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Asteatotic Eczema

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A 38-year-old man presented with dry scaly skin on his left shin. The man had encountered a motor-bike accident, about 16 months back, which had resulted in compartment syndrome of his left lower leg. Trauma management had included an emergency fasciotomy on his left lower leg. Thereafter, he recovered well, however with a well-demarcated reduced sensation in his anterior left shin.

On examination, the patient elicited an area of hypoesthesia on his anterior shin. This region exhibited erythematous polygonal fissures with a serous exudate and signs of bleeding. 

Bacterial culture was advised, which did not depict infection. After excluding myxedema, cellulitis, stasis dermatitis, allergic contact dermatitis, irritant contact dermatitis, nummular dermatitis and cutaneous distension syndrome, a confirmatory diagnosis of asteatotic eczema was arrived upon. 

Initially, topical corticosteroids were prescribed, which alleviated the lesions. Emollients were adjuncted after the lesions reduced in severity. After 3 weeks of therapy, the scaly patches on the skin disappeared. The patient was asked to continue the emollients routinely for maintenance.

Discussion

Asteatotic eczema – also known as xerosis or eczema craquelé, is among the most common subtypes of dermatitis. It is more common during the winter months and is characterized by dry, cracked and scaling skin that is pruritic and inflamed. The classic appearance has been described as “cracked porcelain,” “crazy pavement” or a “dry riverbed”. The disease initiates as dryness of skin and then increases in severity causing cracks and fissures. These fissures manifest due to epidermal water loss and the irregular fissuring and scaling patterns are referred to as "crazing paving".

Asteatotic eczema is more common in the elderly due to the dysfunction in sweat and sebaceous glands with advancing age. This pruritic dermatitis can occur on any skin area of the body; common sites are – the anterolateral aspects of the lower legs, back, trunk and arms. Individuals with this condition harbor decreased amount of free-fatty acids in the stratum corneum. This feature facilitates transepidermal water loss up to 75 times. This hampers the integrity of the keratin layer, which then splits and fissures—and may even reach the dermal capillaries to cause bleeding. Furthermore, the dryness may induce scratching, which may render excoriations, edematous patches and lichen planus. The compromised epidermal barrier also invites allergens and bacteria and makes the skin prone to secondary infection.

An underlying systemic cause may be contributing to asteatotic eczemas, such as malignancy, hypothyroidism, radiation and malnutrition. 

The diagnosis of asteatotic eczema is mainly clinical and is based on the patient’s history and physical examination. The hallmark of the disease is skin dryness with pruritus. Typically, accentuation of the skin lines (xerosis) can be appreciated. Excoriation marks may be apparent as red plagues with thin, long, horizontal superficial fissures. Other findings may include bleeding from polygonal or curvilinear fissures and secondary lesions of erythematous and edematous patches. 

Management usually comprises hydration of the skin with lotions and emollients. Topical steroids may be used in conjunction. Adjunctive treatments may be used to control pruritus, for example alpha-hydroxyl acid moisturizers.

Preventive measures include – decreasing the frequencies or bathing, minimizing the use of soap, modification of diet, change of medications and detergent and using a humidifier in dry environments.  

Suggested Reading

  1. Zhou LJ, Lyu ZF. Asteatotic dermatitis: etiology and pathogenesis.Zhejiang Da Xue Xue Bao Yi Xue Ban. 2015;44(4):465-70.
  2. Schulz P, Bunselmeyer B, Bräutigam M, et al. Pimecrolimus cream 1% is effective in asteatotic eczema: results of a randomized, double-blind, vehicle-controlled study in 40 patients. J Eur Acad Dermatol Venereol. 2007;21(1):90-4.
  3. Specht S, Persaud Y. Asteatotic Eczema. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549807/
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