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Case Report/Case Series
Asteatotic Eczema in Hypoesthetic Skin
A Case Series
Nicole M. Cassler, MD; Ashley M. Burris, BS; Josephine C. Nguyen, MD
IMPORTANCE Asteatotic eczema (eczema craquelé, xerotic eczema) occurs most frequently in
areas of dehydrated skin, most often during the winter months when decreased humidity
results in increased water loss from the stratum corneum. We present 5 cases in which asteatotic
eczema was found outside of its normal distribution, within desensitized skin and scars.
OBSERVATIONS Five patients with a history of trauma and scar formation presented with
erythematous, dry plaques with fine crackling involving hypoesthetic skin. Each of the 5
patients had classic asteatotic eczema skin findings, the only commonality being
hypoesthesia. Borders of the hypoesthetic skin were identified using light touch and
compared with the regions affected by asteatotic eczema. In all cases, the skin affected by
asteatotic eczema was within the hypoesthetic areas.
CONCLUSIONS AND RELEVANCE Asteatotic eczema developing on skin with altered sensation
is an underreported condition. Prompt recognition and treatment may lead to a more
efficient patient encounter and alleviate unnecessary patient stress.
JAMA Dermatol. 2014;150(10):1088-1090. doi:10.1001/jamadermatol.2014.394
Published online July 16, 2014.
A
steatotic eczema (eczema craquelé, xerotic eczema) is
typically associated with cutaneous loss of lipids, resulting in xerosis of the skin secondary to transepidermal water loss, most commonly seen during the winter months.
The classic description is that of polygonal erythematous fissures separating plates of dry scaly skin, sometimes described as “cracked porcelain,” “crazy pavement,” or a “dry riverbed” appearance.1,2 Asteatotic eczema is more common in
older individuals, possibly because of an age-dependent decrease in sebaceous and sweat gland activity and deficient formation of membrane-coating granules, which lead to the disappearance of the lipid film that surrounds the cells in the
stratum corneum.3,4 The intercorneocyte lipid is formed by expulsion of ceramides from the lamellar bodies in the granular
layer to form broad sheets in the intercorneocyte space that
help form the water barrier.5 Analysis of sebum-derived lipids present in the stratum corneum revealed a significant decline in free fatty acids and triglycerides in asteatotic eczema.6
Although asteatotic eczema has been observed in denervated skin, it is an underrecognized condition when presenting in younger patients and in unusual locations.7 We describe 5 cases in which the condition was limited to scars or
on hypoesthetic skin.
Corresponding Author: Nicole M.
Cassler, MD, Department of
Dermatology, Walter Reed National
Military Medical Center, 8901
Wisconsin Ave, Bethesda, MD 20889
([email protected]).
he had sustained several gunshot wounds, resulting in compartment syndrome of his left lower leg. He underwent emergency fasciotomy of his left lower leg, and has had resultant
well-demarcated decreased sensation in his anterior left shin
since that time. On presentation, the area of hypoesthesia on
his anterior shin to his sock line had a plaque of erythematous polygonal fissures with serous exudate and yellow crust.
A bacterial culture was positive only for normal skin flora. Resolution of the dermatitis was achieved rapidly with topical corticosteroids and treatment was transitioned to emollients for
maintenance.
Case 2
Another male wounded military member in his 30s presented with a chronic dermatitis on a large area of his left hip.
Approximately 2 years earlier, he had experienced a traumatic left hemipelvectomy, in addition to soft-tissue injuries
to his right forearm and back. He had developed a plaque of
erythematous polygonal fissures limited to the areas of skin
with decreased and absent sensation. On his left residual pelvis and hip, the plaque was well demarcated and encompassed nearly all areas of decreased sensation (Figure 1). On
his forearm and back, a similar-appearing plaque of erythematous fissures was limited to all of his well-healed scars.
Case 3
Report of Cases
Case 1
A male wounded military member in his 30s presented with a
new dermatitis on his left shin. Approximately 5 months prior,
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Author Affiliations: Department of
Dermatology, Walter Reed National
Military Medical Center, Bethesda,
Maryland (Cassler, Nguyen);
student, Edward Via Virginia College
of Osteopathic Medicine, Blacksburg
(Burris).
A wounded military member in his 20s presented with a mildly
pruritic waxing and waning dermatitis of traumatic and surgical scars, as well as a skin graft site. He had a history of traumatic
left below-the-knee amputation and extensive right lower ex-
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Asteatotic Eczema in Hypoesthetic Skin
Case Report/Case Series Research
Figure 1. Area of Outlined Sensation Tested Using Light Touch
Figure 3. Anterior Left Breast With Decreased Sensation
A faint, well-healed scar is visible laterally across the surface, in the background
of asteatotic eczema.
Nearly the entire area of hypoesthetic skin on the patient’s left residual pelvis
and hip had skin findings of asteatotic eczema.
Figure 2. Asteatotic Eczema Within Scars and Skin Graft Site
on the Right Thigh
earlier, and had resultant lymphedema and decreased sensation on his anterior right thigh. He developed a wellcircumscribed nummular 5-cm plaque of erythematous polygonal fissures, which responded rapidly to topical
corticosteroids.
Case 5
A woman in her 80s with a history of breast cancer presenting for an unrelated skin condition was found to have plaques
of erythematous polygonal fissures along scars on both breasts.
She had undergone breast surgery 2 decades ago and had resulting decreased sensation across the anterior portion of both
breasts. The fissures were limited to well-healed scars on bilateral anterior breasts (Figure 3).
Discussion
All involved sites were hypoesthetic.
tremity soft-tissue injury, with resultant split-thickness skin
grafts, 1 year prior to presentation. He had received clobetasol
propionate, 0.05%, ointment for an unspecified dermatitis 8
months earlier and had been intermittently using it on his waxing and waning dermatitis. He noted resolution of the dermatitis within several days when he used topical corticosteroids,
but it returned within 2 weeks of cessation. On examination,
multiple scattered plaques of mild erythema with brightly erythematous polygonal fissures, contained within the borders of
scars on his residual left lower extremity and right lower extremity scars and graft site, were noted (Figure 2). Histologic findings from a biopsy sample obtained within the scar of the left
leg were consistent with spongiotic psoriasiform dermatitis with
eosinophils, supporting a diagnosis of asteatotic eczema.
Case 4
A man in his 30s with a history of metastatic melanoma presented with a new dermatitis on his right lateral thigh. He had
undergone a right inguinal lymph node dissection 9 months
jamadermatology.com
Asteatotic eczema can be localized or generalized. The localized form is thought to be due to cutaneous loss of lipids, which
then leads to transepidermal water loss.8,9 The water loss increases skin sensitivity to environmental insults including soap,
decreased humidity, and decreased temperature. There are
many references in the literature to asteatotic eczema in neurologic disorders, but nearly all refer to one case report10 in 1975
of a presentation in skin with decreased sensation. We report
a series of 5 patients who similarly presented with asteatotic
eczema in the setting of altered skin sensation to draw attention to a condition that is underreported but may be highly
prevalent.
The skin of all 5 patients was tested using light touch. The
borders of the hypoesthetic skin were defined, and all asteatotic eczema was confined within these areas, although not all
hypoesthetic skin was involved. None of the patients reported a history of atopic dermatitis or the use of special cleansers, ointments, or dressings in the affected areas. Allergic and
irritant contact dermatitis were initially considered, but were
less likely given the lack of special treatment.
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Research Case Report/Case Series
Asteatotic Eczema in Hypoesthetic Skin
Hypotheses for why asteatotic eczema occurs within hypoesthetic skin are limited. A contributing factor to asteatotic
eczema is lipid loss, leading to transepidermal water loss. The
common factor in all 5 patients was decreased sensation to light
touch. Murray and Forsey10 described areas of decreased sensation as having decreased sweating and hypothesized that eccrine glands have a contributory role in the development of
eczema. Eccrine glands are innervated by the sympathetic nervous system, specifically through cholinergic and adrenergic
fibers.11,12 When the sympathetic nervous system is activated, there is an increase in the secretion of sweat. A similar
outcome is seen with the stimulation of the autonomic nervous system. If this system is dysfunctional, sebaceous glands
will not release sebum-derived lipids and the skin will lose water and become dry, predisposing to the development of
eczema.6 Generally, asteatotic eczema is caused by low humidity and the incidence increases during the winter months,
but the body may be able to simulate these circumstances with
decreased eccrine innervation.
Another explanation why asteatotic eczema occurs within
hypoesthetic skin may be a dysfunction in the intercorneocyte lipid formation. If there is a problem with the release of
ceramides from the lamellar bodies, the water barrier will be
unable to form properly. The scar tissue seen in these 5 patients may affect the function of the granular layer and the
transportation capabilities of the skin. The main function of
ARTICLE INFORMATION
Accepted for Publication: February 19, 2014.
Published Online: July 16, 2014.
doi:10.1001/jamadermatol.2014.394.
Author Contributions: Dr Cassler had full access to
all the data in the study and takes responsibility for
the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Cassler, Nguyen.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: Cassler, Nguyen.
Administrative, technical, or material support:
Cassler.
Study supervision: Cassler, Nguyen.
Conflict of Interest Disclosures: None reported.
Disclaimer: The opinions and assertions contained
herein are the private views of the authors and are
not to be construed as official or as reflecting the
views of the US Navy, US Army, or the Department
of Defense.
Additional Contributions: Thomas N. Darling, MD,
PhD, Uniformed Services University, assisted with
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the stratum granulosum is lubrication and protection of keratin. One study13 described an increase in keratinocytes in the
stratum granulosum and reepithelialization after an inflicted
wound in mice. This hyperkeratinization may impair the ability of the skin to produce this intercorneocyte lipid film.
Conclusions
Asteatotic eczema in hypoesthetic skin, both scarred and not
scarred, is underrepresented in the literature. Basic science research on asteatotic eczema is also limited, leading to much
conjecture about the development of this condition. Although the treatment remains the same as the standard of care,
the importance of diagnosis and reassurance cannot be understated. In our patient population of wounded members of
the military services, some of whom have undergone unusual and life-threatening complications, the eruption of a mysterious undiagnosed dermatitis is an added stressor. For both
dermatologists and primary care physicians caring for these
patients, rapid diagnosis and treatment may save unnecessary additional concern and stress, as well as hasten a plan to
improve the skin barrier, resulting in lower infection risk. The
goal of this article is to increase awareness, especially in the
setting of increased numbers of wounded military members
returning to their home communities.
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