"Craquelé" in French means "covered with cracks", as seen on the surface of old china. It was first described by the French dermatologist Brocq in 1907. The condition is thought to be the result of excess water loss from the epidermis and a reduction in free fatty acids in the stratum corneum. Shrinkage of cell volume leads to reduction of skin elasticity and the formation of fissures.¹

Epidemiology¹

The condition is common in the elderly. The average age of presentation is 69 years, although it is not unknown in young people. Men are more affected than women. The incidence is highest in the winter and in cold climates.

Risk factors

• Low humidity environments (e.g. central heating).
• Dehydration.
• Frequent prolonged bathing in hot water
• Contact with irritants (e.g. soaps, detergents, wool).
• Malnutrition (zinc and fatty acids).
• Discontinuation of steroid therapy.
• Degreasing agents.
• Anti-androgen therapy.
• Diuretics.

Presentation¹

The typical presenting picture is an elderly patient complaining of itchy, dry skin in the winter. Younger age groups and even children can, however, be affected. The classical distribution is on the legs, although hands, arms and trunk can also be affected. The appearance is of slightly scaly fissured skin, which has been described as crazy paving or cracked porcelain (see Document reference 2 for a picture).² Areas of excoriation, erythema and bleeding may be evident, due to rubbing or scratching. Most patients have a localised condition, but a more severe generalised form is sometimes seen.

Differential diagnosis^1,2

• Cellulitis.
• Contact dermatitis (allergic or irritant).
• Stasis dermatitis.
• Nummular (discoid) eczema (a chronic eczema causing irritating coin-shaped lesions on the arms, back, buttocks and legs).
• Thrombophlebitis.
• Scabies.

Associated diseases¹

• Atopic dermatitis.
• Neurological disorders (due to decreased sweating in denervated areas).
• Myxoedema.
• Malignancies¹ (with the generalised form) - breast cancer, large-cell lung carcinoma, colorectal carcinoma, malignant lymphoma,³ gastric carcinoma,⁴ and other rarer tumours.

Investigations

• Laboratory tests may be required to exclude associated diseases if clinically suspected.
• Histology of a skin biopsy shows spongiosis (increased intracellular fluid in the epidermis)⁵ and some inflammatory dermal infiltrate. These are unfortunately nonspecific findings found in many inflammatory conditions, and the diagnosis is usually made clinically.

Management¹

• Avoid long hot baths, excessive use of soap and harsh skin cleansers. Air-conditioned rooms should be humidified.
• Petroleum-based emollients and moisturisers should be used liberally.
• Mild topical steroids may be required for patients who do not respond to these measures. For resistant cases, a mid-strength steroid (e.g. triamcinolone) under an occlusive dressing for 24-48 hours is the first-line treatment.
• Some studies have reported benefit with pimecrolimus or tacrolimus cream.

Prognosis

The condition normally responds rapidly to treatment but aggravating factors need to be addressed to prevent it from recurring.

Document references

1. Anderson C et al; Asteatotic Eczema, Medscape, Sep 2009
2. Asteatotic eczema, eczema.dermis.net, DermIS (Dermatology Information System)
3. Sparsa A, Liozon E, Boulinguez S, et al; Generalized eczema craquele as a presenting feature of systemic lymphoma: report of seven cases. Acta Derm Venereol. 2005;85(4):333-6. [abstract]
4. Guillet MH, Schollhammer M, Sassolas B, et al; Eczema craquele as a pointer of internal malignancy--a case report. Clin Exp Dermatol. 1996 Nov;21(6):431-3. [abstract]
5. Spongiosis; Dermatology Glossary

Internet and further reading

• Eczema Craquele, DermAtlas (Dermatology Image Atlas), 2011; image