What is xerosis

Xerosis is a medical term for dry skin, is a condition of rough dry skin with fine scaling of skin and, occasionally, with small cracks in the skin. Xerosis is also known as winter itch, xeroderma or asteatosis (lack of fat). When the dry skin of an elderly person is itchy without a visible rash, it is sometimes called winter itch, 7th age itch, senile pruritus or chronic pruritus of the elderly.

Serious dry skin conditions — an inherited group of disorders called ichthyosis — can sometimes be disfiguring and upsetting. Fortunately, most dry skin is caused by environmental factors that can be at least partially controlled. These factors include hot or cold weather, low humidity, frequent bathing, soaking in hot water and by medical conditions, such as atopic dermatitis and malnutrition. Xerosis develops due to a decrease in the natural oils in the outer layer of skin, which makes the skin lose water.

You can do a lot on your own to improve your skin, including using moisturizers and avoiding harsh, drying soaps. Chronic or severe dry skin problems may require evaluation by a doctor who specializes in skin (dermatologist).

Xerosis is often temporary — you get it only in winter, for example — but it may be a lifelong condition.

Xerosis isn’t usually serious, but it can be uncomfortable and unsightly.

Figure 1. Xerosis feet

Xerosis home remedies

The following measures can help keep your skin moist and healthy:

• Moisturize. Moisturizers provide a seal over your skin to keep water from escaping. Apply moisturizer several times a day and after bathing. Thicker moisturizers work best, such as over-the-counter brands Eucerin and Cetaphil. You may also want to use cosmetics that contain moisturizers. If your skin is extremely dry, you may want to apply an oil, such as baby oil, while your skin is still moist. Oil has more staying power than moisturizers do and prevents the evaporation of water from the surface of your skin. Another possibility is ointments that contain petroleum jelly (Vaseline, Aquaphor). These may feel greasy, so you might want to use them only at night.
• Use warm water and limit bath time. Long showers or baths and hot water remove oils from your skin. Limit your bath or shower to five to 10 minutes and use warm, not hot, water.
• Avoid harsh, drying soaps. It’s best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol.
• Apply moisturizers immediately after bathing. Gently pat your skin dry with a towel so that some moisture remains. Immediately moisturize your skin with an oil or cream to help trap water in the surface cells.
• Use a humidifier. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to your furnace adds moisture to the air inside your home. Be sure to keep your humidifier clean to ward off bacteria and fungi.
• Choose fabrics that are kind to your skin. Natural fibers, such as cotton and silk, allow your skin to breathe. But wool, although natural, can irritate even normal skin.

Wash your clothes with detergents without dyes or perfumes, both of which can irritate your skin. These products may be labeled as “free.”

If dry skin causes itching, apply cool compresses to the area. To reduce inflammation, use a nonprescription hydrocortisone cream or ointment, containing at least 1 percent hydrocortisone. If these measures don’t relieve your symptoms or if your symptoms worsen, see your doctor or consult a dermatologist.

Healthy bathing habits can improve dry skin:

• Take a bath or shower only once daily. More frequent bathing can make the skin lose water (dehydrate).
• Use lukewarm (not hot) water.
• Limit bath time to 5 to 10 minutes.
• Avoid harsh deodorant soaps (or limit their use to armpits, groin, and feet).
• Use non-soap cleansers.
• Pat (don’t rub) the skin dry after bathing.
• Apply moisturizer immediately after bathing, while the skin is still moist.
• When choosing a moisturizer, look for oil-based creams and ointments, which work better than water-based lotions.

The following over-the-counter products may be helpful:

• Petrolatum or petroleum jelly (Vaseline®)
• Fragrance-free creams or ointments
• Preparations containing alpha-hydroxy acids such as glycolic acid or lactic acid
• Creams containing urea
• Over-the-counter cortisone cream (if the areas are itchy)
• Topical antibiotics applied immediately to any cracks in the skin to help prevent infection

Use a humidifier in the bedroom during the cold, dry seasons to help prevent dry skin.

In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. If you have very dry and scaly skin, your doctor may recommend you use an over-the-counter (nonprescription) cream that contains lactic acid or lactic acid and urea.

If you have a more serious skin disease, such as atopic dermatitis, ichthyosis or psoriasis, your doctor may prescribe prescription creams and ointments or other treatments in addition to home care.

Sometimes dry skin leads to dermatitis, which causes red, itchy skin. In these cases, treatment may include hydrocortisone-containing lotions. If your skin cracks open, your doctor may prescribe wet dressings to help prevent infection.

See your doctor for an evaluation if the above self-care measures do not cure your dry skin.

Who gets xerosis?

Dry skin can affect males and females of all ages. There is some racial variability in water and lipid content of the skin.

• Dry skin that starts in early childhood may be one of about 20 types of ichthyosis (fish-scale skin). There is often a family history of dry skin.
• Dry skin is commonly seen in people with atopic dermatitis.
• Nearly everyone > 60 years has dry skin.

Dry skin that begins later may be seen in people with certain diseases and conditions.

• Postmenopausal females
• Hypothyroidism
• Chronic renal disease
• Malnutrition and weight loss
• Subclinical dermatitis
• Treatment with certain drugs such as oral retinoids, diuretics and epidermal growth factor receptor inhibitors

People exposed to a dry environment may experience dry skin.

• Low humidity: in desert climates or cool, windy conditions
• Excessive air conditioning
• Direct heat from a fire or fan heater
• Excessive bathing
• Contact with soap, detergents and solvents
• Inappropriate topical agents such as alcohol
• Frictional irritation from rough clothing or abrasives

Xerosis causes

Xerosis can be seen in people of any age, of any race, and of either gender. However, the incidence of dry skin increases with age; nearly all individuals over the age of 60 have some degree of dry skin.

Xerosis often has an environmental cause. Certain diseases also can significantly affect your skin. Potential causes of dry skin include:

• Weather. Skin tends to be driest in winter, when temperatures and humidity levels plummet. But the season may not matter as much if you live in desert regions.
• Heat. Central heating, wood-burning stoves, space heaters and fireplaces all reduce humidity and dry your skin.
• Hot baths and showers. Taking long, hot showers or baths can dry your skin. So can frequent swimming, particularly in heavily chlorinated pools.
• Harsh soaps and detergents. Many popular soaps, detergents and shampoos strip moisture from your skin as they are formulated to remove oil.
• Other skin conditions. People with skin conditions such as atopic dermatitis (eczema) or psoriasis are prone to dry skin.

Xerosis is due to abnormalities in the integrity of the barrier function of the stratum corneum, which is made up of corneocytes.

• There is an overall reduction in the lipids in the stratum corneum.
• Ratio of ceramides, cholesterol and free fatty acids may be normal or altered.
• There may be a reduction in proliferation of keratinocytes.
• Keratinocyte subtypes change in dry skin with decrease in keratins K1, K10 and increase in K5, K14.
• Involucrin (a protein) may be expressed early, increasing cell stiffness.
• The result is retention of corneocytes and reduced water-holding capacity.

Xerosis is caused by several medical conditions including:

• Ichthyosis
• Atopic dermatitis
• Diabetes
• Hypothyroidism
• Down syndrome
• Liver or kidney disease
• Malnutrition
• HIV/AIDS
• Lymphoma

The inherited forms of ichthyosis are due to loss of function mutations in various genes (listed in parentheses below):

• Ichthyosis vulgaris (FLG).
• Recessive X-linked ichthyosis (STS)
• Autosomal recessive congenital ichthyosis (ABCA12, TGM1, ALOXE3)
• Keratinopathic ichthyoses (KRT1, KRT10, KRT2)

Acquired ichthyosis may be due to:

• Metabolic factors: thyroid deficiency
• Illness: lymphoma, internal malignancy, sarcoidosis, HIV infection
• Drugs: nicotinic acid, kava, protein kinase inhibitors (eg EGFR inhibitors), hydroxyurea

Risk factors for developing xerosis

Anyone can develop dry skin. But you may be more likely to develop the condition if you:

• Are in your 40s or older. The risk increases with age — more than 50 percent of older adults have dry skin.
• Live in dry, cold or low-humidity climates.
• Have a job that requires you to immerse your skin in water, such as nursing and hairstyling.
• Swim frequently in chlorinated pools.

Xerosis prevention

Try these tips to keep skin from getting excessively dry:

• Reduce frequency of bathing.
• Humidifier in winter and air conditioner in summer
• Limit water exposure. Keep bath and shower time to 10 minutes or less. Turn the dial to warm, not hot. Try to bathe no more than once a day.
• Use lukewarm, not hot, water.
• Replace standard soap with a substitute such as a synthetic detergent cleanser, water-miscible emollient, bath oil, anti-pruritic tar oil, colloidal oatmeal etc.
• Apply an emollient or moisturizer liberally and often, particularly shortly after bathing, and when itchy. The drier the skin, the thicker this should be, especially on the hands.
• Cover as much skin as possible in cold weather. Winter can be especially drying to skin, so be sure to wear a scarf, hat and gloves when you go out.
• Wear rubber gloves. If you have to immerse your hands in water or are using harsh cleansers, wearing gloves can help protect your skin.

Xerosis symptoms

The most common locations for xerosis of skin include:

• Legs, especially the fronts of the lower legs (shins)
• Arms
• Trunk, especially the side areas between the bottom rib and the hip (flanks)
• Backs of the hands

Xerosis is likely to cause one or more of the following:

• A feeling of skin tightness, especially after showering, bathing or swimming
• Skin that feels and looks rough
• Itching (pruritus)
• Slight to severe flaking, scaling or peeling
• Fine lines or cracks
• Gray, ashy skin
• Redness
• Deep cracks that may bleed

Xerosis appears as dull, rough skin with fine scales that flake off easily. In more advanced stages of dry skin, the skin may have cracks that resemble a dry lake bed. Inflammation of the areas may lead to pink or red patches.

Xerosis can be completely without symptoms (asymptomatic), though more inflamed skin tends to be mildly to severely itchy.

Xerosis complications

Xerosis is usually harmless. But when it’s not cared for, dry skin may become itchy, indicating a form of eczema/dermatitis has developed.

• Atopic dermatitis (eczema). If you’re prone to develop this condition, excessive dryness can lead to activation of the disease, causing redness, cracking and inflammation, especially in people with ichthyosis vulgaris.
• Eczema craquelé — especially in elderly people. Also called asteatotic eczema
• A dry form of nummular dermatitis/discoid eczema — especially in people that wash their skin excessively

Other complications of xerosis of skin may include:

• Skin infection when bacteria or viruses penetrate a break in the skin surface
• Overheating, especially in some forms of ichthyosis
• Food allergy, e.g., to peanuts, has been associated with filaggrin mutations
• Contact allergy, e.g., to nickel, has also been correlated with barrier function defects

These complications are most likely to occur when your skin’s normal protective mechanisms are severely compromised. For example, severely dry skin can cause deep cracks or fissures, which can open and bleed, providing an avenue for invading bacteria.

How is xerosis diagnosed?

The type of xerosis is diagnosed by careful history and examination.

In children:

• Family history
• Age of onset
• Appearance at birth, if known
• Distribution of dry skin
• Other features, eg eczema, abnormal nails, hair, dentition, sight, hearing

In adults:

• Medical history
• Medications and topical preparations
• Bathing frequency and use of soap
• Evaluation of environmental factors that may contribute to dry skin

Sometimes, skin biopsy may be requested. There may be additional tests requested to diagnose some types of ichthyosis. Your doctor may also suggest certain diagnostic tests to check whether your dry skin is the result of an underlying medical condition, such as an underactive thyroid (hypothyroidism).

Xerosis treatment

The mainstay of treatment of dry skin and ichthyosis is moisturizers/emollients. They should be applied liberally and often enough to:

• Reduce itch
• Improve barrier function
• Prevent entry of irritants, bacteria
• Reduce transepidermal water loss

When considering which emollient is most suitable, consider:

• Severity of the dryness
• Tolerance
• Personal preference
• Cost and availability

Emollients generally work best if applied to damp skin, if pH is below 7 (acidic), and if containing humectants such as urea or propylene glycol.

Additional treatments include:

• Topical steroid (cortisone) cream if the skin is inflamed (dermatitis) or very itchy — choose an emollient base
• Topical calcineurin inhibitors if topical steroids are unsuitable
• Cream containing alpha- or beta-hydroxy acids (glycolic acid, lactic acid, salicylic acid)
• Urea-based cream
• Preparation containing high concentrations of propylene glycol

If the physician suspects that a medical condition is causing your dry skin, then he or she may do blood tests or other diagnostic procedures. The best treatment for dry skin caused by a medical problem is to treat the medical problem.