The craquelé effect on the skin is often found on the legs of the elderly, especially in winter. The name of these lesions, eczema craquelé, is very intuitive, but not very well known among professionals who treat leg ulcers. So, let’s dedicate a post to understand why it occurs, identify how it presents itself and how to prevent and treat it.
What is eczema craquelé?
Eczema craquelé, also known as asteatotic eczema, is characterised by the presence of superficial, criss-crossed fissures on a more or less erythematous and scaly base, with the subsequent appearance of craquelure or cracked pavement. It is usually very itchy.
The extent of the lesions is variable and scratching may aggravate the inflammation and lead to erosions or ulcers.
As mentioned above, it usually affects the lower limbs of older people.
Why does it occur?
It has been classically associated with xerosis (dry skin) and factors that alter the barrier function of the stratum corneum (the most superficial layer of the epidermis), such as age, the use of soaps, long showers with hot water or a cold, dry environment.
Old people have reduced activity of the sebaceous and sweat glands. In addition, age-related alteration of the defensive functions of the stratum corneum leads to increased permeability which will cause inflammation and pruritus.
However, this crackling is also observed in cases of rapid onset oedema, such as decompensation of heart failure, hypoproteinaemia or phlebolymphoedema. In fact, the distension of the skin secondary to these causes of rapid oedema is the cause of the production of “fractures” in the stratum corneum and the rest of the epidermis. It is therefore possible that even in the classic presentation of eczema craquelé (old person with xerosis) the preference for the legs may reflect the frequent occurrence of oedema due to venous hypertension in this age group. Moreover, the term “acute oedema-cutaneous distension syndrome” has been proposed to include this “craquelé” presentation in the spectrum of skin lesions associated with rapid onset oedema. Depending on the elasticity of the skin, the person will respond to this oedema with blisters or with eczema craquelé. 2
This photo shows a case of eczema craquelé in the context of a flare-up of phlebolymphoedema.
On the other hand, in addition to the typical presentation, eczema craquelé can also occur in other locations, such as on the trunk or generalised over the whole body, and in younger people. In these cases, as it may be the expression of an underlying systemic disease, such as a malignancy, a detailed study must be carried out.3
How can it be treated and prevented?
Prevention is just as important as treatment. Bearing in mind that xerosis is the main trigger for these lesions on legs, the strategy will always be focused on promoting skin hydration and avoiding external factors that damage the skin’s hydrolipidic film. Therefore, these are the main recommendations, which should be explained to the patient and family members:
- Lower the water temperature and shorten the shower time.
- Avoid the use of soaps
- Apply emollients several times a day, especially after bathing.
- Use humidifiers
- Use cotton clothing and avoid wool.
- Avoid scratching
- Control of oedema if it is the trigger (therapeutic compression, anti-oedema measures).
- In case of extensive, very itchy lesions, which are not controlled with the previous measures, use topical corticosteroids of medium-high potency. Ideally, it should be mixed with moisturiser and applied to damp skin after showering and immediately put on cotton pyjamas. Use it for 1 to 2 weeks, depending on the evolution. Calcineurin inhibitors are an alternative to topical corticosteroids.4
- Oral antihistamines can be added to control pruritus.
References:
- Yang CS, Lott JP, Bunick CG, Bolognia JL. Eczema craquelé associated with nephrotic syndrome. JAAD Case Rep. 2016;2(3):241-243.
- Cox, Neil, Chalmers, Robert, MB, FRCP, Bhushan, Monica. The Acute Edema/Cutaneous Distension Syndrome. Arch Dermatol. 2003;139(2):224-225.
- Sparsa A, Boulinguez S, Liozon E, Roux C, Peyrot I, Doffoel-Hantz V, Labrousse F, Vidal E, Bordessoule D, Bonnetblanc JM, Bédane C. Predictive clinical features of eczema craquelé associated with internal malignancy. Dermatology. 2007;215(1):28-35.
- Schulz P, Bunselmeyer B, Bräutigam M, Luger TA. Pimecrolimus cream 1% is effective in asteatotic eczema: results of a randomized, double-blind, vehicle-controlled study in 40 patients. J Eur Acad Dermatol Venereol. 2007 Jan;21(1):90-4.
