Eczema Craquelé (Asteatotic Eczema)

Definition

• Also known as Winter Itch or Xerotic Eczema

• Characterised by dry, cracked ("craquelé") skin, often in a "crazy-paving" or "cracked porcelain" pattern

• Most common in elderly individuals with inherently dry skin; exacerbated by winter months and low humidity

• Common sites: Extensor surfaces (especially lower legs)

Aetiology & Associations

• Elderly & Dry Skin States

  • Reduced skin barrier function with age, decreased natural oils

  • Low humidity, overheated rooms, frequent hot showers

• Hypothyroidism

  • Dry, brittle hair and nails; possible weight gain or lethargy

  • Subclinical or overt hypothyroidism may manifest as severe dry, cracking skin

• Medication-Induced Dryness

  • Diuretics, lipid-lowering agents (e.g., statins), possibly retinoids

  • Underlying pathology (renal impairment, malnutrition) can worsen dryness

• Seasonality

  • Often worse in winter due to colder, drier air

Clinical Features

• Appearance

  • Thin, dry, scaly plaques with fissures creating "crazy-paving" or "cracked porcelain" pattern

  • Erythema within fissures; may weep if severely cracked

• Location

  • Most commonly affects shins

  • May also involve forearms, backs of hands, trunk

• Symptoms

  • Itch (pruritus) ranging from mild to severe

  • Stinging or burning if fissures are deep

  • Mild exudate or localised infection possible in severe cases

• Red Flags

  • Sudden onset with systemic symptoms (weight loss, malaise): investigate underlying causes

  • Significant weeping/crusting: rule out secondary bacterial infection (e.g., staphylococcal)

Differential Diagnosis

• Eczema (Atopic, Nummular): More inflammatory, potential weeping or lichenification

• Psoriasis: Sharply demarcated plaques, silvery scale, possible nail involvement

• Fungal Infections: Typically localised to feet (tinea pedis) or groin (tinea cruris)

• Ichthyosis: Congenital forms, lifelong dryness

• Hypothyroidism: Can mimic or exacerbate dry skin conditions

• Contact Dermatitis: Localised dryness/cracking, usually identifiable irritant or allergen

Diagnosis

• Clinical Assessment

  • Hallmark "craquelé" pattern on visual inspection

  • Identify triggers: winter, indoor heating, bathing habits, hypothyroidism, medications

• Investigations

  • TFTs (thyroid function tests) if suspicion of hypothyroidism (cold intolerance, hair thinning, weight gain)

  • Additional tests (FBC, UEC, CRP/ESR) if sudden onset or systemic features present

Management

• Skin Hydration & Protection (Mainstay)

  • Reduced Bath Frequency

    • Shorter, lukewarm showers; avoid hot water

    • Use bath oils or soap-free washes

  • Gentle Cleansing

    • Cream cleansers or soap substitutes

    • Pat skin dry; avoid vigorous rubbing

  • Emollients

    • Thick ointments (petroleum jelly) multiple times daily

    • Apply immediately post-bathing (within 3 minutes)

    • Transition to lighter creams/lotions once improved

  • Avoid Direct Heat

    • Limit direct exposure to heaters

    • Use humidifiers if the environment is very dry

• Pharmacological Treatment

  • Mild Topical Steroids

    • Hydrocortisone 1% or mild corticosteroids once/twice daily (short courses: 3–5 days) for inflammation

    • Minimise use; primary goal is rehydration

  • Other Measures

    • Non-sedating antihistamines if severe itch

    • Antibiotics only if secondary infection evident (weeping, crusting)

Prevention & Lifestyle Measures

• Daily moisturising to prevent recurrence

• Avoid overwashing or harsh soaps

• Protective clothing in cold weather, humidify environment

• Identify/correct underlying issues (thyroid disorders, medication side effects)

• Adequate nutrition and hydration to support skin integrity

Prognosis & Follow-Up

• Chronic condition in predisposed individuals, especially elderly

• Typically responds well to regular moisturising and mild topical therapies

• Monitor for complications (infection, severe fissuring) requiring additional treatment

Key Points

• Eczema Craquelé is eczema due to severe skin dryness.

• Characteristic "crazy-paving" pattern with red fissures.

• Common in elderly, especially during winter or with hypothyroidism.

• Primary treatment: emollients, minimise irritants, mild topical steroids if inflammation present.

• Investigate underlying causes: thyroid disorders, medications, possible malnutrition.