Classification, Research, and Treatment of Eczema Craquele

First described by Brocq in 1907, with the term eczema craquelé, asteatotic eczema (a.k.a. Winter Itch) is characterized by pruritic, dry, cracked, and polygonally fissured skin with irregular scaling. It most commonly occurs on the shins of elderly patients, but it may occur on the hands and the trunk.

In 1971, Domonkos described the appearance of this form of eczema as cracked porcelain. The pattern of cracking has been likened to a crazy pavement pattern. In 1999, Fitzpatrick likened asteatotic eczema to a dried-up riverbed. According to Caplan, superficial bleeding and fissures can occur as the epidermis loses water, as it splits, and as it cracks deeply enough to disrupt papillary dermal capillaries. The inflammation can be associated with asymmetric leg edema. Eczema with increased lichenification occasionally supervenes as patients rub and scratch the pruritic areas.

Craquele in French means, "marred with cracks" as in old china. Craquele eczema describes a condition often seen in elderly persons during the winter. It is usually caused by bathing too often in hot soapy water or showers or in houses with low humidity and high temperature.

Eczema Craquele describes skin that has a "crazy paving" appearance. It is also known as asteatotic dermatitis, eczema craquelatum, xerotic eczema, winter itch, eczema hiemalis, eczema fendille, etat craquelé.

Eczema craquele generally occurs in older people who have thinner and dryer skin. Large dry scales may form on the skin giving a "crazy-paving" appearance to the skin. It is extremely common in communities of elderly people and may be triggered by soap remaining on the skin after a bed bath. Using a good moisturizing routine and switching from soap to a cleansing bar for dry sensitive skin (such as Cetaphil "moisturizing gentle cleansing bar") can alleviate it. Steroid creams are generally best avoided because the underlying skin is already very thin and delicate.

Fair-skinned, sensitive or elderly people who bathe a lot in hot showers or tubs can develop an eczema craquele. Remembering that the skin's pH is acidic, around 5.0, and all water is slightly alkaline, especially if there are many calcium and magnesium salts in it, it is easy to see how this happens. Cessation of bathing and showering for a while may be necessary to clear the skin of these unfortunate patients. An alkaline skin is increasingly susceptible to the irritant effects of water alone, and the hyper-irritability of the skin can be prolonged; it takes 3 months for a fracture to heal, similarly with the skin. The skin must be put at rest and allowed lubrication for that length of time before it recovers.

The eruption can be generalized or localized. Generalized asteatosis is a distinct entity and should provoke a search for possible associated diseases. Guillet divides the localized forms into 4 types:

• Asteatotic eczema of the lower extremities in elderly persons secondary to aging, dehydrated skin, and malnutrition
• Cracked erythema secondary to irritant contact eczema from soaps or detergents
• Eczema craquelé in areas in which corticosteroid therapy was discontinued
• Asteatotic eczema in neurological disorders

Initially, excess water loss from the epidermis results in dehydration of the stratum corneum with upward curling of corneocytes. The outer keratin layers require 10-20% water concentration to maintain their integrity. A significant decrease in free fatty acids in the stratum corneum is present in people with asteatotic dermatitis. Stratum corneum lipids act as water modulators, and cutaneous loss of these lipids can increase transepidermal water loss to 75 times that of healthy skin. Elderly persons with decreased sebaceous and sweat gland activity, patients on antiandrogen therapy, people using degreasing agents, and people bathing without replacing natural skin emollients lost to bath water are at risk for asteatotic eczema.

When the stratum corneum loses water, the cells shrink. A significantly decreased cellular volume can stress the skin's elasticity, creating fissures. Edema in the dermis leads to additional stretch on the overlying epidermis. Fissures rupture dermal capillaries, causing clinical bleeding. The disruption of cutaneous integrity can result in inflammation with risk of infection. Transepidermal absorption of allergens and irritants is increased as the epidermis is damaged, increasing susceptibility to allergic contact dermatitis and irritant contact dermatitis. Allergic contact dermatitis and irritant contact dermatitis may cause a persistent and possibly more extensive dermatitis despite therapy. Furthermore, low environmental humidity contributes to xerosis, creating a clinical picture of asteatotic dermatitis in some dermatologic conditions, such as atopic dermatitis.

Seasonality is prominent, and most patients present in the winter months, especially in areas where indoor humidity is decreased by heating. The frequency of eczema craquele is increased in the northern United States, particularly during the winter season.

Although most cases resolve without ill effects, can be chronic with relapses frequent during the winter months and during times of low humidity.

Causes of Eczema Craquele

Multiple factors may contribute to cause eczema craquele, including the following:

• Xerosis and friction
• Frequent or prolonged bathing in hot water, use of soap on the involved site, and infrequent use of emollients for water retention in the stratum corneum
• Degreasing agents such as Solvents and Cleansers
• Decreased sebaceous and sweat gland activity in elderly persons
• Decreased keratin synthesis in elderly persons
• Low environmental humidity and cold winds that increase the loss of water by convection
• Radiation
• Long-term mal-absorption of essential fatty acids, including linoleic acid and linolenic acid
• Nutritional deficiencies such as zinc deficiency and essential fatty acid deficiency, such as linoleic acid deficiency or linolenic acid deficiency
• Atopy
• Ichthyosis
• Thyroid disease - Myxedema and other thyroid diseases with diminished sweat and sebaceous gland activity
• Neurologic disorders - Decreased sweating in denervated areas
• Drugs - Antiandrogen therapy and diuretic therapy
• Malignancies - Malignant lymphoma, gastric adenocarcinoma, glucagonoma, angioimmunoblastic lymphadenopathy, breast cancer, large-cell lung carcinoma, and colorectal carcinoma.

Symptoms of Eczema Craquele

This form of eczema results from exsiccation of the skin due to factors like aging, atopy, dry climate, overexposure to water and detergents and malnutrition. Men are slightly more often affected than women.

The skin is dry and dull, with fine scaling. In more advanced stages, a pattern of superficial cracks and fissures of the horny layer presents, possibly accompanied by erythema, oozing and crusting. Mild xerosis is asymptomatic, whereas itching and stinging may be present in more pronounced lesions.

Primary lesions include slightly scaly, inflamed, curvilinearly cracked and/or fissured skin most commonly involves the lower leg area, but it may also occur on the thighs, on the hands, and on the trunk.

Secondary lesions include excoriated, erythematous, edematous patches may result from rubbing or scratching. Bleeding fissures secondary to the disruption of dermal capillaries have been described in exaggerated eczema craquelé, which begins as superficial cracks in the epidermis.

Typically the shins are involved, but lesions may also occur on the arms, thighs and the trunk.

Eczema Craquele is mainly seen on legs, arms and hands as dry cracked skin with slight scaling. Constant scratching can lead to lichenification, which can last for weeks or months even when environmental factors have been changed.

Controlling Eczema Craquele

There are many ways of controlling and treating eczema craquele or winter itch including:

• Making sure the patient uses moisturizers regularly, particularly after bathing.
• Avoiding overheating rooms.
• Using humidifiers to keep heated indoor air moist. Humidified air is easier to breathe, too. Room humidifiers in bedroom may help (keep humidity above 50%).
• Limiting and adjusting the method of bathing the patient. Baths dry out the skin more than showers, and hot or cold water is more drying than warm. One or two thorough baths or showers a week can be supplemented by daily sponge baths under the arms.
• Avoiding the use of deodorant soaps and instead opting for cleansing bars such as Cetaphil gentle cleansing bar for dry, sensitive skin.
• Avoiding excessive friction on the skin, such as scrubbing with harsh washcloths or wearing woolen clothing. Stay away from irritants or substances, which can trigger allergic reactions.
• Dressing the patient warmly for trips outside. Cover exposed skin in windy or cold weather.
• Using a moisturizer like jojoba oil will effectively treat dryness and even difficult areas such as heels and elbows, softening the skin and providing protection.
• Applying Eczema-Ltd III patented topical skin conditioner disks to the affected skin as directed.