present, tends to persist simply because the damaged skin tolerates the normal trauma of everyday life very poorly. In fact, patients often unintentionally worsen the process by increasing the frequency and intensity of bathing in a misguided attempt to treat their rash through better cleanliness. Healing of xerotic skin requires cessation of excess water loss through the epidermis long enough for regrowth of epithelial cells to bridge the cracks. Once healed, the skin may remain normal for considerable periods of time. Pathogenesis

Xerotic eczema is the inflammatory end stage of xerosis. This process begins when, because of insufficient and on the surface of the skin, epidermal water loss resulting in evaporation exceeds replenishment from below. In this setting, epithelial cells shrink to the point where islands of cells separate in a manner similar to that seen on the dirt bed of a dried-up lake. The term "xerotic eczema," as opposed 10 simple xerosis, is used when the cracks and fissures are (leep enough to cause visible inflammatory changes.

Factors that reduce surface lipid and thus enhance water loss include aging, excess bathing, and excess rubbing of the skin. All of these factors are particularly troublesome for atopic individuals, since they constitutionally have skin that is drier than normal. Environmental factors also adversely influence water loss from the skin. Thus low humidity, especially when building air is heated in the winter, shifts the equilibrium toward increased water loss. The presence of air flow such as occurs with wind and fan-driven air enhances evaporation and thus aggravates the effect of low humidity. Therapy

The therapy of xerotic eczema depends on reducing the rate of water loss from the skin. This is accomplished by reducing the removal of natural lipid and by the addition of artificial lipid. Lipid loss can be lessened primarily by changing bathing habits. Patients should bathe less frequently (every other day), use cooler water, decrease the use of soap, and pat, rather than rub, the skin dry. Artificial lipid is added through the process of lubrication . Moisturizing creams ("hand creams") should be applied 4 to 8 times/day on the hands and twice daily on the trunk and extremities. Lubricants are particularly helpful when applied to wet skin immediately after bathing, since they then trap additional moisture before evaporation occurs. Bath oils are often recommended, but they are not easily used in the showers that most people prefer, and in any event, their overall role in skin lubrication is minor.

Inflammation, when present, must also be treated. This is accomplished through the twice daily application of mid-potency steroids. In the setting of xerosis an ointment base is frequently preferable to a cream base. Rarely, short-term use of systemic steroids is also necessary.

Scratching, when present, must also be controlled, lest further epithelial destruction occur.

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