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Therapeutic Strategies

Xerosis

Timothy Berger Bruce Wintroub

Friday, September 04, 2009

Overview

Xerosis can reflect an inherited tendency toward dry skin as it is seen as a part of the atopic diathesis, or it can occur in normal individuals as a consequence of frequent bathing with excessively hot water and harsh soaps and/or after prolonged exposure to unusually low environmental humidity (as occurs with forced-air heating during winter months in cold climates). Finally, xerosis can occur as a consequence of asteatosis, which may result from suppression of sebaceous gland function during isotretinoin therapy of acne. Whether xerosis occurs solely as a natural consequence of aging is not known, but it seems clear that normal aging is at least a predisposing factor.

First Steps

  1. A daily bath is an excellent way to hydrate the stratum corneum. Overly compulsive bathers should be encouraged to bath less frequently, no more than daily. The frequency of bathing is not as critical as reduction of the water temperature from hot to a comfortable warm temperature. Hydration immediately after bathing is critical in maintaining the hydrating benefit of the bath.
  2. Use of mild soaps.
  3. For patients who take tub baths, an oilated solution or colloidal oatmeal can be added.
  4. Immediately after bathing, pat skin dry, and apply an emollient cream or ointment. Petrolatum is an excellent option. They should be applied to xerotic skin surfaces and rubbed in well while skin is still damp.
  5. If several members of a household all have xerosis or other dry skin-related problems, a cool-air vaporizer in the bedroom or other living areas can be useful during winter months to counteract the low humidity of closed-air heating systems.
  6. Emollients containing 10-20% urea or up to 12% lactic acid are very effective for the scale accompanying xerosis. The can be added to the hydrating approaches above, if visible xerotic scale is still present.


Subsequent Therapy

Severe xerosis responds dramatically to occlusion therapy. Immediately after bathing, the patient applies a moisturizer as above. A vinyl suit, or for selected areas, plastic wrap, is used to cover the affected area for at least 4 hours, retaining the humidity and hydrating the skin.

Pitfalls

  1. If left untreated, xerotic skin may become eczematous, resulting in erythema, increased pruritus, and occasionally, nummular dermatitis.
  2. The recent onset of generalized xerosis, with or without pruritus, can reflect underlying metabolic or neoplastic disease.
  3. Recalcitrant xerosis with secondary pruritus can be the harbinger of systemic disease. If the above intensive protocol does not bring relief in 2-3 weeks, a search for an underlying metabolic or neoplastic cause should be instituted.
  4. Antihistamines may be helpful adjuncts to the management of itch, but should be used with caution in the elderly due to additive sedative effects of multiple medications, and/or anticholinergic side effects, including urinary retention, precipitation of closed-angle glaucoma, and supraventricular tachycardias (all rare). Nevertheless, antihistamines should be given before bedtime only, or in very low doses initially.
  5. Older persons are particularly at risk of slipping in the tub, so patients should be warned and appropriate precautions should be taken, such as use of a rubber bath mat.
  6. Lactic-acid-containing products of higher concentration than 5% can induce significant pruritus and dermatitis, especially in the atopic patient with xerosis.

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