Eczema craquelé (asteatotic eczema)
Asteatotic eczema; xerotic eczema; winter itch; eczema craquelé; eczema fissuratum
Eczema craquelé is a common inflammatory dermatosis in older adults — pruritic, dry, fissured skin with a characteristic "crazy-paving" or "dried river-bed" appearance, predominantly on the lower legs, forearms and trunk. It results from impaired skin-barrier function (reduced sebum, ceramides), exacerbated by low humidity (winter), over-washing, hot baths, soap, diuretics, ICI therapy, hypothyroidism and zinc / essential fatty-acid deficiency. In skin-oncology clinic it is a frequent mimic of mycosis fungoides (patches), nummular eczema and contact dermatitis — and a recognised cutaneous toxicity of immune checkpoint inhibitors and chemotherapy. Most cases respond to emollients and avoidance of triggers; chronic refractory disease warrants biopsy and workup for systemic / neoplastic cause.
Clinical features
- Dry, fissured, scaly skin with characteristic crazy-paving or dried river-bed surface.
- Itch, sometimes severe.
- Distribution — anterior shins (commonest), forearms, hands, trunk; rarely face / scalp.
- Erythema, eczematisation and excoriation may supervene.
- Onset — winter, after hot bath, soap exposure, diuretic initiation, ICI / chemotherapy.
- Older patients, immunosuppressed, on multiple medications.
Skin-oncology context
- Common in cancer patients — chemotherapy, ICI, EGFRI all cause xerosis.
- Frequent mimic of mycosis fungoides early patch stage — chronic, refractory, multiple sites; biopsy if persistent > 6 months despite optimal emollient therapy.
- Underlying systemic cause to consider — hypothyroidism, malabsorption, zinc / essential-fatty-acid deficiency, malnutrition, drug-induced.
- Refractory generalised xerosis in adults — consider underlying haematological malignancy (CTCL, lymphoma), HIV.
- Recurrent / generalised acquired ichthyosis — see acquired ichthyosis.
Management
- Emollients — generous, frequent application (3–4×/day):
- Greasy ointments (white soft paraffin, 50:50 white soft paraffin / liquid paraffin).
- Urea creams 10–20% (humectant).
- Glycerin-containing creams.
- Soap substitutes — emollient washes, aqueous cream as wash-off (not leave-on).
- Avoid hot baths and over-washing.
- Topical mid-potency corticosteroid (mometasone, betamethasone valerate) for inflammatory phase.
- Topical tacrolimus 0.1% for face / sensitive sites.
- Treat underlying cause — adjust diuretic dose, correct deficiency, optimise thyroid.
- Humidify environment in winter.
- Biopsy if persistent / atypical to exclude MF.
References
- Wolf R, Wolf D. Asteatotic eczema and related conditions. Clin Dermatol; 2012.
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