Incidence

1. Xerosis occurs in 48% to 98% of patients with atopic dermatitis.
2. It occurs more frequently in elderly patients.

Pathogenesis

1. Dry skin may fissure, appear shiny and cracked, and leave subsequent inflammatory changes.

Predisposing Factors

1. Frequent bathing with hot water and harsh soaps.
2. Cold air.
3. Low humidity.
4. Central heating or cooling.
5. Alcohol use.
6. Poor nutrition.
7. Cholesterol-lowering drugs.
8. Systemic disease manifested by thyroid, renal, or hepatic disease, anemia, diabetes, or malignancy.

Common Complaints

1. Dry, rough skin, especially on legs.

Other Signs and Symptoms

1. Pruritic, scaling skin, particularly on legs, with cracks and/or fissures.
2. Pruritus may be associated with systematic disorders or other infections. Itching of scabies is particularly intense at night.
3. Plaques 2 to 5 cm in diameter.
4. Erythema.
5. Wheal-and-flare response typical of urticaria.

Subjective Data

1. Obtain the patient’s description of the onset of symptoms and whether it was sudden or gradual.
2. Ask the patient to identify any discomfort. Ask if the skin is itchy or painful.
3. Assess lesions for any associated discharge (blood or pus).
4. Determine whether the patient has recently ingested any new medicines (antibiotics, cholesterol-lowering medications, or other drugs), alcohol, or new foods.
5. Ask the patient about use of any topical medications.
6. Identify any preceding systemic symptoms (fever, sore throat, anorexia, or vaginal discharge).
7. Ask the patient about bathing in hot water and if patient is bathing regularly.
8. Review the patient’s full medication history for comorbid conditions.

Physical Examination

1. Inspect: Inspect skin for lesions, noting texture of skin.
2. Palpate:
   1. Palpate abdomen for masses and hepatosplenomegaly.
   2. Palpate lymph nodes.

Diagnostic Tests

1. There are no diagnostic tests for xerosis.

Differential Diagnoses

1. Xerosis.
2. Scabies.
3. Atopic dermatitis.

Plan

1. General interventions:
   1. Hydration and lubrication of skin.
   2. Assess for and treat secondary infection.
2. See Section III: Patient Teaching Guide “Xerosis (Winter Itch).”
   1. Avoid alkaline soaps: Use Dove, Basis, mild soap, or soap substitute, such as Cetaphil or Aquanil.
3. Pharmaceutical therapy:
   1. Apply emollient cream or lotion (Sarna, Lac-Hydrin, or Eucerin).
   2. Use over-the-counter (OTC) skin lubricants (petroleum jelly, mineral oil, or cold cream).
   3. Topical corticosteroid:
      1. Triamcinolone 0.025% two to four times daily or 0.1% two to three times daily; apply sparingly. Advise not to use steroid treatments any longer than 2 weeks without notifying the primary provider.
      2. Hydrocortisone 1% or 2.5% two to four times daily for no longer than 2 weeks. Recommend applying a thin film and avoiding the face.
   4. Systemic antihistamine to control pruritus, such as diphenhydramine (Benadryl) 25 to 50 mg every 4 to 6 hours as needed.

Follow-Up

1. Follow up as indicated until resolved.

Consultation/Referral

1. Consult or refer the patient to a dermatologist if no improvement is seen.

Individual Considerations

1. Geriatrics:
   1. Monitor the patient for possible skin breakdown and/or ulceration.
   2. Xerosis is common among elderly population. Several nonpharmacological treatments to consider before using topical hydrocortisone would include increasing home environment humidity, avoiding excessive bathing and bath oils, encouraging oatmeal baths, and using emollient ointment (e.g., Aquaphor or Eucerin) and ceramide lotions (e.g., AmLactin) to smooth cracked rough skin and decrease pruritus.