Asteatotic eczema (winter eczema, eczema craquelé)

Definition

Asteatotic eczema (winter eczema, xerotic eczema) is an eczema that develops on markedly dry skin (xerosis cutis). Its hallmark is a network of fine, reddened fissures in dry, scaly skin – resembling the cracked glaze of porcelain (French craquelé), crazy paving or a dried-out riverbed. It typically affects the lower legs of older people and worsens in the cold, dry season.

Classification

• By severity: xerosis cutis (dry skin without inflammation) → asteatotic eczema with inflamed fissures (eczema craquelé) → severe disease with secondary eczematisation, swelling and vesicles, rarely spreading as disseminated eczema (autosensitisation).
• By cause: commonly environmental and age-related (dry heated air, frequent washing, skin ageing); less often symptomatic of an underlying disease or caused by drugs – then often unusually extensive, of rapid onset or without a seasonal pattern.

Occurrence & epidemiology

• Asteatotic eczema is one of the most common forms of eczema in older age and occurs mainly in winter.
• The underlying xerosis cutis is very common in older people: in a French primary care study 55.6% of patients aged 65 or older had xerosis; in the population-based Rotterdam Study (middle-aged and elderly participants) 60% had dry skin, a fifth of them generalised. These figures describe dry skin, not the eczema itself.
• Factors associated with dry skin included older age, female sex, low outdoor temperature, body mass index, smoking, a history of eczema or atopic dermatitis and certain drugs (e.g. diuretics).

Aetiopathogenesis

• Barrier dysfunction: with age, stratum corneum lipids and sebum production decline; the horny layer loses water and suppleness, becomes brittle and cracks. Inflammation develops within the cracks – hence the red “grout lines” between the dry plates.
• External factors: low humidity (winter, central heating, fan heaters, high altitude), frequent and hot baths or showers, soaps and detergents, friction.
• Internal factors and associated conditions: ichthyoses (inherited or acquired), hypothyroidism (myxoedema), malnutrition (including zinc and fatty acid deficiency), marked weight loss, oedematous states (e.g. nephrotic syndrome), reduced skin sensation; rarely paraneoplastic, especially with lymphomas (including Hodgkin lymphoma in older patients).
• Drugs: including diuretics, retinoids, protein kinase inhibitors and some cytostatic agents (e.g. taxanes).

Clinical features

• Dry, finely scaling skin with a network of shallow, reddened fissures; between them polygonal to diamond-shaped plates of skin – the typical “craquelé” pattern.
• Predilection sites: extensor aspects of the lower legs (shins), often bilateral after starting on one side; also extensor aspects of the arms, flanks and trunk, hands.
• Itch and burning, excoriations; deep fissures may bleed and hurt (haemorrhagic fissures).
• Complications: bacterial superinfection, secondary eczematisation with redness, swelling and vesicles, rarely disseminated spread.
• Course: worsening in winter, improvement in more humid months; recurrences are common without consistent emollient care.
• Dermoscopy (adjunct): white scales with a double free edge arranged in a linear pattern, resembling railway tracks.

Diagnosis

• Clinical diagnosis based on the typical appearance and distribution; in most patients no further tests are needed.
• History: bathing and showering habits, cleansing and skin care products, indoor climate, medication list (e.g. diuretics), weight trend and general symptoms.
• Targeted work-up: thyroid function tests if there are clinical signs of hypothyroidism; with recent, extensive or persistent disease – especially with marked scaling (acquired ichthyosis), weight loss, fever or night sweats – a search for an internal cause including lymphoma.
• If the course is atypical or treatment fails: fungal testing (tinea), patch testing (contact allergy to topical products), biopsy to distinguish e.g. mycosis fungoides or premonitory bullous pemphigoid. Histology shows a non-specific spongiotic dermatitis.

Differential diagnoses

• Nummular eczema (discoid eczema)
• Stasis dermatitis (venous eczema)
• Contact dermatitis (contact eczema)
• Atopic dermatitis (atopic eczema)

• Ichthyosis (inherited or acquired)
• Tinea corporis
• Scabies (eczematised)
• Bullous pemphigoid (premonitory stage)
• Mycosis fungoides (early stage)

Treatment principles

• The basis is consistent emollient skin care and reducing drying influences (frequency, duration and temperature of baths and showers, mild soap-free cleansing, indoor climate).
• Inflamed areas are treated briefly with topical glucocorticoids; antiseptic measures are added if there is superinfection.
• In symptomatic forms, treating the underlying disease or reviewing causative drugs takes priority; because relapses are common, basic skin care is continued long term.

Specific treatment regimens with drugs and doses are covered in the DermaFuchs app.

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References (selection)

1. Srivastava D, Sathe NC, Persaud Y. Asteatotic Eczema. StatPearls, updated 01/2026 (PMID 31747214)
2. Harries L et al. Eczema and its treatment in older adults [in German]. Dermatologie (Heidelb) 2023;74:678–686 (PMID 37638989)
3. Paul C et al. Prevalence and risk factors for xerosis in the elderly: a cross-sectional epidemiological study in primary care. Dermatology 2011;223:260–265 (PMID 22104182)
4. Mekić S et al. Prevalence and determinants for xerosis cutis in the middle-aged and elderly population: A cross-sectional study. J Am Acad Dermatol 2019;81:963–969 (PMID 30586613)
5. Park JS et al. Acquired ichthyosis, asteatotic dermatitis or xerosis? An update on pathoetiology and drug-induced associations. J Eur Acad Dermatol Venereol 2023;37:47–56 (PMID 36165597)
6. Le Clainche Compagnie A et al. Asteatotic eczema, a cutaneous manifestation of Hodgkin lymphoma in older patients. EJHaem 2024;5:883–884 (PMID 39157615)
7. Patrizi A et al. Eczema craquelé, an uncommon clinical manifestation of myxedema. J Dtsch Dermatol Ges 2015;13:453–454 (PMID 25918092)
8. Cassler NM et al. Asteatotic eczema in hypoesthetic skin: a case series. JAMA Dermatol 2014;150:1088–1090 (PMID 25029204)
9. DermNet: Asteatotic eczema

Cross-references