Are You Confident of the Diagnosis?
What to be alert for in the history
When a patient scratches the xerotic skin, the scratching can produce red plaques with long, superficial fissures and is similar in appearance to cracked porcelain (eczema craquelé) , known as asteatotic eczema (Figure 1, Figure 2). If asteatotic eczema is not treated, and continues to worsen, “cracked porcelain” fissures become deeper and wider fissures that frequently drain and may have purulent drainage if chronic enough. When the patient presents at this stage, the chief complaint may be pain instead of itching. Scratching or the use of calamine lotion can aggravate the inflammation, leading to infection with purulence and crusts.
Multiple etiologic factors can coexist with asteatotic eczema. They include xerosis, nutritional deficiencies of zinc and essential fatty acids, Ichthyosis, thyroid disease, neurologic disorders, drugs in association with antiandrogen therapy and diuretic therapy, and other malignancies such as various carcinomas. These conditions should be carefully monitored when choosing appropriate therapy.
Expected results of diagnostic studies
Spongiosis and a varying amount of inflammatory dermal infiltrate similar to that of mild, subacute eczema are seen in histologic findings. Xerosis tends to be on a whitish scale whereas asteatotic eczema appears as a cracked riverbed or porcelain vase.
Diagnosis is mainly clinical, often associated with xerosis, and treated with moisturizers and topical corticosteroids. Ichthyosis vulgaris is similar in appearance to asteatotic eczema but with symmetrical scaling of the skin and lesions on legs (more common on the shin) that resemble fine fish scales. It is also important to consider any other conditions in the patient’s history that could either mimic or exacerbate the problem, such as hypothyroidism or underlying stasis dermatitis.
Who is at Risk for Developing this Disease?
Most elderly patients who have xerosis or pruritus may develop asteatotic eczema. Patients who live in areas of low humidity in the winter months are more likely to develop the disease than those living in areas of warm, humid climate. Men over 60 years tend to develop asteatotic dermatitis more commonly than women. It can occur in younger individuals also, but less frequently.
What is the Cause of the Disease?
Research at the Sheffield University has shown that soaps and detergents are common irritants that may predispose the breakdown of the skin barriers, allowing the entry of allergens. Therefore, the use of hypoallergenic, non-fragranced, gentle –skin products and emollient therapy are beneficial in a eczematous conditions accompanied by skin breakdown.
Systemic Implications and Complications
The main complication of asteatotic dermatitis would be secondary infection, resulting in cellulitis. As multiple etiologic factors can coexist with asteatotic eczema, these of course could have systemic implications. They include xerosis, nutritional deficiencies of zinc and essential fatty acids, Ichthyosis, thyroid disease, neurologic disorders, drugs in association with antiandrogen therapy and diuretic therapy, and other malignancies such as various carcinomas.
Soak and Smear method
Optimal Therapeutic Approach for this Disease
In its early inflammatory stages, asteatotic eczema may be treated with mid-level topical steroid ointments, such as triamcinolone 0.1% ointment.
More severe stages of asteatotic eczema may need to be treated initially with wet compresses for 1-2 days and antibiotics, especially those convering staphylococcal or streptococcal infections (for example, Cefuroxime axetil 500mg twice a day for 10 days).
Culture and sensitivities are valuable, especially in cases that are weeping and have not responded to standard antibiotic treatment If lesions are not weeping or crusting, combination of emollients and topical steroids may be used. Schulz et al ran a randomized, double-blind vehicle-controlled study and showed pimecrolimus cream 1% to be effective in treating asteatotic eczema.
NUMMULAR ECZEMA, ASTEATOTIC ECZEMA, AND XEROTIC
Soak and Smear Treatment
These dermatological conditions are common inflammatory skin conditions that cause a compromised skin barrier and may be associated with pruritus, fissuring, or scaling. In a study by Gutman, et al. these conditions respond well to a “Soak and Smear” treatment.
Soaking removes crust and scale, and hydrates the damaged stratum corneum, promoting desquamation. Smearing traps the moisture in the stratus corneum, and delivers the topical medication in the ointment. Smearing after showering, shorter soaks, or soaking in chlorinated pools or hot tubs does not produce the same improvements, and can lead to irritation. By using the Soak and Smear technique, often systemic medications can be avoided.
The treatment is a plain water 20-minute soak followed by smearing of mid- to high-strength corticosteroid ointment, such as triamcinolone 0.1% ointment, onto the wet skin. The treatment is done at bedtime. A cream of the same strength is also applied in the morning to the affected areas. The patient is also educated to avoid washing of the skin with soaps, and to use moisturizers after any washing.
This treatment is done for up to 2 weeks. In more severe cases, the patient may then use the ointment only at night for 2 more weeks. When the patient has cleared, he may be switched to the soak and smear therapy with only white petroleum jelly. Eventually the patient can go to using moisturizer lotion only after showers and before bedtime as maintenance.
In the study, the soak and smear therapy was often successfully done with the same topical corticosteroid that failed in the patient in the past when it was simply applied topically, even with occlusion, but without prior soaking. If the corticosteroid was continued for a month or longer, purpura at sites of trauma, usually of the upper extremities, was seen. Therefore, it is important to instruct the patient to make the changeover to petroleum jelly, and then to moisturizers.
When using the Soak and Smear Treatment, part of the maintenance therapy involves also educating patients regarding the need to reduce the use of soap and increase the use of moisturizers. These patients may have flares of the eczema, but, once having been educated about the cause and treatment, they can redo the soak and smear treatment and find relief.
Ceramides and Skin Function
As reported by Coderch et al, ceramides are the major lipid present in the stratus corneum, and are necessary to maintain the water permeability and barrier functions of the epidermis. Coderch and his team found that most dermatology conditions with decreased barrier function have ceramide deficiency and alteration. Therefore skin lotions with ceramides and ceramide precursors can improve the barrier function of the skin, and help treat skin conditions with impaired barrier function.
It has been reported that topical pimecrolimus is less effective than moderate and potent corticosteroids and 0.1% tacrolimus. In another small study, no evidence of benefit was found for antimicrobial interventions for patients with atopic eczema, and it was acknowledged that further larger studies are needed to form conclusive long-term outcomes.
Many commonly used skin moisturizers do not correct the stratus corneum ceramide deficiency that causes the impaired skin barrier in inflammatory dermatoses. Since glucocorticoids and other immunosuppressive agents do have a risk of toxicity, a ceramide-dominant barrier repair emollient provides a safe treatment for atopic dermatitis and other inflammatory dermatoses that are characterized by impaired skin barrier. Moisturizers such as Cerave were found to improve the skin barrier function.
Dry skin is often linked to an impaired skin barrier, as seen in xerosis and asteatotic eczema. Petrolatum and ceramides have a barrier-repairing effect, without the odors that may be found objectionable to some people. 5% urea makes skin less susceptible to breakdown and damage from sodium laurel sulfate. Treatments improving the skin barrier relieve and may even prevent episodes of many dermatologic conditions.
Staphylococus aureus is frequently found in the lesions of patients with eczematous skin conditions. It has been found that early topical treatment of
moderate to severe eczematous skin conditions benefited from a combination of mupirocin plus a topical corticosteroid, and reduced colonization of S aureus. An antibiotic-corticosteroid combination and corticosteroid alone both gave good therapeutic effect in eczema and in atopic dermatitis, and both reduced colonization by S aureus. Early combined topical therapy is beneficial to patients with moderate to severe eczema and atopic dermatitis and it is unnecessary to use antibiotics at later stages of disease or in mild eczema.
Some new skin care lotions and cleansers contain ceramides. A comparative study of the use of fluocinonide 0.05% cream plus ceramide-containing liquid cleansers and moisture creams versus fluocinonide 0.05% cream plus bar soap in the treatment of mild to moderate eczema was performed. The study showed that the high-potency corticosteroid cream, when used with ceramide-containing skin care products, enhanced the treatment outcome in mild to moderate eczema when compared to the use of the corticosteroid cream used with bar soap. Therefore, ceramide-containing skin care products can help when used in the treatment regimen for mild to moderate eczema.
Additionally, in a study of adult patients with atopic dermatitis, Nakagawa found that the most prevalent adverse reactions to tacrolimus 0.1% ointment were local application site irritations, which generally resolved with continued therapy. The findings suggest that 0.1% tacrolimus ointment is an effective and safe nonsteroidal therapy for adult patients with atopic dermatitis.
Patients should be advised to take general precautions in addition to therapy. These include taking short baths with decreased water temperature, reducing soap usage in affected areas, avoiding harsh cleansers with high pH, avoiding scrubbing, and applying petrolatum-based emollients following bathing, and using humidifiers. Prognosis is generally good, however, if causative factors are not treated, chronic eczema can occur. If prone to secondary infection, bleach baths may of value.
Unusual Clinical Scenarios to Consider in Patient Management
When using the Soak and Smear Treatment, part of the maintenance therapy involves educating patients regarding the need to reduce the use of soap and increase the use of moisturizers. These patients may have flares of the eczema, but once they are educated about the cause and treatment, they can redo the soak and smear treatment and find relief.
What is the Evidence?
Coderch, L, López, O, de la Maza, A, Parra, JL. “Ceramides and skin function”. Am J Clin Dermatol. vol. 4. 2003. pp. 107-29. (The authors shed light on ceramides as the major lipid present in the stratus corneum, and elaborate on their ability to maintain the water permeability and barrier functions of the epidermis. Coderch and his team found that most dermatology conditions with decreased barrier function have ceramide deficiency and alteration.)
Gutman, AB, Kligman, AM, Sciacca, J, James, WD. “Soak and Smear: a standard technique revisited”. Arch. Dermatol. vol. 141. 2005. pp. 1556-59. (This study described a simple, inexpensive, effective topical treatment with an accompanying patient educational sheet. Hydration for 20 minutes before bedtime followed by ointment application to wet skin and alteration of cleansing habits, was shown to be an effective method for caring for several common skin conditions.)
Nakagawa, H. “Comparison of the efficacy and safety of 0.1% tacrolimus ointment with topical corticosteroids in adult patients with atopic dermatitis: review of randomised, double-blind clinical studies conducted in Japan”. Clin Drug Investig. vol. 26. 2006. pp. 235-46. (This study compared the efficacy and safety of 0.1% tacrolimus ointment with topical corticosteroids in atopic patients. Nakagawa suggests that 0.1% tacrolimus ointment is an effective and safe nonsteroidal alternative therapy for adult patients with atopic dermatitis.)
Schulz, P, Bunselmeyer B., Bräutigam,, M, Luger, T. “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. vol. 21. 2007. pp. 90-4. (Schulz et al ran a randomized, double-blind vehicle-controlled study and showed pimecrolimus cream 1% to be effective in treating asteatotic eczema.)
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